ASK DR. ROACH Physician revokes driver’s license without an explanation

DEAR DR. ROACH >>

My wife’s handicap parking placard expired, and she asked her primary care physician to fill out a renewal application. The new placard was received, followed by a letter from the DMV instructing my wife to return her license within 10 days because a medical professional had deemed it unsafe for her to drive. There was no discussion with my wife about driving.

My wife had a stroke about two years ago, but there are no obvious signs that she shouldn’t be driving outside of that. She recently had a Watchman device placed, but no one ever said she shouldn’t drive. My wife has had no symptoms since the surgery. She saw the cardiologist who performed the Watchman surgery, and he said she is doing well. She also saw her regular cardiologist, and he said she is doing well. She saw both of these physicians after she saw the physician who notified the DMV that she should not drive.

I have seen the aftervisit notes of all the doctors my wife has seen in the last three months. All say that she is doing well. The doctor involved said, in her notes: “She is doing well, no concerns.” She has not had any device implanted to maintain rhythm. Was it unethical to not discuss revoking my wife’s license with her before doing it?

— Anon.

DEAR READER >>

The Watchman device is placed to reduce the risk of stroke in people with atrial fibrillation, a rhythm disturbance of the heart. Its placement has no bearing on her driving, but the atrial fibrillation potentially does. Atrial fibrillation does predispose people to strokes and, occasionally, to a heart rate so fast that people can’t think properly. Conceivably, a person could have a stroke or a very fast heart rate while driving, but this is a very rare cause of motor-vehicle accidents. The most common medical cause for impairment while driving is epilepsy, which is a whole separate discussion.

There are international guidelines to help clinicians decide whether a person with a history of arrhythmia is safe to drive. In the case of atrial fibrillation, the guidelines are consistent that only if a person is having symptoms or is incapacitated should they stop driving, and they may resume once the symptoms or incapacity is better. From what you tell me, she had no reason for her driving to be restricted. Unless her primary care physician knows something that you haven’t told me, this decision was not supported by consensus guidelines.

Was the decision ethical? I don’t think so. An ethical decision is one that minimizes harm, both to your wife and to the community. Your wife has been harmed, and I don’t think the community is safer because she can’t drive. I don’t think she was treated fairly. Lack of truth-telling undermines trust, which is essential for ethical patient care.

It is possible that the decision to restrict her driving privileges was done in error, either by her physician or by the DMV. I do feel strongly that her physician should have told her that her driving privileges would be restricted: This would have allowed for some discussion, perhaps with her cardiologists, and would remove the question of whether there was an error.

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