DERMATOETHICS
CONSULTATION
The alcoholic bus driver and the dermatology consultation: Legal, moral, and ethical considerations Eunice Song, BS,a Barry D. Kels, JD, MD,b and Jane M. Grant-Kels, MDb Farmington, Connecticut
CASE SCENARIO An adult female school bus driver presented to the dermatology clinic with her husband. After discussing the patient’s history of illness, review of symptoms and social history revealed that she consumed large amounts of alcohol every night. Upon further discussion the patient stated she remained sober during the day and took regular breathalyzer tests, but it was unclear who monitored the tests. The dermatologist was very concerned as the patient’s job involved driving children. On physical examination the patient appeared anxious and tremulous, and her breath smelled of alcohol. The patient denied needing help even after the dermatologist advised her to seek assistance and stop drinking. The dermatologist was hesitant to intervene as he did not want the patient to lose her job as she was supporting a son and her spouse was unemployed. The patient’s husband agreed with the physician and wanted his wife to seek assistance. The dermatologist should: A. Ignore the alcoholic history, as the patient’s chief symptom was straightforward and could be easily treated without the need for follow-up, thereby protecting patient privacy. B. Report the patient to her bus company to protect the children she is transporting and disregard patient privacy and the consequences to the patient’s family and financial well-being. C. Admit the patient to a psychiatric unit for alcohol detoxification and rehabilitation. D. Call Alcoholics Anonymous to seek their assistance in addressing the situation. E. Call the patient’s primary care physician (PCP) to discuss management of the patient’s drinking. F. Report the patient to the state’s Department of Motor Vehicles (DMV).
DISCUSSION
Abbreviations used:
This case illuminates the ethical tension between the obligations of physicians to protect patient privacy while at the same time protecting the general public from foreseeable injuries. The patient’s presenting dermatologic issue was straightforward. In a busy clinic it could be easily addressed and the patient might be dismissed within minutes. However, the patient’s prodigious alcohol intake
DMV: HIPAA:
From the University of Connecticut School of Medicinea and Health Center.b Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jane M. Grant-Kels, MD, Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].
580
PCP:
Department of Motor Vehicles Health Insurance Portability and Accountability Act of 1996 primary care physician
and physical appearance created a complex dilemma for the dermatologist.
J Am Acad Dermatol 2016;74:580-3. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.12.001
J AM ACAD DERMATOL VOLUME 74, NUMBER 3
The patient described herein is clearly at risk for not only alcohol-related health problems, but also motor vehicle accidents endangering the lives of her passengers, pedestrians, and other drivers. Inasmuch as nearly 3 in 10 adults in the United States meet criteria for risky drinking, it is not uncommon for physicians to encounter patients with unhealthy drinking habits.1 In light of the evidence that brief behavioral counseling interventions are effective in reducing alcohol consumption, the US Preventative Services Task Force recommends that clinicians in primary care screen adults 18 and older for alcohol misuse and provide brief behavioral counseling.2 Although the patient above presented to a dermatology office, the face-to-face encounter still provides an opportunity to counsel this patient. It is quite feasible to spend a few minutes reviewing the risks associated with excessive drinking, but ethical and legal difficulties arise if the patient does not appreciate the severity of her drinking. At this point the clinician must make a difficult ethical decision between respecting the patient’s autonomy and privacy while exposing the public to foreseeable harm or intervening further and sacrificing the patient’s privacy and financial security. Patient privacy and confidentiality are central to the integrity of the physician-patient relationship. Lack of confidentiality prevents the free flow of information between physician and patient and compromises the quality of care given to the patient. Maintaining confidentiality is not only an ethical duty, but also a legal obligation. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes the HIPAA Privacy Rule, which outlines the responsibilities of health care providers to protect individuals’ health information. However, the privacy rule states a physician may ‘‘disclose protected health information to public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability.’’3 Similarly, the American Medical Association Code of Medical Ethics states that physicians should uphold patient confidentiality except in situations ‘‘which are ethically justified because of overriding considerations.’’4 Although both government and professional guidelines expressly protect the privacy of patients, the circumstances in which physicians can breach confidentiality are somewhat ambiguous. There are a few circumstances in which physicians are well aware that breaching patient confidentiality is required, such as in suspected child or elder abuse and threats of self-harm or harm to
Song, Kels, and Grant-Kels 581
others. In regards to driving, there is no national protocol, but many states have laws in place to guide physicians. Laws vary from state to state in regard to reporting medically unsafe drivers and span the spectrum from mandatory reporting to permissive reporting to requiring patient permission for reporting (Table I). Connecticut has a permissive law that states a physician may report to the DMV any person diagnosed with a ‘‘chronic health problem which in the physician’s judgment will significantly affect the person’s ability to safely operate a motor vehicle.’’5 Chronic health problems that clearly affect the ability to drive include vision impairment, seizure disorders, dementia, and sleep disorders. However, the evaluation of a patient with unsafe drinking habits is more complicated inasmuch as the amount and frequency of alcohol use is not always apparent. The majority of states do not specify when to report drivers with substance abuse problems. Oregon is one state that does provide physicians with guidelines specific to substance use. The Oregon DMV states that in general, alcohol and drug use do not fall under the mandatory reporting category because impairments are not uncontrollable. However, an individual may be reported when substance abuse has led to the development of ‘‘permanent impairments that are severe and uncontrollable.’’6 In Oregon, this particular case would not meet the criteria for mandatory physician reporting, but could still be reported to the DMV under voluntary reporting criteria. Beyond the legal aspects of this case, the physician must also consider the psychosocial implications of intervening with this patient. The patient is the only source of income for the family and further intervention would likely result in loss of income with subsequent negative effects on the young child and husband. If, as she stated, the patient truly remained sober when driving, reporting the patient to legal authorities may unnecessarily jeopardize the financial stability of the family. Many individuals with alcohol use disorder do not experience legal trouble or job loss, nor do they necessarily neglect their children or responsibilities.7 If the patient were this type of ‘‘high-functioning’’ alcoholic, the dermatologist could provide brief behavioral counseling, emotional support, and notify the patient’s PCP to closely monitor the patient. The burden of reporting the patient to state authorities may outweigh the risk to the public and may jeopardize the patient’s job. It is quite possible that the patient could recover from her alcohol abuse and safely maintain her current position. However, given the patient’s appearance suggesting signs of alcohol withdrawal, close
J AM ACAD DERMATOL
582 Song, Kels, and Grant-Kels
MARCH 2016
Table I. Physician reporting procedures of medically unsafe drivers by state States with permissive reporting procedures
Alabama Alaska Arizona*y Arkansas Colorado Connecticut* District of Columbiay Florida*y Georgia* Hawaii Idaho Illinois*y Indiana* Iowa* Kansas Kentucky Louisiana Maine Marylandy Massachusetts Michigan Minnesota* Mississippi Missouriy Montana* Nebraska New Hampshire New Mexico* New York North Carolina* North Dakota* Ohio Oklahoma* Rhode Island* South Carolina South Dakota Tennessee* Texas Utah* Virginia Washington West Virginia Wisconsin* Wyoming*
States with mandatory reporting laws (reportable conditions)
Other
California*y (disorders characterized by Vermont (reporting only allowed with permission from the patient) loss of consciousness) Delaware*y (loss of consciousness caused by central nervous system disease) Nevada*y (epilepsy, any seizure disorder or other disorder characterized by loss of consciousness) New Jersey* (seizures, periods of unconsciousness or the impairment or loss of motor coordination, such as those associated with various forms of epilepsy) Oregon* (functional and/or cognitive impairments that are severe and uncontrollable) Pennsylvania* (diagnosed as having a condition that could impair ability to safely operate a motor vehicle)
Data obtained from state-specific guidelines.8 *In general, physicians acting in good faith for the good of the public are free from legal liability. y Anonymous reporting available if requested.
monitoring alone may be insufficient. The physician must use his or her judgment and determine whether the patient can be trusted. Ultimately the difficult
decision of when to ethically and legally breach patient privacy and confidentiality for the good of the public must be made by the physician.
J AM ACAD DERMATOL VOLUME 74, NUMBER 3
ANALYSIS OF CASE SCENARIO The most prudent response for the dermatologist would be to inform the patient that she should enroll in an alcohol treatment program. However, given the patient’s denial of the need for intervention, the most appropriate response would be F (report the patient to the state’s DMV). This would allow for an independent medical evaluation of the patient’s driving abilities. In the few states that have mandatory reporting laws, lack of reporting may expose the physician to significant liability for any prospective injuries related to the future negligence of the patient. Option A (ignore the alcohol history) upholds patient privacy, but is irresponsible. Although the physician is free from any legal implications for not reporting the patient in the majority of US states, disregarding the risk posed by the patient to the general public would be irresponsible and unethical. Option B (report
BOTTOM LINE Dermatologists are physicians of the skin, but we are nonetheless ethically responsible for not only the well-being of the patient, but also society. Ignoring the patient’s alcohol intake puts the community at risk and would be unethical. REFERENCES 1. National Institute on Alcohol Abuse and Alcoholism. About rethinking drinking. Available from: URL: http://rethinking drinking.niaaa.nih.gov/About.aspx. Accessed October 5, 2015. 2. Moyer VA, Preventative Screening Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:210218. 3. US Department of Health and Human Services. Summary of the HIPAA privacy rule 2003. Available from: URL: http://www.hhs. gov/ocr/privacy/hipaa/understanding/summary/privacysummary. pdf. Accessed September 28, 2016.
Song, Kels, and Grant-Kels 583
the patient to her company) would breach the patient’s privacy and break HIPAA regulations. Instead, reporting the patient to the state’s DMV allows for an investigation that maintains the patient’s privacy. Option C (admit the patient for detoxification) does not seem appropriate at this time as involuntary inpatient commitment is usually reserved for patients with grave alcohol use disorders as a last-resort intervention.9 Option D (consulting Alcoholics Anonymous) may help connect the patient with community resources for achieving sobriety, but this option does not address the immediate risk to the public. The dermatologist should also consider Option E (contacting the patient’s PCP) to see if the PCP has any knowledge of the patient’s alcohol abuse. The PCP is a wonderful resource to help confirm the dermatologist’s concerns and to ensure that the patient gets appropriate help and follow-up.
4. American Medical Association. Opinion 5.05econfidentiality. AMA code of medical ethics 1983. Available from: URL: http:// www.ama-assn.org/ama/pub/physician-resources/medical-ethics/ code-medical-ethics/opinion505.page. Accessed September 27, 2015. 5. National Highway Traffic Safety Administration. Connecticut reporting procedures. Available from: URL: http://www.nhtsa. gov/people/injury/olddrive/OlderDriversBook/pages/Connecticut. html. Accessed September 28, 2015. 6. State of Oregon. Mandatory reporting FAQs. Available from: URL: http://www.oregon.gov/ODOT/DMV/pages/faqs/mandatory_ reporting.aspx. Accessed October 4, 2015. 7. Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health. 2010;33(1-2):55-63. 8. National Highway Traffic Safety Administration. Reporting procedures. Available from: URL: www.nhtsa.gov/people/injury/ olddrive/OlderDriversBook/pages/Contents.html. Accessed January 1, 2016. 9. McCormack RP, Williams AR, Goldfrank LR, Caplan AL, Ross S, Rotrosen J. Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders. Lancet. 2013;382:995-997.
CONSULTATION
The alcoholic bus driver and the dermatology consultation: Legal, moral, and ethical considerations Eunice Song, BS,a Barry D. Kels, JD, MD,b and Jane M. Grant-Kels, MDb Farmington, Connecticut
CASE SCENARIO An adult female school bus driver presented to the dermatology clinic with her husband. After discussing the patient’s history of illness, review of symptoms and social history revealed that she consumed large amounts of alcohol every night. Upon further discussion the patient stated she remained sober during the day and took regular breathalyzer tests, but it was unclear who monitored the tests. The dermatologist was very concerned as the patient’s job involved driving children. On physical examination the patient appeared anxious and tremulous, and her breath smelled of alcohol. The patient denied needing help even after the dermatologist advised her to seek assistance and stop drinking. The dermatologist was hesitant to intervene as he did not want the patient to lose her job as she was supporting a son and her spouse was unemployed. The patient’s husband agreed with the physician and wanted his wife to seek assistance. The dermatologist should: A. Ignore the alcoholic history, as the patient’s chief symptom was straightforward and could be easily treated without the need for follow-up, thereby protecting patient privacy. B. Report the patient to her bus company to protect the children she is transporting and disregard patient privacy and the consequences to the patient’s family and financial well-being. C. Admit the patient to a psychiatric unit for alcohol detoxification and rehabilitation. D. Call Alcoholics Anonymous to seek their assistance in addressing the situation. E. Call the patient’s primary care physician (PCP) to discuss management of the patient’s drinking. F. Report the patient to the state’s Department of Motor Vehicles (DMV).
DISCUSSION
Abbreviations used:
This case illuminates the ethical tension between the obligations of physicians to protect patient privacy while at the same time protecting the general public from foreseeable injuries. The patient’s presenting dermatologic issue was straightforward. In a busy clinic it could be easily addressed and the patient might be dismissed within minutes. However, the patient’s prodigious alcohol intake
DMV: HIPAA:
From the University of Connecticut School of Medicinea and Health Center.b Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jane M. Grant-Kels, MD, Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].
580
PCP:
Department of Motor Vehicles Health Insurance Portability and Accountability Act of 1996 primary care physician
and physical appearance created a complex dilemma for the dermatologist.
J Am Acad Dermatol 2016;74:580-3. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.12.001
J AM ACAD DERMATOL VOLUME 74, NUMBER 3
The patient described herein is clearly at risk for not only alcohol-related health problems, but also motor vehicle accidents endangering the lives of her passengers, pedestrians, and other drivers. Inasmuch as nearly 3 in 10 adults in the United States meet criteria for risky drinking, it is not uncommon for physicians to encounter patients with unhealthy drinking habits.1 In light of the evidence that brief behavioral counseling interventions are effective in reducing alcohol consumption, the US Preventative Services Task Force recommends that clinicians in primary care screen adults 18 and older for alcohol misuse and provide brief behavioral counseling.2 Although the patient above presented to a dermatology office, the face-to-face encounter still provides an opportunity to counsel this patient. It is quite feasible to spend a few minutes reviewing the risks associated with excessive drinking, but ethical and legal difficulties arise if the patient does not appreciate the severity of her drinking. At this point the clinician must make a difficult ethical decision between respecting the patient’s autonomy and privacy while exposing the public to foreseeable harm or intervening further and sacrificing the patient’s privacy and financial security. Patient privacy and confidentiality are central to the integrity of the physician-patient relationship. Lack of confidentiality prevents the free flow of information between physician and patient and compromises the quality of care given to the patient. Maintaining confidentiality is not only an ethical duty, but also a legal obligation. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes the HIPAA Privacy Rule, which outlines the responsibilities of health care providers to protect individuals’ health information. However, the privacy rule states a physician may ‘‘disclose protected health information to public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability.’’3 Similarly, the American Medical Association Code of Medical Ethics states that physicians should uphold patient confidentiality except in situations ‘‘which are ethically justified because of overriding considerations.’’4 Although both government and professional guidelines expressly protect the privacy of patients, the circumstances in which physicians can breach confidentiality are somewhat ambiguous. There are a few circumstances in which physicians are well aware that breaching patient confidentiality is required, such as in suspected child or elder abuse and threats of self-harm or harm to
Song, Kels, and Grant-Kels 581
others. In regards to driving, there is no national protocol, but many states have laws in place to guide physicians. Laws vary from state to state in regard to reporting medically unsafe drivers and span the spectrum from mandatory reporting to permissive reporting to requiring patient permission for reporting (Table I). Connecticut has a permissive law that states a physician may report to the DMV any person diagnosed with a ‘‘chronic health problem which in the physician’s judgment will significantly affect the person’s ability to safely operate a motor vehicle.’’5 Chronic health problems that clearly affect the ability to drive include vision impairment, seizure disorders, dementia, and sleep disorders. However, the evaluation of a patient with unsafe drinking habits is more complicated inasmuch as the amount and frequency of alcohol use is not always apparent. The majority of states do not specify when to report drivers with substance abuse problems. Oregon is one state that does provide physicians with guidelines specific to substance use. The Oregon DMV states that in general, alcohol and drug use do not fall under the mandatory reporting category because impairments are not uncontrollable. However, an individual may be reported when substance abuse has led to the development of ‘‘permanent impairments that are severe and uncontrollable.’’6 In Oregon, this particular case would not meet the criteria for mandatory physician reporting, but could still be reported to the DMV under voluntary reporting criteria. Beyond the legal aspects of this case, the physician must also consider the psychosocial implications of intervening with this patient. The patient is the only source of income for the family and further intervention would likely result in loss of income with subsequent negative effects on the young child and husband. If, as she stated, the patient truly remained sober when driving, reporting the patient to legal authorities may unnecessarily jeopardize the financial stability of the family. Many individuals with alcohol use disorder do not experience legal trouble or job loss, nor do they necessarily neglect their children or responsibilities.7 If the patient were this type of ‘‘high-functioning’’ alcoholic, the dermatologist could provide brief behavioral counseling, emotional support, and notify the patient’s PCP to closely monitor the patient. The burden of reporting the patient to state authorities may outweigh the risk to the public and may jeopardize the patient’s job. It is quite possible that the patient could recover from her alcohol abuse and safely maintain her current position. However, given the patient’s appearance suggesting signs of alcohol withdrawal, close
J AM ACAD DERMATOL
582 Song, Kels, and Grant-Kels
MARCH 2016
Table I. Physician reporting procedures of medically unsafe drivers by state States with permissive reporting procedures
Alabama Alaska Arizona*y Arkansas Colorado Connecticut* District of Columbiay Florida*y Georgia* Hawaii Idaho Illinois*y Indiana* Iowa* Kansas Kentucky Louisiana Maine Marylandy Massachusetts Michigan Minnesota* Mississippi Missouriy Montana* Nebraska New Hampshire New Mexico* New York North Carolina* North Dakota* Ohio Oklahoma* Rhode Island* South Carolina South Dakota Tennessee* Texas Utah* Virginia Washington West Virginia Wisconsin* Wyoming*
States with mandatory reporting laws (reportable conditions)
Other
California*y (disorders characterized by Vermont (reporting only allowed with permission from the patient) loss of consciousness) Delaware*y (loss of consciousness caused by central nervous system disease) Nevada*y (epilepsy, any seizure disorder or other disorder characterized by loss of consciousness) New Jersey* (seizures, periods of unconsciousness or the impairment or loss of motor coordination, such as those associated with various forms of epilepsy) Oregon* (functional and/or cognitive impairments that are severe and uncontrollable) Pennsylvania* (diagnosed as having a condition that could impair ability to safely operate a motor vehicle)
Data obtained from state-specific guidelines.8 *In general, physicians acting in good faith for the good of the public are free from legal liability. y Anonymous reporting available if requested.
monitoring alone may be insufficient. The physician must use his or her judgment and determine whether the patient can be trusted. Ultimately the difficult
decision of when to ethically and legally breach patient privacy and confidentiality for the good of the public must be made by the physician.
J AM ACAD DERMATOL VOLUME 74, NUMBER 3
ANALYSIS OF CASE SCENARIO The most prudent response for the dermatologist would be to inform the patient that she should enroll in an alcohol treatment program. However, given the patient’s denial of the need for intervention, the most appropriate response would be F (report the patient to the state’s DMV). This would allow for an independent medical evaluation of the patient’s driving abilities. In the few states that have mandatory reporting laws, lack of reporting may expose the physician to significant liability for any prospective injuries related to the future negligence of the patient. Option A (ignore the alcohol history) upholds patient privacy, but is irresponsible. Although the physician is free from any legal implications for not reporting the patient in the majority of US states, disregarding the risk posed by the patient to the general public would be irresponsible and unethical. Option B (report
BOTTOM LINE Dermatologists are physicians of the skin, but we are nonetheless ethically responsible for not only the well-being of the patient, but also society. Ignoring the patient’s alcohol intake puts the community at risk and would be unethical. REFERENCES 1. National Institute on Alcohol Abuse and Alcoholism. About rethinking drinking. Available from: URL: http://rethinking drinking.niaaa.nih.gov/About.aspx. Accessed October 5, 2015. 2. Moyer VA, Preventative Screening Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:210218. 3. US Department of Health and Human Services. Summary of the HIPAA privacy rule 2003. Available from: URL: http://www.hhs. gov/ocr/privacy/hipaa/understanding/summary/privacysummary. pdf. Accessed September 28, 2016.
Song, Kels, and Grant-Kels 583
the patient to her company) would breach the patient’s privacy and break HIPAA regulations. Instead, reporting the patient to the state’s DMV allows for an investigation that maintains the patient’s privacy. Option C (admit the patient for detoxification) does not seem appropriate at this time as involuntary inpatient commitment is usually reserved for patients with grave alcohol use disorders as a last-resort intervention.9 Option D (consulting Alcoholics Anonymous) may help connect the patient with community resources for achieving sobriety, but this option does not address the immediate risk to the public. The dermatologist should also consider Option E (contacting the patient’s PCP) to see if the PCP has any knowledge of the patient’s alcohol abuse. The PCP is a wonderful resource to help confirm the dermatologist’s concerns and to ensure that the patient gets appropriate help and follow-up.
4. American Medical Association. Opinion 5.05econfidentiality. AMA code of medical ethics 1983. Available from: URL: http:// www.ama-assn.org/ama/pub/physician-resources/medical-ethics/ code-medical-ethics/opinion505.page. Accessed September 27, 2015. 5. National Highway Traffic Safety Administration. Connecticut reporting procedures. Available from: URL: http://www.nhtsa. gov/people/injury/olddrive/OlderDriversBook/pages/Connecticut. html. Accessed September 28, 2015. 6. State of Oregon. Mandatory reporting FAQs. Available from: URL: http://www.oregon.gov/ODOT/DMV/pages/faqs/mandatory_ reporting.aspx. Accessed October 4, 2015. 7. Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health. 2010;33(1-2):55-63. 8. National Highway Traffic Safety Administration. Reporting procedures. Available from: URL: www.nhtsa.gov/people/injury/ olddrive/OlderDriversBook/pages/Contents.html. Accessed January 1, 2016. 9. McCormack RP, Williams AR, Goldfrank LR, Caplan AL, Ross S, Rotrosen J. Commitment to assessment and treatment: comprehensive care for patients gravely disabled by alcohol use disorders. Lancet. 2013;382:995-997.
