What happens when the legal system requires doctors to report certain medical diagnoses to the state?
In some cases this is undisputed. For example, all fifty states require treating physicians to report cases of suspected child abuse to authorities. Children by nature lack the full ability to stand up for or protect themselves from abuse by parents or legal guardians. Thus, both the medical and legal communities generally recognize such mandatory reporting laws as part of protecting the individual rights of the affected child.
(Thorny issues may arise as to whether specific cases meet the threshold to require a report to the state. But I agree with the general principle.)
Other reporting requirements are more controversial. For example, some (but not all) states require physicians to report suspected elder abuse. Some states similarly require doctors to report suspected domestic violence (also known as “intimate partner violence” or IPV). A few states require physicians to report suspected alcohol or drug abuse by pregnant patients, which can lead to harm to the developing fetus.
The American College of Emergency Physicians takes a nuanced position on such mandatory reporting laws, especially when it comes to intimate partner violence. The ACEP strongly recommends that emergency physicians be familiar with the signs and symptoms of domestic violence and also “develop policies, protocols, and relationships with outside agencies that oversee the management and investigation of domestic violence.” However, ACEP also “opposes mandatory reporting of intimate partner violence to the criminal justice system.” Instead, ACEP “encourages reporting to the criminal justice system, social services and resources that provide confidential advice and assistance only when consistent with the patient’s wishes.”
Disabled senior falls asleep while driving.
There is a similar controversy over state laws requiring doctors to report suspected dementia among older drivers. Recent research suggests that such laws can have perverse, unintended consequences.
Dr. Hankyung Jun and colleagues from Harvard Medical School and the University of Southern California have studied the effects of such reporting requirements in states such as California. They found that doctors in states with mandatory reporting requirements were 59% greater chance of underdiagnosis of dementiacompared to physicians in states without such mandates.
Jun and colleagues suspect that “a requirement to report dementia diagnoses may discourage physicians from making or documenting these diagnoses.” One possible explanation is that patients with early dementia may choose to “hide their symptoms or refuse further examinations” in order not to lose their driver’s license. Another possibility is that doctors may be reluctant to “further investigate the symptoms of dementia for fear that their patient could lose their driver’s license.” The researchers also note that there is no clear evidence that such reporting requirements actually reduce the risk of crashes and traffic fatalities.
In a accompanying editorial for JAMA, notes Dr. Donald Redelmeier and colleague Vidhi Bhatt note that “the tension between patient privacy and community safety does not provide an easy solution for individuals in the US who may not fully trust their state governments.” (Redelmeier and Bhatt advocate a counseling-based approach instead.) Dr. Soeren Mattke, director of the USC Brain Health Observatory, similarly concludes: “In light of our findings, lawmakers should weigh the potential downside of requiring physicians to report dementia diagnoses to the DMV.”
In 2007, the American Academy of Neurology took a stand against mandatory reporting laws for medical conditions that can affect drivers, warning that these “can have a strong negative impact on the patient-physician relationship, and ultimately may not provide greater safety benefits to the public or the patient, who may feel compelled to take important medical withhold information. ” The recent research by Jun and colleagues seems to support this view.
Dementia is a serious medical condition. Impaired drivers also pose a serious public safety problem. I do not want to downplay the importance of these issues. However, forcing physicians to act as indirect agents of law enforcement can sometimes backfire. Lawmakers must take such unintended consequences into account.
