Are you fit to drive?

Doctors are required to report patients with conditions that would make driving dangerous, but it's not that simple.

car crash police 298.88 (photo credit: Channel 10)
car crash police 298.88
(photo credit: Channel 10)
All of Israel's physicians are caught between an unimplementable 1961 law requiring them to report patients who they feel are unsuited for driving and the possibility that if such drivers keep their license, they will kill someone. Many doctors are unaware of their legal obligations, but those who were informed are confused about the law and a 1998 Health Ministry director-general's explanation that makes it even more complicated. Among the dozens of conditions that - according to the ministry - require a report to its National Center for Road Safety (NCRS) - is kleptomania (the urge to steal) and pyromania (the urge to set fires), which are hardly relevant to driving. Prof. Avinoam Reches, a senior neurologist at Hadassah University Medical Center in Jerusalem's Ein Kerem and head of the Israel Medical Association's Ethics Bureau, initiated an open discussion of the subject last week at the Mishkenot Sha'ananim Adenauer Conference Center. Scores of people attended, despite the pre-Pessah timing of the conference, which was organized by the Jerusalem Ethics Center and Or Yarok, the voluntary organization that fights road accidents. ON THE BASIS of what was said, Reches said he will ask the Health and Transport Ministries to set up a committee of experts to recommend how to reform the law. Everyone in the audience, which included physicians and activists against road accidents, seemed to approve. Daniel Milo, chairman of the ethics center, presented the core problem. Suppose a 76-year-old man with a number of serious health problems is asked to go to a doctor for an authorization that his health remains good enough to drive. Worrying that he will be rejected, he sets an appointment with a private doctor who doesn't have his medical history. He avoids telling the doctor the whole truth about his medical condition so the physician will not report him to the NCRS. A driving license is vital to the old man, whose wife is disabled and has to be driven around, and for his own sense of independence. If he had gone to his health fund doctor, whom he has known for decades, the physician would be reluctant to report a patient who is a personal friend. Reches disclosed a traumatic experience he himself had several years ago. "I was in an elevator and saw a person I knew by face but not by name. I said hello, but he didn't reply. I thought he had a hearing problem and said hello again. He didn't answer. Then I asked him why he was not reacting and he said: 'Because you killed my daughter. You gave a clean bill of health to an epilepsy patient who later ran over and killed my daughter.' "I rushed to my office to find the relevant documents. In fact, I had written a letter for the NCRS giving the patient's condition and my recommendations, but had left it to the NCRS to decide." Reches said he sometimes writes letters to the NCRS describing the clinical condition of a patient and recommending that he be given a driving license, "and sometimes I give a negative recommendation, especially if the patient drives as a professional." But, Reches added, whether to grant a license or not is the responsibility of the NCRS authorities." "The existing law is a dead letter. Doctors do not observe it...," said Reches. "There is no evidence that if we took the license away from all drivers with one of the conditions on the lists that accidents would stop. The law requires doctors to tell their patients that they are about to inform the NCRS. It could lead to violence. And if a patient has an early stage of Alzheimer's or Parkinson's? How do we protect doctors?" COMMANDER AVI BEN-HAMU, head of the Traffic Branch of the Israel Police, admitted that the 1961 law and the Health Ministry regulations "are not good enough. There is no scientific list of conditions and drugs that are clearly dangerous. It would be hard to defend the law in court, so we need a new one." But he added that something had to be done. Since 1948, more than 30,208 Israelis have been killed on the road; many fewer died in wars and from terror. "I have an elderly neighbor who is a Holocaust survivor. His car has more dents in it every week. I advised him to give up his car. It wasn't easy, but he finally decided to sell it." He added that drunkenness, which was rare for most of Israel's history, is now commonly a cause of accidents. "Drinking affects driving like certain medications," Ben-Hamu continued. "Even drugs for hay fever or a cold can affect driving. We need a balance between the right to drive and the right to live. A decision must be made. One day, there will be lawsuits against doctors who didn't report drivers who are a danger." UZI YITZHAKI, the Transport Ministry's deputy director-general in charge of traffic and licensing, said licensing authorities "have the right to give a license" to an individual if he is able to drive. "It is not an automatic right. We can also take the license away. Today, license suspension is based on how many points they have. Thirty-six mean it's suspended for three months. Tens of thousands of people have gone through it, and they have to pass a test to get it back. There are wild drivers who have lost their licenses even for 20 years." After a particularly tragic case in which a truck driver who had dozens of moving violations killed a father and daughter on Highway 1, the authorities looked for those 130 other drivers who had a very high number of moving violations. They found only 80, as the rest lived in unrecognized places in the Negev and elsewhere. Those who were located were invited to a hearing, and some were kept off the road (or, at least, lost their licenses) for up to three years. Chronic violators "themselves don't know they are ticking bombs. They themselves don't know what they have done on the road," Yitzhaki continued. There are 120,000 new drivers a year. If they drive a public vehicle, they are obliged to undergo an eye test at 50. "There have been many phoney doctors, who are not eye doctors as they claimed, or not doctors at all." Ordinary drivers have to pass a test every two years from the age of 65. A bill is due to be voted on in the new Knesset requiring such a test for all from the age of 40, said Yitzhaki, who noted that the risk of an accident is nine percent higher when the driver has a vision problem. In the United Kingdom, the demands are even more liberal. Eye examinations are required only above the age of 70. Although there must be hundreds of thousands of drivers whose conditions are covered by the medical conditions for reporting to the NCRS, only 3,000 are reported each year, he said. "If everybody is so healthy," he quipped, "all the country's hospitals and health fund clinics should be empty. There is a terrible violation. Doctors are thus criminals. We have to deal with it." Yitzhaki said he recently received a letter from a hospital emergency-room nurse begging the authorities to cancel the license of her father-in-law, who is demented, sometimes drinks "and can't even remember where he parked his car. We checked the records. His family doctor had approved his license renewal." The ministry official conceded that only a fifth of fatal road accidents are investigated in depth. There is counterfeiting of documents, especially when driving is a profession. And Israeli drivers are living longer and getting older. There is a serious shortage of 3,000 truck and bus drivers, who endure poor wages and low status. There are even proposals to import drivers from Rumania and Turkey. He added that there are many young physicians who don't even know they are required to report dangerous conditions. Health Ministry associate director-general Dr. Boaz Lev said all factors involved have conflicts of interest. "Few doctors even report infectious diseases, even though this is required. So reporting on patients about driving is even rarer. I won't say the law is a 'dead letter' but it is a dying one. Maybe responsibility should lie at another address." Lev suggested that doctors should first patiently explain to patients unsuited to driving. "He will then understand himself and voluntarily give it up," he said, continuing that computerized simulators could also be used. Whether a driver with a certain condition can drive safely is individual, Lev said. "We don't know even how many accidents are due to this factor or that. It is almost hopeless to enforce the existing law, though the highways are like the Wild West even without limitations caused by disease. Regulations have to be based on proven data." BUT NCRS director Prof. Joseph Ribak was less critical of the law. "We put the criteria for doctors' decisions onto the Internet. It is there for all to see. I have been in this job for two years, and during that time we adopted the relatively rigorous Canadian law, which sets down clear criteria. As for the claim that doctors don't learn the subject in medical school, there are many things not learned in medical school." Regarding the argument that reporting violates privacy and the doctor-patient relationship, Ribak insisted that "everywhere you go and whatever you do, you are exposed to camera and other invasions. Anyone who has evidence has to report suspected child abuse. Doctors could tell the health funds if patients are not suited for driving, just as they have to fill out reports on how many patients have high cholesterol or unbalanced diabetes. And as health factors are rarely investigated after fatal accidents, I suggest that aviation accident experts be called." A physician whose staffers each see up to 40 patients per day, the head of the emergency department at Tel Aviv Sourasky Medical Center, Dr. Pini Halperin, said that "although a doctor should be able to assess mental and physical effects on driving, most are not trained. The law is too big for us to deal with. Among the patients in an emergency room are accident victims. Health fund doctors see patients for an average of eight minutes. There is no chance we can enforce the law without tools. A doctor has to acquire a tremendous amount of information; he doesn't have time to read medical articles on many other important subjects." Halperin shows a US map stating that in most states, there is no reporting requirement. Only a small handful, including New York and California, do. In most others, reporting is not mandatory, or there is no law at all. There are too many laws that are not enforced and nothing comes from them, he continued. Maybe, he asked, the hospital director, or the nurse or a clerk should be the one required to do the reporting? Dr. Kobi Peleg, director of trauma and emergency medicine at the Gertner Center at Tel Hashomer and head of disaster medicine at Tel Aviv University's Sackler Medical School, said that since the list of reportable diseases is unproven and unmanageable, the Health Ministry or other experts should cut the list down. If such a list were enforced - and if action were taken against a few doctors who failed to report patients with these dangerous diseases, things would improve. Only one percent of drivers are reported to the NCRS - and most of these are by the Israel Defense Forces. If the ministries cannot handle reform of the laws, perhaps a new MK eager to make a name for him/herself could initiate a private member's bill.