Unsafe at Any Speed?

Driving privileges of people with hepatic encephalopathy (HE) should be restricted until they demonstrate that they are safe on the road, according to Stanley Martin Cohen et al. in the February issue of Clinical Gastroenterology and Hepatology. Because there are few laws about which patients with HE or other mental disabilities can drive, physicians might bear the responsibility of identifying hazardous drivers.

HE causes neuropsychiatric abnormalities in 30%–80% of patients with cirrhosis or other liver dysfunctions. Drivers with HE are involved in a greater number of traffic violations and motor vehicle accidents—even minimal HE can impair driving skills, as 44%–60% of patients with subclinical HE are deemed unfit to drive. However, there are no published, standardized recommendations about whether or when physicians must refer potentially unsafe drivers to motor vehicle authorities.

“In the absence of these statutes and laws, we were concerned that physicians and patients could be at risk for legal ramifications of accidents that occur,” explains Cohen in a video abstract that accompanies the article:

Cohen et al. examined each state’s motor vehicle code laws and requirements for reporting potentially impaired patients with HE. They also investigated whether there were any lawsuits filed against physicians for motor vehicle accidents that involved HE patients, or against the diagnosed patients themselves.

They found significant differences among states regarding ‘medically impaired drivers.’ None of the states’ motor vehicle codes specifically mentioned HE or referred to impairments from advanced liver diseases, although they did mention some neurologic disorders. There were also significant differences among states about whether physicians should report medically impaired drivers. Only 6 states had mandatory reporting laws, and 35 states permitted reporting. Thirty-one states provided legal immunity to physicians who reported potentially dangerous drivers to the motor vehicle department. However, the laws varied on whether physicians could be held liable if they did not report the patient and a motor vehicle accident subsequently occurred.

Cohen et al. found that no lawsuits had been filed against physicians for failure to warn against driving or diagnosing HE that subsequently resulted in a motor vehicle accident; nor were there any lawsuits against patients with HE for causing auto accidents.

Physicians are placed in the difficult situation of protecting an individual patient’s right to privacy vs. the right of safety for society. Cohen et al. state that the medical community needs to balance liability of reporting a patient (disclosing confidential information) against that of not reporting a patient (allowing a dangerous driver on the roads). They propose restricting the driving privileges of patients with any degree of HE—this might decrease motor vehicle accidents and traffic violations, and also be cost effective, because cirrhotic patients have a higher risk for poor outcomes after a motor vehicle crash. However, physicians are not specifically trained to evaluate driving competency— the physician’s role is to identify and report such patients to the proper government agency for further driving evaluation.

Read the article online. This article has accompanying CME.
Cohen SM, Kim A, Metropulos M, et al. Legal ramifications for physicians of patients who drive with hepatic encephalopathy. Clin Gastroenterol and Hepatol 2011;9:156–160.

Read the accompanying editorial:
Bajaj JS, Stein AC, Dubinsky RM. What is driving the legal interest in hepatic encephalopathy? Clin Gastroenterol and Hepatol 2011;9:97–98.

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