“A Lebanon County man admitted that he drank a 6-pack a day. A Pa. law required PennDot to be alerted.” (Philadelphia Inquirer )This article is doing the weblog rounds as a heinous example of Big Brother coming to the doctor’s office. I beg to differ, and I am surprised that people so uncritically have that take on the issue.
Driving under the influence is a heinous offense placing the innocent public at large at enormous risk, as any number of tragic incidents should remind us. Anyone who tells you that someone who drinks 6-10 beers a day can be trusted when they assure you that they can safely avoid driving under the influence is whistling in the dark. “I’m just a regular Joe six-pack,” the article quotes this hapless Joe as saying, and then goes on to opine that a man so large can be trusted to keep his blood alcohol level within legal limits by pacing his drinking. (The rule of thumb we are taught in our medical training is that an accurate estimate of a patient’s drinking is around twice what they admit to.) This is nothing so much as colluding in the minimization and denial that accompanies heavy drinking, a world in which, if you listen to the drinkers, no one is an alcoholic or in any way impaired by their drinking.
The problem in this case is that doctors and other professionals allow a naive notion of confidentiality to reign unchallenged in the eyes of the lay public. Preserving confidentiality always take a back seat to averting an imminent harm, but doctors entering into a treatment relationship with a new patient rarely go into the nuances of the limits and exceptions to doctor-patient privilege as they should. The problem, of course, is the fear that an accurate description of the situations in which a doctor will violate her patient’s confidence will have a chilling effect on patient honesty. So what is most common, instead, is a blanket assurance that anything said in the office will remain confidential. <
While the article takes pains to inform us that only six states have laws requiring doctors to report unfit drivers to the motor vehicle authorities, the ethical and public health burden lies no less heavily on the physicians in the other forty-four states, IMHO. To complain that including alcohol abuse as a reportable offense without adequately defining what constitutes abuse is unfair ignores the fact that this achieves precisely what it should — to allow a doctor to exercise her professional judgment on whether an impairment ensues from her patient’s pattern of use. This, I think, is far preferable to codifying inflexible criteria in nonnegotiable laws. It is pitiful to hear the psychiatrist and medical ethicist quoted in the article complain that the judgment of the individual physician opens the way to arbitrariness and relativity. It is a sorry reflection on the state of modern medicine that the call for standards is really the stalking horse for a phobic avoidance of relying on one’s own professional judgment. In this vein, those whose license is revoked can, in Pennsylvania and elsewhere, get their license back on a doctor’s say-so that they are safe to drive. The sobering (forgive me) effect of a wrongful death lawsuit if a physician restores a license to someone who later commits vehicular homicide while drunk will surely be a more effective hedge against the physician taking her obligation frivolously than many other incentives!
The other apparent failing of the physician in this case was in doing the mandatory reporting and springing the license revocation on the patient as a surprise. When I am faced with a competing harm-avoidance need that supersedes the confidentiality right of a patient of mine, the first thing to do is to talk about it with my patient, not the last! This goes a long way toward avoiding the potential sense of betrayal, enhancing the patient’s insight about the risk they are presenting and may well have been denying. Equally important, one encourages the patient to take preventive action themselves — installing a breathalyzer ignition interlock or cutting down significantly on one’s alcohol are both discussed in this article — and maintain their control and dignity, rather than making it a matter of law enforcement at all.
The situation in which violating a patient’s confidence comes up most often for me is not reporting a patient as a potentially unsafe driver but the so-called Tarasoff duty — to warn a prospective victim or take other appropriate harm-avoidance measures if I have learned in confidence that a patient of mine intends to do harm to a specific other individual. But in discussing my considering doing so, the patient will often choose to preempt my plan and take measures themselves to diffuse the risk, certainly a far more therapeutic outcome.
The article’s conclusion is further confused, suggesting that the incident led the man to cut down on his alcohol abuse “not just to get (his) license back” but for his health. While this may have been a by-product of the situation described, I hope the reporter who wrote this story is not suggesting that the benefits to the man’s health justified the means. The end that justifies the means here is the enhancement of public health and safety, not that of the individual.