Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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If you have any questions on ethics, please submit them to EthicsQuestion@aoa.org. The AOA Ethics and Values Committee will respond to your questions as soon as possible. If you have an ethical challenge you wish to share, please feel free to submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA Ethics and Values Committee and may be featured in a future Ethics Forum.

Vision and Driving

By Morris S. Berman, O.D.

Case Study #2

One of your regular patients Sue schedules her 85-year-old dad Bill for his first appointment in the practice. The examination on Bill reveals vision loss. The best corrected acuities are 20/40 (OD) and 20/40- (OS). Stereoacuity is compromised. Intraocular pressures are slightly elevated and there are drusen and macular changes in one eye. Sue discusses with you her growing concern for the safety of her dad as he continues to drive local roads and reports some minor fender benders over the past two years. Sue is concerned about Bill's vision capabilities along with his diminishing mental alertness. She confides in you that she would rather her dad give up driving and asks your help in documenting this to the Department of Motor Vehicles in the state. What are the ethical and legal considerations that the optometrist must address?

Discussion

This case is representative of a common occurrence in optometric practice and is presenting with increasing frequency as longevity of the population continues to rise. The dilemma must be examined from the perspective of the law and the ethics of doing what is right for your patients (beneficence). The determination made by each doctor must also take into account the ethical and legal issues including confidentiality, HIPAA regulations, patient autonomy and paternalism.

The legal standards for vision and driving are established independently by each state. In the absence of a national (federal) law, the prevailing standards always include corrected visual acuity requirements while peripheral vision criteria exist in some but not all state laws. Variable requirements also relate to other vision impairment factors including night vision, glare resistance and recovery, visual perception, and eye movements. Some states even require an assessment of cognitive, psychological, and physical capabilities.

In 2012, there were almost 36 million US licensed drivers ages 65 and older which is a 34 percent increase from 19991,2. Evidence from the National Highway Traffic and Safety Administration suggests that individual drivers aged 65 and older were responsible for 17 percent of traffic fatalities in 2012. Driving helps older adults stay mobile and independent, while the attendant risk of being injured or killed in a motor vehicle crash increases with age. In 2012, more than 5,560 older adults were killed and more than 214,000 were injured in motor vehicle crashes. Per mile traveled, fatal crash rates increase noticeably in the 70‒74 year age range and are highest among drivers 85 years and older. This is largely due to increased susceptibility to injury and medical complications among older drivers rather than an increased tendency to get into crashes. Age-related declines in vision and cognitive functioning (reasoning and recall skills), as well as physical changes, may affect some older adults' driving abilities.

The ethical dilemma facing optometrists in this case centers on privacy versus protecting the public. This is one of the tenets contained in the AOA Code of Ethics3 and supported in the Standards of Professional Conduct4 . The legal considerations must be carefully understood as statutes vary considerably from state to state regarding the authority for reporting patients who do meet safe vision standards for driving.

In this case study there are several considerations that the optometrist must take into account.

Vision Status

  • Does patient Bill demonstrate vison findings that satisfy the state's driving standards? This appears to be the case and the encounter records should document the findings. Any report submitted to a third party should only reflect your diagnostic assessment and the patient education that was delivered.

Reporting Requirements

  • Despite Sue's desire for the optometrist to determine that he should not be driving, Bill meets the vision requirements for a state driver's license and the optometrist cannot falsify any communication to the Department of Motor Vehicles (DMV). The optometrist therefore has no legal obligation to submit a report the DMV unless there is another component of the state's visual requirements that must be considered.

Health Status

  • Based on communication from Bill's daughter, the patient appears to be experiencing diminished mental adeptness. The optometrist should attempt to formulate his/her own opinion as part of the examination protocol. However, this concern should be forwarded to the appropriate health professional to make any definitive diagnosis and the optometrist should provide referrals for the patient.

Patient Autonomy

  • It is important at the outset to establish whether the visual findings and recommendations can be discussed with the patient and his daughter. Confidentiality and patient autonomy are the conflicting ethical principles that must be considered. The optimal situation would be for the patient to agree to engage in an open conversation with the daughter present. The patient must give his/her permission for the daughter to be present during the examination and discussion. Failing this, the optometrist is limited to influencing the outcome via the patient only and this becomes a family matter between the parent and daughter.

Paternalism

  • Paternalism may be defined as the practice on the part of people in positions of authority of restricting the freedom and responsibilities of those subordinate to them in the subordinates' supposed best interest5 . In the case of a patient whose vision is compromised but meets the state driving requirements, the optometrist may decide to be direct and assertive by recommending the patient stop driving. In this instance, this would be a voluntary decision by the patient. There is the possibility that the conversation is accepted well and there is always the possibility that this could backfire and result in the patient becoming angry and severing his or her relationship with you.

Whatever course of action is taken, it is important for the optometrist to openly and truthfully explain to the patient the potential risks and dangers to the driver and others when vision and health become compromised. The reality of removing driving privileges often has significant consequences as this represents a significant loss of independence. This is often accompanied by a refusal by the patient to acknowledge or recognize that he or she is potentially a safety danger to himself or herself and others if he or she continues to drive under less than optimal conditions. The optometrist has the obligation to weigh all of the components of the case to create an appropriate treatment plan and convey the findings to the patient.

REFERENCES

1.  Federal Highway Administration, Department of Transportation (US). Highway Statistics 2012. Washington (DC): FHWA. [cited 2015 Mar 25]. Available from URL: fhwa.dot.gov/ohim/hs99/tables/dl20.pdf

2.  Federal Highway Administration, Department of Transportation (US). Highway Statistics 1999. Washington (DC): FHWA. [2015 Mar 26]. Available from URL: fhwa.dot.gov/ohim/hs99/tables/dl20.pdf

3.  AOA Code of Ethics, aoa.org, About the AOA, Ethics and Values

4.  AOA Standards of Professional Conduct, aoa.org, About the AOA, Ethics and Values

5.  oxforddictionaries.com