Wednesday, August 26, 2009

No, Dr. Moffic, That Is Not the... Answer!

In his article “To Drive or Not to Drive? That Is the…” (The Ethical Way, Clinical Psychiatry News, Volume 35, Issue 10, Page 41 (October, 2007), Dr. H. Steven Moffic has established a new duty of treating psychiatrists to evaluate the “fitness to drive” of each patient, and a new exception to physician patient privilege “…when you are reasonably sure of potential danger” arising from psychiatrically impaired ability to drive.

Dr. Moffic has paid scant attention to the damage such a conflict of role or interest might have on the treatment relationship. He also failed to reference any ethical precept, including the most relevant: “A psychiatrist who regularly practices outside his or her area of professional competence should be considered unethical.” (American Psychiatric Association, The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2006 Edition; accessed November 5, 2007). Instead, he takes the position that the treating psychiatrist should perform even a questionably competent evaluation because “practically speaking, such information usually is difficult to obtain.” He described this difficulty in one case as arising only from the fact that the patient “lived alone.” Regardless of whether a patient lives alone, a forensic psychiatrist can answer questions about disability, competence or capacity, and fitness with little or no conflict of role or interest, leaving your relationship with your patient unharmed.

The duty of a clinical psychiatrist is to diagnose and treat mental illness. The only well-accepted exceptions are the Tarasoff duty to protect, the duty to report physician misconduct, and the duty to notify authorities of child abuse. There is no duty to “fill out forms.” There is no duty to ensure that a patient can obtain a license to drive a motor vehicle, to practice medicine or to fly an airplane. There is no duty to obtain insurance money for a patient. If a duty to protect the public from drivers impaired by their medications or mental disorders has been established, Dr. Moffic should cite applicable statutory or case law.

Treating psychiatrists are no more qualified to perform "clinical assessments" of fitness for driving than to determine whether their patients should or should not be permitted to own or use firearms, return to work, be considered disabled, be considered competent to make a will, or to stand trial. They are not qualified to determine whether a patient is fit to procreate, raise children, or ride a bicycle. All such assessments result in a conflict of role, if not a conflict of interest, which will probably interfere with the physician’s care of the patient.

Dr. Moffic recommends that we “Do receive informed consent” but fails to specify to what the patient must consent. The need to obtain authorization to release information is obvious. The clinician who follows this recommendation should also, however, advise the patient of the limitations of the psychiatrist’s ability to perform a “clinical assessment of the patient’s driving” and the potential adverse effect on the treatment relationship. He should also warn the patient before undertaking a psychiatric evaluation that he might determine that the patient is unfit to drive and that he might report this to “authorities” whether the patient wants him to or not.

As long as psychiatrists like Dr. Moffic find it more expedient to “just sign the form,” attorneys, insurers, bureaucrats, and a host of other third parties will exploit this free and easy alternative to forensic evaluation with no regard for the resulting damage to the doctor-patient relationship or for the quality of the assessment.

Dr. Moffic asks, “What is the clinician to do?” when your patient asks you to “fill out a form.” The answer: Focus on treating the patient to the best of your ability and to follow your instincts and the admonition of Nancy Reagan and, “Just say no.”

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