Driving to distraction — certification of fitness to drive with epilepsy

Several fatal seizure-related motor vehicle accidents have highlighted the roles and responsibilities of patients with medical conditions that may influence driving safety, their treating doctors, and driver licensing authorities (DLAs).1-7 Here, we focus on epilepsy, but the same issues are relevant to many medical conditions that affect fitness to drive.

DLAs have the legal responsibility to determine eligibility to drive, and the treating doctor’s role is to provide relevant medical information. Although DLAs claim that they decide on a patient’s medical fitness to drive, it is a responsibility that is, in practice, shifted to the treating doctor.8 Drivers with some medical conditions are asked by the DLA to consult their doctor, who is issued with a set of guidelines that he or she applies when certifying a patient as fit or unfit to drive. This system is fraught with problems.

The shift of responsibility to the treating doctor creates a conflict of interest. The doctor is acting as an agent of the DLA and may be the only person standing between the patient and their drivers licence. The doctor needs to establish and maintain a trusting relationship with the patient to encourage the patient to follow their advice on treatment, accept possible side effects of treatment and provide accurate information on their progress. The patient often expects that the doctor will be their advocate against a bureaucracy that removes one of their basic rights and sometimes their livelihood. Decisions regarding driving will influence, and will be influenced by, doctor–patient relationships. Some doctors feel under pressure from their patients to make “favourable” decisions (E R S, A B B and J W D, unpublished observations). Some patients develop the perception that their treating doctor has deprived them of their livelihood or imposed hardship when their drivers licence is suspended. They can react by blaming the doctor, not following medical advice or making threats.8

DLAs suggest that this can be solved by referring the patient for a driving assessment or to a specialist.8 However, a driving assessment is not helpful in conditions such as epilepsy, where the impairment is intermittent, and referral to a specialist passes the responsibility from one doctor to another. DLAs offer no advice on how a specialist should proceed when fitness is uncertain. Medical report forms provided by DLAs do not include the option to refer the decision to the DLA.8 Some DLAs suggest to patients that the doctor is responsible for certifying their fitness. For example, some patients who have been reported as unfit to a DLA by a neurologist have been advised by the DLA that their licence is suspended but that it will be reinstated on receipt of a satisfactory report from a neurologist (E R S, unpublished observation). Some of these patients have then seen another neurologist and supplied a different history to regain their licence. Information held by the reporting neurologist and by the DLA is not made available to the new neurologist, who may have no reason to doubt the accuracy of the information provided by the patient.

Neurologists have become acutely aware of a further complication of certification by the treating doctor: their vulnerability to civil and criminal proceedings when injury or death arises from a seizure at the wheel experienced by a patient whom they have certified as fit to drive. In May 2002, a man with a history of epilepsy had a seizure while driving a bus on a country road, colliding with a tree. He and three of his passengers died. The coroner suspended the inquest, concluding that “the admissible evidence is capable of satisfying a jury beyond reasonable doubt that a known person has committed an indictable offence... There is a reasonable prospect that a jury properly instructed would convict that person” and referred the case to the New South Wales Director of Public Prosecutions.7 A NSW coronial inquest into the deaths of Gregory Arthur Petrie, Caroline Page, Barbara Alice Crouch and Kelvin John Fearn was started by coroner Tony Murray but suspended in 2006. The “known person” was the driver’s neurologist. The Director of Public Prosecutions declined to charge the doctor.

A poll of members of the Australian and New Zealand Association of Neurologists (ANZAN) in December 2006 revealed a high level of dissatisfaction among neurologists with the current system of certification (Box).9 As a result, ANZAN recommended that its members continue to certify driving fitness for patients with epilepsy only where fitness or otherwise is beyond doubt, and to refer other cases to the DLA, providing sufficient clinical information for an appropriately qualified person to determine fitness.9 This led to dialogue between the Epilepsy Society of Australia (ESA) and the National Transport Commission (NTC) and then with the Austroads Registration and Licensing Taskforce, which represents all driver licensing jurisdictions in Australia. In September 2007, the Taskforce accepted a recommendation from the NTC that “all medical reminder forms/letters will be revised to stipulate that responsibility for determining a person’s fitness to drive rests with the driver licensing agency”. (David Stuart-Watt, Program Manager, Registration and Licensing Program, Austroads, personal communication, October 2007). To our knowledge, this has not been implemented. At the same meeting, the Taskforce accepted, in principle, a proposal by the ESA and the ANZAN that certification be performed by the DLA, using relevant information provided by the treating doctor, rather than relying on the treating doctor’s opinion.

Driving by people with epilepsy is a serious, complex and sensitive issue. When handled inappropriately, it can damage the doctor–patient relationship, hamper effective treatment, lead to the suppression of information and ultimately result in injury or death of the patient or other road users.

Responses of Australian neurologists in a poll on their preferred course of action regarding certification of fitness to drive, November 2006