Impaired drivers: Meeting a dual responsibility

Guidelines adopted by the AMA last year call on doctors to report impaired patients to state drivers' license bureaus -- not to law enforcement bodies -- if other interventions fail.

Editorial. May 15, 2000.

It probably was not long after the invention of the automobile when the first problems with impaired drivers were recognized. The impaired driver -- whether from alcohol or from physical conditions -- has been a common element in automobile crashes for most of the past century.

The modern-day statistics are unequivocal. In 1996, more than 56,000 U.S. drivers were involved in fatal crashes. Nearly 20% of them were intoxicated. About 14% of those involved in fatal crashes were older than 70 -- an age group that makes up only 9% of the nation's population.

Some of these deaths -- and many other accidents -- are preventable, and last year the American Medical Association's House of Delegates adopted a new ethical guideline that emphasizes the role of the physician in curbing this epidemic. The official wording of the guideline will be presented at the AMA's Annual Meeting next month.

The delegates adopted a thoughtful report prepared by the AMA's Council on Ethical and Judicial Affairs that calls on doctors to report impaired patients to state drivers' license bureaus -- not to law enforcement bodies -- if other interventions fail.

The guidelines call for the physician to evaluate, on a case-by-case basis, patients' physical or mental impairments that might adversely affect driving. The physical or mental impairment must be documented and clearly relate to driving ability, causing the driver to pose a clear risk to public safety. The physician then should consult with the patient and, if appropriate, the family, recommending therapy that might eliminate the impairment and/or suggesting a change in driving patterns to minimize risk.

The guideline was approved at the AMA's Interim Meeting in December 1999. It was the council's second attempt to put in place an ethical standard for physicians in these sensitive situations; the House of Delegates had rejected a slightly more stringent ethical guideline six months earlier.

CEJA's report emphasized that the impaired-driver problem "illustrates the fundamental conflict between the responsibility physicians have to society and their responsibility to individual patients."

The physician's ethical requirement to protect the public may in some cases entail reporting patients who have impairments that may limit their ability to drive safely and pose a threat not only to the patient but also to others. By reporting such a patient, CEJA's report reasons, the physician protects both the public and the patient.

The reporting is not mandatory. The guidelines state that it is "desirable and ethical" for a physician to notify the appropriate state agency if an impaired patient fails to appropriately restrict his or her driving. The report excludes physicians "who treat patients on a short-term basis," such as emergency physicians, from the ethical mandate.

There was a vigorous debate over the CEJA policy statement. Some physicians expressed concern over what, to them, was a clear violation of the confidential relationship between physician and patient. Proponents saw not only the obligation to protect the public but also the potential for positive counseling of patients with impairments.

The result of the deliberations of CEJA and the House of Delegates is a measure that provides guidance for the practitioner. It is a step forward that needed to be taken, despite the fact that both opponents and proponents can cite shortcomings. As one AMA delegate put it at the Interim Meeting, "Perfect is the enemy of the good."

The matter now rests with physicians everywhere who, for the first time on the issue of impaired drivers, have guidelines that will help them to balance the needs of their individual patients with the good of their communities.