When my father was declining from Alzheimer’s disease, my family often talked about when we should make him stop driving.
Of all his children, I held out the longest, hoping to preserve his freedom even as we gradually decreased the distance we would let him drive. One day, while driving on a busy street, he asked his caregiver which was the gas pedal and which was the brake. Not long after, he hit a neighbor’s car while backing out of the driveway. That was when we put his old Audi up for sale.
Over the course of those years, I don’t remember my father’s doctors ever asking about his ability to drive, let alone advising him to stop. Being a doctor myself, this did not come as a surprise. Few of us have the time or inclination in a brief office visit to wade into a fraught subject like when a patient should stop driving. Many doctors are also wary of breaching patient confidentiality by reporting impaired drivers to state authorities.
Yet doctors are perhaps uniquely qualified to address this issue. We treat many common conditions that affect the ability to drive, including seizures, heart arrhythmias, eye diseases and dementia. We are privy to our patients’ abilities and to medications that may affect their driving. Our patients also tend to follow our advice on matters of health and lifestyle.
For all these reasons, states should make it mandatory for doctors to report medically impaired drivers to the Department of Motor Vehicles, while at the same time providing legal protections to those who do. A final determination regarding fitness to drive would be made by the state. Society cannot leave a matter that so affects public health to family judgment.
Of course, revoking someone’s driving privileges is no small matter. In most of America, driving is essential for mobility and independence. The ability to drive gives us access to work, friends, recreation and many other things that make our lives worth living. Taking away this privilege can worsen the isolation that medically or cognitively impaired patients already struggle with.
Still, it is often necessary. A colleague of mine once took care of a patient, a school bus driver, who received a defibrillator implant after suffering cardiac arrhythmias that caused him to lose consciousness. When my colleague advised the man to quit his job because of the potential risk to young children, the man refused, so my colleague reported him to the Department of Motor Vehicles. It cost the man his job and, not surprisingly, created an irreparable rift in his relationship with my colleague.
It was a price that had to be paid, however. Motor vehicle accidents are a leading cause of death and injury in the United States. People shouldn’t have to share the road with impaired drivers.
A similar legal duty already applies to doctors when it comes to communicable diseases. For example, doctors and lab technicians must report patients with active tuberculosis to state authorities, who can then force compulsory treatment. Patients don’t have a choice in the matter. As Justice Mathew Tobriner of the California Supreme Court wrote in a famous 1976 case requiring mental health professionals to warn individuals who are threatened by their patients with bodily harm, “The protective privilege ends where the public peril begins.”
Yet only six states mandate the reporting of impaired drivers, according to a study published this year. And four of those states require reporting only those conditions that render drivers unconscious, such as seizures. In only three states is there a requirement to report serious visual or cognitive impairment. Moreover, 13 states provide no legal protections to doctors who report unsafe drivers. Only seven offer doctors absolute confidentiality.
This must change. Universal mandatory reporting, along with legal immunity, would allow doctors to serve the public good while absolving them of the guilt and fear of sharing confidential medical information without patient consent.
Of course, physicians will need proper training. Most of us don’t know how to formally evaluate a patient’s suitability for driving. Not everyone with an at-risk condition is an unsafe driver. A case like my father’s is more straightforward than that of a patient with milder cognitive impairment. Insurers can also help by paying for driving assessments at accredited facilities, as a recent article in JAMA Neurology suggested.
Doctors should be required to report patients only when the obstacle to safe driving results from medical impairment. A patient’s general recklessness or casual drug use, for example, might be a good reason to stop him from driving, but such assessments are beyond the scope of medical expertise. It does not make practical or ethical sense to expect doctors to manage bad behavior.
Patients and their families should have the opportunity to review and appeal adverse reports. If driving privileges end up being revoked, doctors and patients’ families should work together to find alternative modes of transportation, such as taxis and ride-sharing services. We ought to strive to maintain as much independence and mobility for patients as possible.
That is what my family ended up doing with my father. When we first took away his car keys, he fought back bitterly. He demanded to know what we had done with his car. He insisted that he should be able to drive without supervision. It was only after his internist phoned to tell him that she agreed with our decision and believed he should stop driving that he finally relented. He spent the remainder of his life as a reluctant but roving passenger.
Sandeep Jauhar is a doctor at Northwell Health in New York and the author of, most recently, “My Father’s Brain: Life in the Shadow of Alzheimer’s.” This article originally appeared in The New York Times.
