**National Ethics Teleconference**

***Provider Reporting of Impaired or Potentially Impaired Drivers***

**February 26, 2002**

**INTRODUCTION**

**Dr. Berkowitz:**

By sponsoring this series of Ethics Hotline Calls, the VHA National
Center for Ethics provides an opportunity for regular education and open
discussion of important VHA ethics issues. Each call features a
presentation on an interesting ethics topic followed by an open
moderated discussion of that topic. After the discussion we reserve the
last few minutes of each call for our \'From the Field\' Section, this
will be your opportunity to speak up and let us know what\'s on your
mind regarding ethics-related topics other than the main focus of
today\'s call.

As we proceed with today\'s discussion on provider reporting of impaired
or potentially impaired drivers, I would like to briefly review the
overall ground rules for the ethics hotline call. We ask that when you
talk you please begin by telling us your name, location and title so
that we can continue to get to know each other better. As the operator
asked, we request that you minimize background noise by using the MUTE
button and please do not put the call on hold as automated recordings
often come on and are very disruptive to the call. Due to the
interactive nature of the call and the fact that at times we deal with
sensitive issues, we think it is important to make two brief final
points. First, it is not the specific role of the National Center for
Ethics to report policy violations. However, please remember that there
are many participants on the line. You are speaking in an open forum and
ultimately you are responsible for your own words. Please remember that
these hotline calls are not an appropriate place to discuss specific
cases or confidential information. Therefore, if during the discussion
we hear people providing such information, we may interrupt and ask them
to make their comments more general.

**PRESENTATION**

**Dr. Berkowitz:**

Now for today\'s discussion of the ethical ramifications of provider
reporting of impaired drivers. Motor vehicles accidents are the third
leading cause of death and injury in America, killing upwards of 50,000
people in two million accidents per year. Most often, excessive speed or
substance abuse are implicated, but other medical conditions that impair
driving ability may also contribute. As providers we routinely care for
patients whose ability to operate a motor vehicle is compromised by
their physical or cognitive condition. Health care providers may be
faced with the ethical dilemma of whether or not to report their
patients who continue to drive despite impairment. To start today\'s
discussion, I\'d like to head over to New Haven, Connecticut and turn to
Richard Marottoli. Dr. Marottoli is the Director of Geriatrics and
Extended Care at the VA Connecticut Healthcare System, and he is the
Chair of the Transportation Resource Board Committee on Safe Mobility of
Older Persons. He has a particular interest in provider assessment and
reporting of impaired drivers and has several publications on this
topic. Dr. Marottoli, could you please give us a brief overview of the
topic from the provider\'s perspective?

**Dr. Marottoli:**

Thank you Dr. Berkowitz. What I would like to do is to provide some
background and a general summary given that we have a relatively limited
amount of time and then go into specifics later in the discussion.
Briefly summarizing, the four major issues-: First, to know what the
legal responsibilities are in your jurisdiction regarding reporting,
that is, is it voluntary or is it mandatory, for what conditions or
disorders, to whom you report, and what happens with that information;
Second, is the issue of the clinician's role. What types of things to
look for, keeping in mind that the issue we have to address is the
presence of any medical conditions or functional impairments that might
affect driving safety, not whether or not someone should drive or not
drive, not whether they are licensed or not licensed. There are a number
of activities underway to approve the tools that clinicians can use to
do that; 3) Does the condition, once it is identified, actually affect
driving performance? Do they necessarily affect their driving
capabilities? That can be determined both historically and by
observation of driving performance. We will go over some of those issues
in a minute; 4) and the last is the issue of "conflict advisement." How
do we synthesize this information, plan for interventions and help
people deal with a change in driving habits if necessary? The overall
objective is to balance the independence and autonomy with personal and
public safety while trying to maintain mobility and trying to keep the
clinician-patient relationship as positive as possible. So with that as
an overview, let me go through some of the general issues with some
background information.

This is not an issue that pertains solely to older drivers, although it
may arise more frequently among them and therefore, I will discuss that
group in detail. There are a variety of conditions and specific issues
that can affect driving ability, so it\'s not necessarily an age issue.
This is something that I hope to impress upon you. First of all, the
number of older drivers is increasing and those individuals are at
increased risk of injury or death from a crash. Whether or not crash
rates actually increase with age depends on which data you look at, and
the absolute number actually decreases although the number of crashes
per mile driven is relatively high amongst the older drivers. The
overall implications, however, are if we can avoid the crash then we can
decrease the likelihood of having injury or death. However, the flip
side, not driving also poses a major impediment to out of home mobility
in the United States and many areas. So it is not a decision to make
lightly. The other take home point is that most older drivers that we
meet are quite safe, and appear to adjust their driving habits and
patterns to match their capabilities and limitations. However, there is
a large group that doesn't. Often patients or families turn to
clinicians for advice. The other question is, how do we provide that?

The first general or overview area is to gather historical information
with the goal being to gather as much information as possible from the
patient and the family regarding the need for change or not. Does the
person drive? How often? Under what circumstances? Have they cut back or
limited their driving to different times or different scenarios or the
overall volume? Is anyone concerned about their driving, either
themselves or their family or friends? Have they had any recent crashes
or moving violations, gotten lost, or are there any new dents or
scratches on the vehicle that weren\'t there before?

The second area is in terms of medical concerns. Are there conditions or
medications that might affect the sensory or cognitive or physical
abilities necessary for safe vehicle operation? This is a bit tricky.
It\'s pretty obvious when there are severe conditions present. However,
what is often the case is that there are several conditions present that
aren\'t necessarily that severe, and it\'s difficult to sort out whether
those are indeed relevant and might affect driving safety. There are a
number of resources available, some states have them as well as the
National Medical Associations in the U.S., Canada, Britain and
Australia. Guidelines that are both disorder and functional area
specific, which can be used as a general guideline.

The third area is the issue of awareness and compensation. Is the driver
aware of the problem and are they making appropriate attempts to
compensate in terms of their exposure as well as their overall driving
practices?

And the fourth area is the effect of the condition or impairment on
driving performance per se. Again, we talked a bit about historical
information, whether they\'ve gotten into trouble with getting lost or
having crashes or violations. Observation of their driving can also play
a role; this can be done either by a concerned family member, or a
gestalt view riding with the patient if there is a need. There is also
the possibility of a professional evaluation. And again, the
availability of that varies depending upon location. In many
jurisdictions there are people available and the state will also provide
that if there aren\'t medical professionals who will do it.

The next overall area is what to do with that information. So you gather
information in terms of what the underlying issues are, were there
historical problems, were there medical issues concerned, and the
question is what do you do with that. The first step obviously is
synthesis; What does it all mean? How do we sort of put that together?
The second is to ask, "Are there interventions, either medical or in
terms of their actual driving that can allow them to either correct the
underlying problem or compensate for it, and are there other issues?
Which brings us to the third area, local resources. The first of these
is in terms of assessment, retraining and education. The second is in
terms of transportation and planning. So if it is clear that someone
will need to change their driving pattern, either cut back or stop
driving, either now or in the future, what are the alternatives
available to them and to help them identify what those resources are?
The last area of concern is the issue of state requirement in terms of
reporting. Is it mandatory or voluntary? There are potential pros and
cons to either of those approaches, but it is important to know what the
requirements are in your given jurisdiction and where that report goes.
So to summarize in terms of the number of practical issues based on what
we outlined, first is to gather as much information as possible. The
second is in discussing the problem with the patient and their family to
explain why change is needed if it is. The third is to involve concerned
family and friends. Ultimately if a change is needed, it is often the
family that will need to help implement it or enforce those decisions
and those changes, particularly in the case of someone who is not able
to necessarily monitor that or actively do it themselves. The last is to
also try and help the patient identify someone who can assist with
finding alternative transportation in the community because if a change
is recommended or required, they will need something to fill the void
that not being able to drive will present. That is pretty much the
background information that I wanted to provide.

**Dr. Berkowitz:**

Thank you Dr. Marottoli. I am sure we will hear more from you during the
discussion. But now to provide us with an ethics-based analysis of
today\'s topic, I will call upon Lea Cheyney. Lea is currently an intern
with us at the National Center for Ethics. She is an occupational
therapist and is working towards a doctorate with an emphasis on health
care ethics at Creighton University. Lea, tell us about the ethical
ramifications of reporting impaired or potentially impaired patients who
drive.

**Lea Cheyney:**

Ken, thank you for the introduction. Where Dr. Marottoli provided the
clinical perspective of physician reporting of impaired drivers, I will
offer an ethical analysis of the topic. I will structure the discussion
by identifying the relevant ethical concepts and then articulating the
ethical concerns involved in reporting. Also, it is important to keep in
mind that there are multitudes of factors that may lead to driver
impairment. Because of a vast fluctuation in ability and circumstance,
each case must be addressed independently by the health care
professional. However, even with the varying circumstances, the ethical
concepts related to reporting of impaired drivers are relatively
consistent. The concepts that help us to address the relevant ethical
dilemmas include autonomy, confidentiality, nonmaleficence and
proportionality.

The ethical concept of autonomy states that health care providers must
respect patients\' self-determination. Autonomy protects the patient\'s
right to choose and exercise independence, based on his or her desires
and values.

Another relevant ethical concept is confidentiality. The concept of
confidentiality denotes that non-authorized disclosure of medical
information is unethical. Confidentiality is fundamental to the
provider-patient relationship and if breached, may erode patient trust.
This ethical concept is not absolute. However, any disclosure of
information without consent requires significant justification.
Therefore, the decision to report impaired drivers to the appropriate
agency without patient permission must be carefully assessed against the
harms that may ensue with the release of such information. This comment
leads us to ethical concept of nonmaleficence. Nonmaleficence indicates
that above all a health care provider should do no harm. However, just
as allowing impaired driving poses a potential serious risk to both the
patient and community, revoking driving privileges can be detrimental to
the patient\'s way of life. Therefore, before reporting a physician must
ask 'am I causing more harm than good by reporting this individual to
the authorities'? Weighing the harms in order to determine if disclosure
without consent is justified directly relates to the ethical concept of
proportionality. According to this concept, a physician must balance
respect for autonomy with his or her responsibility to prevent harm to
both the patient and the community. The benefits and risks of reporting
or ultimately deciding not to report an impaired driver must be
carefully assessed.

Let me talk a little more specifically about the practical implications
of these concepts to the reporting of impaired drivers. First, the
physician must carefully assess the extent of impairment. If the
impairment is substantial and cannot be treated, one should use all
means to convince the patient to voluntarily give up driving. In fact,
efforts made by physicians to inform patients, advise them of their
options and negotiate a workable plan may in many situations render
reporting unnecessary. If a patient refuses to cease driving and the
physician feels strongly that the impairment could result in great harm,
the physician may have a duty to report. Many health care organizations
have offered guidelines on how to addresses the ethical dilemmas
involved in reporting of impaired drivers. For example, in 1997, the AMA
resolved to study physician\'s legal and ethical obligations with
respect to reporting as well as caring for patients with potentially
impaired driving. In 1998 and again in 1999, the AMA Council on Ethical
and Judicial Affairs recommended that before reporting patients to the
Dept. of Motor Vehicles, physicians should suggest additional treatment
depending on the person\'s medical condition. For example, substance
abuse treatment or even occupational therapy. If a physician\'s advice
to discontinue driving goes unheeded or the at-risk driver refuses a
driving assessment, the AMA says it is desirable and ethical for
physicians to notify the appropriate authorities. In order to address
the need to protect physicians who disclose patient information to
authorities without consent, the Association issued a subsequent report
recommending the creation of state statutes that not only promote the
best interest of the patients and the community, but also safeguard
physicians from liability. However, these safeguards do not undermine
the physician's ethical responsibility to carefully review the potential
benefits compared to risk prior to reporting an impaired driver.

Analysis of risk must include recognition of the burden to the patient.
When driving privileges are revoked, a patient may experience loss of
independence, compromised ability to work and provide for dependents,
decline in community participation, and decline in emotional and
physical well-being, just to name a few. In addition, release of patient
information without consent can lead to avoidance of needed health
services and a decline in trust between the patient and physician. If
patients are not honest with physicians about driving habits, the
physician cannot refer patients to the necessary resources or provide
adequate care. In conclusion, ethical decision making with respect to
impaired driving should be based on the facts of a specific case.
Because impaired drivers fall on a risk continuum, health care
professionals must carefully weigh the consequences of their actions
based on the proportionality of the possible outcomes. There are obvious
ethical implications for both reporting and not reporting of impaired
drivers. In these cases there is no deontological rule that supersedes
the ethical reasoning process. This will require professionals to
understand the implications of their actions and the ethical concepts
that help to guide the decision making process.

**Dr. Berkowitz:**

Thank you Lea. With the recognition that there might be medically and
ethically justifiable circumstances where providers might report without
a patient\'s consent, I\'d like to reach out to Bay Pines Florida and
call upon VHA\'s Privacy Officer, Stephanie Putt. Stephanie, could you
please briefly review VHA regulation policy and protocol in this special
area of release of medical information?

**Stephanie Putt**:

Disclosure of any patient information without consent is not only
something that must have significant justification, you also have to
have authority under applicable federal law to make such a disclosure. A
reporting to a Dept. of Motor Vehicles, etc. is no different. The
Privacy Act of 1974 does give federal agencies authority to disclose
information without the patient\'s consent to an entity that has
responsibility under law for protecting public health, whether that
would be to a public health agency or a Dept. of Motor Vehicles, etc.
The applicable policy on releasing information in this situation is
covered under VHA Manual 1, Part 1, Chapter 9 - Release of Information,
under paragraph 9.51. The Chief of Health Information Management at each
VA Medical Center is familiar with this manual. They are familiar with
the reporting requirements in terms of what must be in place in order to
report for various situations such as to the Dept. of Motor Vehicles as
well as others such as abuse. I would recommend that if you have a
situation that you have determined should be reported, that you contact
your Chief of Health Information Management (HIM) to ensure that the
appropriate letters from the Dept. of Motor Vehicles and other
requirements have been met to make that disclosure without consent. The
policy that I am speaking to only discusses disclosing the information
without the patient\'s consent. It does not address documentation
requirements for making a report, etc. I have not been able to find a
policy that outlines a provider\'s responsibility in terms of
documenting in the medical record before making a report to an
organization such as the Dept. of Motor Vehicles. However, a similar
directive does exist for reporting of abuse and neglect cases, and
certainly you can look at that directive to see what similar type of
documentation requirements are out there. And that is VHA Directive
2001-031. And that is all I have on the policy.

**MODERATED DISCUSSION**

**Dr. Berkowitz:**

Thank you very much, Stephanie. That still leaves us about 15 or 20
minutes for open discussion of today\'s topic. So feel free to introduce
yourself and let us know what you are thinking. Has anyone had a
scenario in their facility where they have considered reporting a
patient\'s driving inability to an authority?

**Gary Rolph, Manchester, NH:**

We had one instance where a patient came in obviously under the
influence and had been drinking, admitted to having been drinking, and
he was leaving to go drive a school bus. What would you do in a
situation like that?

**Dr. Marottoli:**

The only one who has authority to actively intervene is the law
enforcement, so either the VA police or the local police need to be
notified.

**Ms. Putt:**

There are policies put out by police and security service that does
address similar type situations. You can talk to your police and
security people locally on how to handle that situation. You should
certainly report to your facility's police and security, and they have
policies, directives, mandates on how to handle that with local law
enforcement.

**Fran Cecere, Syracuse, NY:**

That's a very interesting subject for me because I work with a lot of
oncology patients who are in pain and medicated and then also might be
deteriorating because of their illness. I really find that we are
probably not as proactive as we should be about determining driving
abilities, and it usually isn\'t until family members tell us of their
concerns that we even think about it. I\'m just wondering, are there any
VAs out there who have started a program to increase awareness or
educate primary care providers about this driving, and if they have,
what have they done?

**Dr. Berkowitz:**

Are there any facilities that have policies, protocols or programs that
address the reporting the impairments of drivers?

**Dr. Berkowitz:**

I think that is one of the reasons that we chose this as a topic for
today\'s hotline call. Because I have a sense from discussions with
other providers that there is sort of a void or a vacuum in how to deal
with patients such as this or situations such as this. I think one of
the dangers when there are no clear guidelines and when it is not well
thought out in advance, is that things don\'t play out in a fair,
consistent and just manner.

**John Ciak, Pittsburgh VA:**

I work in the Eye Clinic and we see a lot of impaired drivers because
they fail to meet the visual standard. Our interpretation is that in
Pennsylvania the state law requires reporting of this without consent. I
guess my question is directed to Ms. Putt, from Bay Pines: is that
correct that if the particular state law requires reporting that the
signed release is not required?

**Ms. Putt:**

That is not necessarily correct. The states ordinarily do not compel a
VA facility or its employees to comply with state law. But, as a matter
of policy VHA and the Under Secretary have said they would like medical
centers and outpatient clinics to comply with state laws in reporting
various state reporting requirements such as abuse, neglect, some of the
motor vehicle, gunshot wounds, etc. In order to comply with that state
reporting, you must meet the requirements of the Privacy Act, which is
in the policy that I provided, Chapter 9, which requires you to have a
standing letter signed by the head of the agency who has authority for
that reporting requirement. So for your state, it would need to be
signed by the head of the state Dept. of Motor Vehicles requesting your
VA facility to make those reporting disclosures. You cannot make the
disclosure without legal authority under the law and in compliance with
the policy. It requires what is called a \"standing letter.\" And as I
said, your Chief of HIM is normally the person responsible in a facility
for these standard letters for ensuring that there is compliance with
the Privacy Act and other applicable privacy laws in terms of disclosure
authority. And that is really who you should talk to before you make a
disclosure or want to report a situation to ensure that all of those
measures are in place.

**Dr. Berkowitz:**

And John, I don\'t think that it will be a big surprise if you approach
a Chief of HIM or a local information security officer. I think this is
something they are well aware of. I am not sure it is a daunting as it
sounds.

**Shelly Leister, Columbus, OH:**

Stephanie and panel, for the last 6-7 years we have approached our State
Bureau of Motor Vehicles to provide a standing letter, and we have been
refused. We currently have a request that we are working with our
Regional Counsel to provide a standing letter. Having said this is not a
daunting task, this has been a daunting task for us for almost seven
years. I don\'t know how the current request will come out, and I can
certainly let you know if you want to know. Is there anyone else, or
Stephanie, I am assuming then we cannot get this standing request? We
are kind of in a bind.

**Ms. Putt:**

If I am understanding you correctly, it is the state that is not wanting
to give you a standing letter?

**Ms. Leister:**

That is correct.

**Ms. Putt:**

And you are correct. If the state refuses to give us a standing letter
in order to report to them in accordance with their own state reporting
requirement, there\'s not much we can do. Normally most state agencies,
because they want that information, are willing to give a standing
letter. Most states want to know who came in with a gun shot wound, what
are the abuse cases, who were the people who are legally blind and
should not be having a drivers license. Most states want that
information, and are willing to provide the letter requesting it. I am
very surprised that you have a state agency that doesn't want to do
that.

**Ms. Leister:**

We do have them from a couple of the other agencies, with no problem
whatsoever. A few years back I had an e-mail with the reason why, and I
haven\'t been able to locate that, and if I do, I will send it to you.
And like I say, we have Regional Counsel involved and are waiting for
the outcome on this most current request. If you want to follow upon
that we can provide you with that too, because it is very frustrating.
Our providers are very concerned about liability.

**Ms. Putt:**

Correct. I would be very interested. But as I said, the issue for you is
that the state is refusing to cooperate.

**Ms. Leister:**

That is correct.

**Ms. Putt:**

That\'s somewhat peculiar. It is possible that the state that you are in
doesn\'t require any reporting to the Dept. of Motor Vehicles, and
therefore, they do not want the information.

**Ms. Leister:**

No, it does.

**Ms. Putt:**

I\'m very surprised, that if they do require reporting that they do not
want you to participate.

**Jeff Corzatt, General Counsel\'s Office, Washington:**

First of all, the Regional Counsel\'s Office in Cleveland, which is the
one I assume you are working with, is very knowledgeable in the
information law area, and I\'m glad to hear that they are involved
because that was going to be my advice. If you go to the HIM person, and
further questions develop, please remember that you have a network of VA
attorneys around the country who can provide assistance just as the
Cleveland\'s Regional Counsel\'s office is doing. Now I suspect that
there may be some reluctance on the part of Ohio simple because they are
used to dealing with state entities that they can compel to do things
and they are having a little trouble dealing with a federal entity. But
I found that once you get over that hurdle, and it takes longer in some
states than others, and you start getting it done, the letter has to be
renewed periodically, but at that point it becomes automatic. It\'s like
any good bureaucracy, once it has a provision in place on what to do, it
follows through. Some just have a philosophical difference. I don\'t
know if you can work those out, but you just have to slog through the
best you can. And, as Stephanie said, sometimes it helps to point out
that we want to try to help. If you go on the record and say we really
want to help you and we really want to do this, and all you have to do
to get us to do this, is sign this letter. Then at that point it shifts
the burden back to them, and if something happens, the VA simply says,
look, federal law required this, we were willing to do this and the
state didn\'t do it. The egg is going to be on their face.

**Ms. Leister:**

Thanks. Our HIMS counsel is working with Regional Counsel, and I will
give them a plug. We do have a great Regional Counsel in Cleveland. They
are always very helpful. Thank you.

**Dr. Berkowitz:**

Thank you Ms. Leister. If you have any information related to this could
you also e-mail it to us at VHAETHICS on the Outlook system?

**Ms. Leister:**

Sure.

**Dr. Berkowitz:**

Thank you.

**Dr. Linda Williams, Little Rock, Arkansas:**

I am chair of our Ethics Committee here, and for some time now we have
had our committee working on the issue of compromised drivers. What
happened here is that we had a number of providers come to us and ask
for advice on what they should do when the families ask them to do
something about their compromised loved one who is our patient. And we
got into the conflict between patient confidentiality and the decision
to report. One of our big fears was that our patients, if we started
reporting this, then they would stop seeking medical care and we felt
that we really did not want to deprive them of needed medical care. What
we are working on now is the development of a brochure of information
that we can distribute to our providers that will teach them what they
can do and what they should do and what they should not do in this
situation. We would be interested in any help that anyone could give us
on this.

**Dr. William Nelson, National Center for Ethics:**

I think that sounds like a very interesting idea, and it might be useful
if you would be willing to share that with other sites. They may be
intrigued with that idea because the woman who spoke earlier about
working with oncology patients was seeking protocols or ways of being
able to develop assessment processes. So it seems like having a brochure
or pamphlet like that might be a really good step in terms of nurturing
or educating health care providers on what to be aware of. If you could
share that with the Ethics Center, that would be great.

**Dr. Williams:**

Actually the cases that we have had, questions about having those with
visual impairment, those considerations of driving under the influence
of either alcohol or opioids for the cancer and the different problems.
Also primarily the ones that we deal with are the dementias because of
my role in geriatrics. So I guess we will be happy to share what we have
with the National Center. We are still developing it. I guess my
question, since the different states have so many varied, legal
responsibilities, etc., would there not be some type of national
template that could be developed that would be modifiable for each
different state organization?

**Dr. Michael Cantor, National Center for Ethics:**

I think that it would be a good idea to develop some sort of national
view. I\'m not sure we need a policy or directive necessarily, but some
sort of national guidance or guidelines that could be adapted for local
circumstances and local state laws and regulations. I think, however,
there is a bigger ethical question which we need to really consider very
carefully. That is independent of state rules, regulations and laws,
what is the responsibility of the physician as a professional to the
patient? You just mentioned that you were worried that patients would
stop coming if they felt that their confidentiality was going to be
breached. I think another way of looking at it is to ask, is it the role
of the professional to become an arm of the state identifying impaired
drivers and reporting them to state agencies? There are other ways to
address problem or impaired drivers without necessarily going through
the process of reporting them to a state agency, and I think I would ask
Dr. Marottoli to comment on this. I think it is very hard for
physicians, I am a geriatrician as well, and I think it is really
difficult to look at a patient in my clinic who has some functional
impairment, maybe walks with a cane, had cataract surgery and now in one
eye the vision is good and the other eye is still not so good, and then
sort of figure out functionally what this person can do, and then
secondarily, if I know that, what are my responsibilities as a physician
in terms of trying to manage those impairments and if it can\'t be
managed, to figure out how to get the change in driving pattern. I
don\'t think there is a simple test or assessment that we can do to
determine the level of someone\'s skill as a driver and then I really
wonder, given that uncertainty, how confident we can be reporting to
state agencies that could then suspend or revoke someone\'s license.

**Dr. Berkowitz:**

Dr. Marottoli, I know you\'ve done a lot of work on clinical assessment,
which really has to be objective for the system to be fair. Any comments
on Mike\'s points?

**Dr. Marottoli:**

I think there is certainly that element to it. Part of the difficulty is
that there is so much variability, and you can\'t find one very quick
and easy thing that will really cover everything and all the range of
possible impairments and conditions that could potentially affect one\'s
driving ability. The initial area, more in terms of getting a sense of
who you need to be more concerned about rather than less concerned
about, and then trying to sort of piece backwards. I think reporting as
it has come up before, is more of the end stage issue once the concern
is raised and once you have exhausted the other options. I think
focusing on visual acuity which are obvious standards, but that is not
the end all and be all; cognitive impairment yields particular
difficulties, and whether those translate into actual difficulties on
the road can be hard to determine. That may require having someone
actually look at his or her driving performance.

**Ms. Cecere:**

I just wanted to comment that sometimes we don\'t even have to report to
the motor vehicle bureau. Sometimes all we need to do is talk with the
family, and they take the keys away or they take the access to the car
away, and that can be just as good as reporting to the Dept. of Motor
Vehicles.

**Dr. Berkowitz:**

I think to briefly summarize some of the points that have been made are
to break the decision making down into two phases. One is
**justification** and the other is **authority** as Stephanie so nicely
put it. Under the justification, that requires a clear and objective
clinical assessment and an evaluation of the risks and benefits both for
the patient, the patient-provider relationship and the impact on society
in general. And then once you have your justification and your decision
there, if you can\'t in fact change the patient\'s behavior through
education, attempts at behavior modification, counseling, and advisement
of the patient, then you move into your consideration of what authority
you have. One thing we didn\'t get to touch on today was the special
authority requirements which would be added for patients in specially
protected categories such as patients with HIV, substance abuse, sickle
cell disease. And that again is covered in the Manual, Chapter M1, Part
1, Chapter 9. So we will refer you to that. And as usual, we didn\'t
expect to conclude this discussion in the time allotted. Unfortunately
we have reached the end of time for this part of today\'s discussion. We
do make provisions to continue today\'s discussion in an electronic form
on our WebBoard which can be accessed through the VA National Center for
Ethics Website and we also post on our Website a very detailed summary
of this and each Ethics Hotline Call. So please visit our Website to
review or continue today\'s discussion and I will be sending a follow-up
e-mail for this call which will include the links to the appropriate Web
addresses for the call summary and the WebBoard discussion. We will also
send references for the policies that were mentioned, the regulations
that Stephanie referred to and some of Dr. Marottoli\'s articles. One of
the goals of this series of Hotline Calls is to facilitate networking
among ethics-related VA staff and to facilitate communication between
the field and the National Center for Ethics.

**FROM THE FIELD**

**Dr. Berkowitz:**

We reserve the last few minutes of each call for our From the Field
Section. This is your opportunity to speak up and let us know what is on
your mind about other ethics-related topics. A chance to ask a quick
question, make suggestions, throw out ideas or ask for opinions. Please,
no consultation requests in this conference call format, but From the
Field now, anything that is on anyone\'s mind?

**John Antoine, Dallas:**

I have a question that is a quickie. I take everything we have discussed
this morning pertains also to private pilots?

**Dr. Berkowitz:**

I think that the same ethical analysis would apply, and I think the same
authority, correct me if I am wrong Stephanie, covers release to other
agencies other than Motor Vehicles.

**Ms. Putt:**

Correct. Other state agencies who have authority under the law for
protecting public health, so I would presume that would also apply to a
state aviation association.

**Dr. Berkowitz:**

Or a federal such as the FAA.

**Ms. Putt:**

Correct.

**Dr. Williams:**

I have a question that I would like to raise for possibly a future
discussion. I was trying to find out information about ethics in
disasters and found very little written about that. Would you comment on
anything you know about this topic?

**Dr. Berkowitz:**

That\'s a broad topic. Off the top of my head I am not aware of anyone
who has particular expertise in this that is on the line right now. But
I appreciate that as suggestion for future hotline calls or future
consideration. Any more specifics on what you had in mind?

**Dr. Williams:**

Well, I have become somewhat involved in some disaster planning and was
just considering different scenarios that could possibly arise. Since I
have had a long-standing interest in ethics, I started asking some
questions and couldn\'t find any information on it in the literature. So
that is why I was curious about it.

**Dr. Berkowitz:**

Okay. What I will do, we will toss it over here at the Center and we
will get back to you and tease it out further.

**Dr. Williams:**

Thank you.

**Dr. Berkowitz:**

Anything else on anyone\'s mind or does anyone want to continue the
discussion on the impaired driver reporting.

**Anna, Omaha VA:**

I just had a question or comment. The discussion was very interesting
today, but one group of patients that I did not hear mentioned was
diabetic patients: a lot of them have low blood sugar reactions. So we
run into a similar problem as far as reporting because of their impaired
driving when they have such low sugars. They can have blackouts and
such. So that was one group of patients that I don\'t know has been
discussed before. But that I didn\'t hear mentioned.

**Dr. Berkowitz:**

I think that falls into the category of people with medical conditions
that cause intermittent impairment. And that might be people with
cardiac arrhythmias, people with low blood sugar, people with epilepsy
or seizure disorder, and there is clearly a large category of patients
who fall into that consideration. Other things we didn\'t talk about but
touched on were patients with dementia, sleep apnea, other neurologic
disease such as deficits after stroke or Parkinson\'s disease, as well
as others that we did discuss. So I think the scope of the impairment is
really vast. The analysis, however, might be similar and hopefully in
order to be ethically sound would have to be applied consistently to all
patients that had an objective assessment of similar increased risk of
driving impairment. I think that is an ethical imperative here.

**Dr. Marotolli:**

It\'s also based in part with diabetes and other intermittent issues on
the history of whether they have had problems with hypoglycemia before,
or loss of consciousness, so that if they haven\'t any episodes and
they\'ve gone a period of time without any episodes, it would be
different. But with someone who has repeatedly had difficulty.

**Mr. Corzatt:**

I have a question as to the ethical balance. And I don\'t know, I\'m
just asking whether it is a factor and how it would play out. I\'ve been
involved in several cases where the question has come up in which the
patient is a school bus driver. That\'s pretty common in a lot of rural
areas where you can make some extra spending money and stuff like that.
Does the fact that the person has an intermittent problem, but where
they may be responsible for other people\'s lives, as in the school bus
driver change the ethics involved?

**Dr. Berkowitz:**

I think that under the concept of proportionality that we had discussed
that certainly changes the proportion of the risks that someone is
putting others at when they engage in this type of behavior. I find it
hard to think that is not a consideration.

**Mr. Corzatt:**

There\'s also in general much stricter rules for commercial operators
and there are some federal standards depending on the nature of the
operator, in addition to state and local standards. So it is different
than in private vehicle operation.

**Dr. Berkowitz:**

I would like to thank everyone who has worked hard on the conception,
planning and implementation of this call. It is not a trivial task, and
I appreciate everyone\'s efforts, especially Rich, Lea, Anthony, and
Bill Nelson and Barbara Chanko for their help in setting up this call.
The next call will be Wednesday, March 27 from 1:00 to 1:50 Eastern
Time. Look to the Website and in Outlook e-mail for details and
announcements. You should be getting a follow-up e-mail for this call in
about a week with the e-mail addresses and links to access our Web site,
the summary of the call, the web board and the references. If you don\'t
get it, please send us an e-mail at <vhaethics@med.va.gov>, and please
let us know if you or someone you know should be receiving the
announcements for these calls, that didn\'t or if you have suggestions
for topics for future calls.