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Public safety versus patient interest: Which to choose?

F.J. Gianola, PA

The author is on the faculty of the MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine, Seattle.
He has indicated no relationships to disclose relating to the content of this article.

We encounter life not in general but in particular living beings.

— Albert R. Jonsen, 2005

Case

The following case presents an ethical problem in practice that may not be immediately obvious (see “PA Quandaries in 2007: Send us your ethical quandaries”). It shows the complexity of medical exemptions or privileges by reviewing the granting of medical certification for a commercial driver’s license for a patient with recently diagnosed stage 2 hypertension.

Mr. A. has been a patient in our rural health clinic for a number of years. Because of a depressed economy in this part of the United States, Mr. A. had to sell his dairy herd and much of his farmland to cover loans. He decided to obtain a commercial driver’s license (CDL) 3 months ago, and his hypertension was discovered when I performed the Department of Transportation (DOT) CDL physical examination. His BP was 178/105 mm Hg, which would allow him only a 3-month temporary certification.^1,2 He was asymptomatic, and further extensive testing revealed no end-organ damage. I prescribed lisinopril and hydrochlorothiazide with the goal of lowering Mr. A.’s BP to less than 160/90 mm Hg—the DOT guideline currently in effect. This would allow him a 1-year certification to be renewed annually as long as he was being treated for his hypertension.

When he returned to clinic 3 months later, his BP was 215/120 mm Hg. During the history, I discovered he had not taken his medication because he did not have enough money to pay for both the extensive testing that had been performed and his prescriptions. He had no health insurance, and he chose to pay the bill for his tests. We treated him in clinic with clonidine, which lowered his BP to 140/84 mm Hg. Mr. A. requested that I use this reading, which would be acceptable for another three-month recertification. He has been offered an interstate trucking job that includes health insurance for him and his family. A BP higher than 181/105 mm Hg would disqualify him from certification until his BP was under control.

The ethical quandary

Should I advocate for my patient as my primary responsibility and recertify him, or is my primary responsibility to the public and its safety?

Discussion

PAs are authorized to perform DOT certification exams under the 1992 amended Federal Motor Carriers Safety Regulations (FMCSR). PAs can carry out the exam and medical certification if the state where they are licensed allows them to perform this type of examination.¹ With this authority come the responsibility and the inevitable tension between the individual patient and public safety. Where is that line drawn?

The foundation of each patient contact is based on trust and on the PA–patient relationship. The cornerstone of that foundation is patient confidentiality. The Hippocratic oath states, “What I see or hear in or outside the course of treatment, which on no account must be spread abroad, I will keep to myself, holding such things shameful to speak about.” Modern medicine has loosened the bonds of confidentiality with new technologies, information storage, and access to this information by third parties. These third parties may include insurance companies, employers, and government agencies. It has also been loosened by our casual talk in public about our patients. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has tried to recapture some of that confidentiality.

Can patient confidentiality be broken without the patient’s authorization? If so, when, why, and to whom? Does a law or regulation take precedence over the tenet of confidentiality?

To review our case: Mr. A. is an established patient who is requesting a commercial driver’s license. He has hypertension, he has not been taking his prescribed medication, and his BP is not controlled. He is asking for another extension of his temporary certification. He is requesting the extension so he may accept a job that will provide an income and health insurance for him and his family.

FMCSR guidance and regulations for potentially disqualifying conditions state that “a person is physically qualified to drive a commercial motor vehicle if that person has no current clinical diagnosis of high blood pressure likely to interfere with the ability to operate a commercial motor vehicle safely.”² According to the guidelines in effect at the time of Mr. A.’s case, “if the initial pressure is 181/105 mm Hg or higher, the driver should not be certified. Once the treatment has brought a driver’s blood pressure under control, certification should be issued for no more than one year at a time.”¹ The regulations also specified that “if the blood pressure is higher than 160/90 (either systolic or diastolic) but lower than 181/105 mm Hg, temporary certification may be granted for three months to allow time for the driver to be evaluated and treated.”¹ These criteria have since been updated to reflect revised definitions of hypertension.²

This case might seem straightforward. According to the guidelines, Mr. A. should be disqualified until his BP is under control. However, because of the PA–patient relationship, we have an obligation to consider the context and circumstances that surround the predicament.

What would you do? Pommerenke and colleagues comment on DOT regulations: “Unfortunately, the regulations and supporting literature do not provide firm guidance for every set of circumstances. In the final analysis, public safety is the most important consideration in a DOT certification examination, followed by the driver’s health.”¹ In Mr. A.’s case, his initial BP was 178/85 mm Hg. He did not take his medication. Upon return to clinic, his BP was even higher, but he was asymptomatic and responded to immediate therapy. Mr. A. currently has no end-organ damage that can be identified. He remains asymptomatic. The concern with hypertension and driving is loss of consciousness or confusion. With his response to medication, there is no reason to assume he will not respond to long-term therapy.

In this case, Mr. A. might reasonably be given a three-month medical certification with the caveat that his BP be closely monitored. The rationale for this decision is based on the medical findings of no end-organ damage, the good response to immediate treatment, and close monitoring. The contextual issue considered is Mr. A.’s ability to acquire a paying job with health insurance and—by being employed—purchase and take his prescribed medication. This, combined with close monitoring by the patient and PA, should ensure the public safety and should also maintain patient confidentiality and the patient–PA relationship.

REFERENCES

1. Pommerenke F, Hegmann K, Hartenbaum NP. DOT examinations: practical aspects and regulatory review. Am Fam Physician. 1998;58(2):415-426.

2. Federal Motor Carrier Safety Administration, US Department of Transportation. Medical Advisory Criteria for Evaluation Under 49CFRPart319.41. Available at: http://www.fmcsa.dot.gov/rules-regulations/administration/medical.htm. Accessed January 7, 2007.