Doctors shouldn’t be forced to dob in unfit drivers

Licensing authorities place the onus on drivers to report any medical conditions that might affect their driving. Image from shutterstock.com

Few states mandate that doctors or other health professionals must report unfit drivers to licensing authorities – and for good reason.

Driving is an everyday practice for many Australians, but that doesn’t mean it’s a simple task. It takes several years for crash rates among young drivers to decline, and driving performance can be affected at any time by fatigue, distraction and impairment by alcohol or drugs.

Not surprisingly, people with chronic alcohol and drug misuse patterns are over-represented in crashes, and a variety of medical and psychiatric conditions can also affect driving.

On the face of it, it seems obvious that if someone is a danger to the community as a driver because of a medical condition, they should not be allowed to drive. Since the treating doctor is in the best position to know about their condition, they should be legally responsible for reporting.

But such a scheme could lead to patients withholding information from doctors or “doctor-shopping” for physicians who are less inclined to report.

Driver power

In the first instance, all Australian licensing authorities place the onus on drivers themselves to report any medical conditions that might affect their driving.

Doctors and other health professionals play a role in this approach by advising drivers they have a condition that should be reported. Austroads (a peak body for the road authorities in Australia and New Zealand) guidelines for assessing fitness to drive state:

[the] health professional has an ethical obligation, and potentially a legal one, to give clear advice to the patient in cases where an illness or injury may affect safe driving ability.

The reference to potential legal liability concerns the obligation of the health professional to inform the driver, not the licensing authorities.

There are two obvious flaws in this approach. One is that a driver can choose to ignore the advice. This means they have committed an offence, but charging them after they have had a crash misses the point.

Patients can sue doctors for breaches of confidentiality. Exciting Cebu -- Rusty Ferguson

The second is that the health professional is not obliged to report the condition to the licensing authorities, except in South Australia and the Northern Territory. So the driver will not come to the attention of the authorities unless they have a crash or are involved in some other incident.

Mandatory reporting

From an administrative efficiency perspective, mandatory reporting by health professionals has a straightforward logic, so it’s worth exploring why only South Australia and the Northern Territory have such an arrangement.

While the term “health professionals” covers a range of professions, doctors are the key stakeholders.

One of the long-standing principles that guides doctors is the preservation of patient-doctor confidentiality. This principle retains a strong contemporary relevance: if patients avoid telling their doctor about a condition for fear of being reported, they may not be treated appropriately and this could affect other people as well.

The principle of patient-doctor confidentiality does not override all other considerations, however: where the condition of the patient constitutes a high risk to others, reporting to the authorities is justified.

Where driving is concerned, doctors’ application of the “public safety” principle still assumes the primary onus is on the driver to report. This is established in both the Austroads guidelines and in the Australian Medical Association’s position paper on the issue.

The Austroads guidelines acknowledge the need for confidentiality, then state that health professionals should “consider reporting directly to the driver licensing authority” under three circumstances:

  • where the driver is not able to understand that their condition makes their driving unsafe
  • where they have a cognitive impairment which means they cannot follow the health professional’s recommendations
  • where they keep driving in spite of the advice and potentially endanger public safety by doing so.

The AMA position paper takes a similar line, but also emphasises that medical professionals are not agents of licensing authorities or the law in general. Medical issues are carefully distinguished from judicial issues and the primacy of patient-doctor relationship is stressed:

It is not appropriate that the treating doctor should be the decision-maker. That role places the doctor in a position of unacceptable ethical conflict, and threatens the therapeutic relationship.

Patients can sue doctors for breaches of confidentiality, so legislation about reporting medical conditions is overwhelmingly focused on providing legal protection for discretionary reporting.

Only South Australia and the Northern Territory have mandatory reporting by certain health professionals. South Australia exempts reporting professionals from criminal and civil liability, whereas the Northern Territory does not.

To my knowledge there has been no assessment of the relative success of mandatory reporting in South Australia and Northern Territory, in particular whether it has had any negative impacts.

A dangerous driver can choose to ignore their doctor’s advice not to drive. Image from shutterstock.com

Evidence-based policy development

From time to time, victims’ families claim mandatory reporting would have prevented a crash from occurring and would have saved their loved one. Such cases inevitably generate strong emotions. But while it’s good they lead us to question the systems we have in place, they only tell part of the story.

As we know from the similar issues that arise for older drivers, having mandatory systems and additional administrative requirements does not necessarily translate into greater safety on the road.

In 2011 we conducted research for Queensland’s Older Driver Safety Advisory Committee which considered a range of issues including the role of medical practitioners in assessing fitness to drive. We found that:

drivers of any age suffering medical conditions do not necessarily have a higher crash involvement. Any given condition may affect drivers’ “fitness to drive” in different ways and to different degrees.

An important phenomenon is that many older drivers compensate (not always deliberately) for reduced performance by limiting the amount of driving they do and the times and places they do it.

Ultimately, we concluded that medical practitioners must continue to play a significant role in assessing drivers, but they need information to supplement the Austroads guidelines. While driving cessation is one option for a driver whose safety is compromised by a medical condition, there are driving restrictions that can be imposed with similar benefits and without the loss of mobility imposed by licence loss.

We also recommended information and other support for family members in raising the issue of safe driving or licence surrender. All of these approaches have shortcomings, but there is no perfect solution.

Mandatory reporting of medical conditions by health professionals is not a silver bullet, and can have negative consequences as well as raising ethical issues for doctors and other health professionals. Unless we have convincing evidence that the benefits of mandatory reporting outweigh the costs, we would be better off pursuing more supportive, less draconian approaches.

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