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| health > ethics matters |         |
Back Seat Doctorsby Jeffrey P. Kahn, Ph.D., M.P.H. Director, Center for Bioethics University of Minnesota (CNN) -- The governing body of the American Medical Association (AMA) recently changed its ethics guidelines to encourage physicians to report patients to local authorities when their driving poses a risk to public safety. This change in policy raises concerns for its impact on the doctor-patient relationship, the responsibilities this role creates for physicians, and when the rights of patients should be trumped in favor of public protection.
Doctors as double agentsThe doctor-patient relationship is already under siege. Managed care has created an environment that makes doctors agents on behalf of payers, which has driven a wedge between doctors and their patients. To ask physicians to take on an additional role--as agents of the government reviewing the driving safety of patients--further undermines their ability to focus on patients' best interests. The reduced emphasis on patient advocacy by physicians is one of the major factors fueling the movement toward establishing a patients bill of rights. That makes the changed guideline even more ironic, in that the whittling away of doctors' roles as patient advocates is at the heart the medical profession's (and the AMA's) complaints about managed care. So if making doctors double agents isn't good for patients or physicians, why do it?
There are other circumstances in which physicians are required to place the public's health above their patient's interests, most notably mandatory reporting requirements for infectious diseases like tuberculosis and sexually transmitted diseases. But public health is not the same thing as public safety, and we need to ask whether preventing hazardous drivers is as important to health care as preventing the spread of disease. One approach that may help is the concept of "duty to warn," created in the context of confidentiality and psychiatry. It says that when a patient tells a physician that he intends to harm an identifiable third party, for instance when a emotionally disturbed patient threatens, "If I can't have her, nobody will," there is an obligation to breach patient confidentiality and inform the police and/or the individual at risk. But an elderly driver suffering from early signs of dementia hardly meets this standard. So how much risk is enough to warrant violating patient privacy?
A breach of confidentiality in the doctor-patient relationship is not something to be taken lightly. Confidentiality is an expression of trust, and without it patients won't be honest with their physicians, and may even be driven away from medical care for fear of being reported. In the few cases when breaches of confidentiality are warranted, standards are fairly clear, and laws protect a doctor who breaks it in good faith. But there are no standards for when to report risky drivers, and we can easily foresee liability for either reporting a patient who claims his driving privileges were revoked unnecessarily, or for failing to report a patient who causes a traffic death. Further, why rely on physicians to perform what seems to be the task of government? If the state licenses drivers, why doesn't it test them to make sure they continue to meet standards of safety? For some groups -- the very elderly, those who have been arrested for driving while intoxicated, and so on -- the addition of an annual road test to the usual written exam required for driver's license renewal would go a long way toward keeping hazardous drivers off the road. And it would keep public safety monitoring in the hands of public safety officials and out of doctor's offices. All this points to the wisdom in a system that lets doctors spend their time caring for patients and lets public safety officials worry about keeping unsafe drivers off the road. Otherwise taking a drive with the doctor may become part of our annual check-up, and that is a road best left untraveled.
"Ethics Matters" Archive where you'll find other columns from Jeffrey Kahn on a wide range of bioethics topics. Center for Bioethics and CNN Interactive. RELATED STORIES: Doctors may tell government if patients are risky drivers RELATED SITES: American Medical Association
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