Should healthcare professionals breach confidentiality when a patient is unfit to drive?BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1505 (Published 31 March 2017) Cite this as: BMJ 2017;356:j1505
Poppy-Arabella was 3 years old. On 6 July 2016 she and her mother were on their way to nursery. As they crossed a road at a red traffic light, a car approached. It did not slow down or swerve, and it struck them both in the middle of the crossing. Poppy-Arabella was killed; her mother, seriously injured.
The driver, John Place, was 72. He had poor eyesight and did not see the red light, the crossing, or the pedestrians.
Three weeks earlier, two optometrists had told Place to stop driving. He pleaded guilty to causing death by dangerous driving and was sentenced to four years in prison. This case raises the familiar question about medical secrecy: should healthcare professionals breach confidentiality when a patient is unfit to drive?
The General Medical Council (GMC) has guidance on reporting concerns to the Driver and Vehicle Licensing Agency (DVLA).1 Doctors should explain to patients deemed unfit to drive that their condition may affect their ability to drive and that they—the patients—have a legal obligation to inform the DVLA about their condition.
If the patient continues to drive, the GMC advises that “you should make every reasonable effort to persuade them to stop.” If persuasion fails or the doctor discovers that the patient is continuing to drive, the doctor should contact the DVLA to disclose the medical information.
The trouble with this approach is that it relies on patients’ honesty. As far back as Hippocratic times, doctors were instructed to look out for the lies of patients.2 Two and a half thousand years later the advice still holds true. In a 1994 study on 754 adult patients, Burgoon and colleagues found that 85% admitted to concealing information from their doctors, and over a third said that they had lied outright.3 Many patients will lie to avoid the loss of their driving licence. They will falsely promise to inform the DVLA and to stop driving. And the chances of the doctor discovering that the patient is continuing to drive are slim.
To rely on the assurances of patients, knowing that they lie to please others and to get out of trouble, is naive and irresponsible
Motor vehicles are lethal objects. They maim and kill innocent people just as efficiently as infectious diseases or terrorist attacks. Yet doctors in the public interest are required by law to report patients who have certain infectious diseases or who may commit terrorist acts—but not patients who may cause serious harm through their unfitness to drive.
Logic calls for the law of disclosure to extend to patients deemed unfit to drive or fly. The GMC, whose new guidance on confidentiality comes into effect on 25 April 2017, should consider making disclosure to the DVLA mandatory, even if the patient confirms that this has been or will be done. To rely on the assurances of patients, in the knowledge that they—like most of us—lie to please others and to get out of trouble, is naive and irresponsible. It can also cost lives.
Poppy-Arabella’s parents are calling for this strict disclosure policy to become law. Such a policy may dissuade patients from disclosing information that they would otherwise reveal if secrecy was guaranteed. Yet secrecy is not guaranteed at present: it can be breached if the patient refuses to discharge his or her legal obligation to inform the DVLA or if the doctor discovers that the patient is still driving. The difference is that doctors would no longer rely on the unverified promises of the patient. They would automatically tell the DVLA that the patient is unfit to drive.
This new law would not erode doctor-patient confidentiality. It offers a solution to the reluctance of impaired drivers to appreciate the danger they pose to others, as well as the recognition that some patients will deceive to continue driving.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.