MIAMI BEACH — Only six states have mandatory reporting laws, so most physicians can be in a quandary when a patient is alcohol dependent and works where impairment could threaten public safety, according to a poster presented at the annual meeting of the American Academy of Psychiatry and the Law.
When a patient with a 30-year history of alcohol dependence was admitted in ketoacidosis to the Cleveland Clinic's internal medicine service, the psychiatry service was asked to assess any legal or ethical obligations to report the condition of the patient, a commercial bus driver, to his employer.
“Initially, my legal department told me not to report him. Then I got three different answers,” said Dr. Mia Zaharna, chief resident of general adult psychiatry at the Cleveland Clinic. Liability issues, confidentiality concerns, and a fear patients will lose their jobs are possible reasons for a lack of definitive guidance, Dr. Zaharna said.
She and her associates checked Ohio statutes and federal law for definitive guidance, but found none. Next, they sought guidelines from the American Psychiatric Association, the American Medical Association, and the American Society of Addiction Medicine (ASAM). “I was surprised how vague it all seems to be. The APA, AMA, and [ASAM] have some recommendations for talking with patients about not drinking and driving, but when it comes to telling physicians what to do [about duty to report impairment], it's all over the place.”
According to an ASAM public policy statement, it is appropriate to report a substance-dependent patient to authorities when the patient “is considered … to pose an immediate threat to public safety” as in the case of “acute incapacitation by substances” (J. Addict. Dis. 2000;19:125–7).
With more severe cases of impairment, disclosure of confidential patient information is permitted or even obligatory, according to the 1976 California Supreme Court decision in Tarasoff v. Regents of the University of California. The majority opinion stated that mental health professionals have a duty to protect a third party when a patient is threatening to do them bodily harm. The duty can include notifying police and the intended victim and/or taking other reasonable steps to protect the threatened individual.
When a potential threat is less clear, however, physicians must weigh the likelihood of harm to third parties against risks to the patient. Assess how functionally impaired the patient is likely to be while on the job, Dr. Zaharna suggested.
More precise guidance on this issue would reduce confusion for physicians. The six states with mandatory reporting laws are California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania. “It's up in the air in the other states,” she said.
In the case of the bus driver, “we ended up informing this patient about the risks—health risks and driving risks—associated with his alcohol use, but we did not report him to his employer or to the [Bureau of Motor Vehicles] at the advice of our legal department,” she said.