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Editorial

Reporting Epileptic Drivers to Licensing Authorities

Is Unnecessary and Counterproductive

Wally Lee, MD

Tim Wolfe, MD

Division of Emergency Medicine

Department of Surgery

University of Utah School of Medicine

Salt Lake City, UT

Scott Shreeve, MD

University of Arizona School of Medicine

Tucson, AZ

Address for reprints: Wally Lee, MD, Division of Emergency Medicine, 1150

Moran Building, 75 North Medical Drive, Salt Lake City, UT 84132; 801-581-

2730, fax 801-585-6699; E-mail Wally.Lee@hsc.utah.edu.

Copyright © 2002 by the American College of Emergency Physicians.

0196-0644/2002/$35.00 + 047/1/121520doi:10.1067/mem.2002.121520

Reporting Epileptic Drivers to LicensingAuthorities Is Unnecessary andCounterproductive

[Lee W, Wolfe T, Shreeve S. Reporting epileptic drivers tolicensing authorities is unnecessary and counterproductive.Ann Emerg Med. June 2002;39:656-659.]

Before the late 1940s, all persons with epilepsy were pro-hibited from driving because of the potential for suddenloss of consciousness and the risk of a motor vehiclecrash (MVC).1 With the development of antiepilepticmedications and electroencephalography, this prohibi-tion was modified to allow epileptics in “good control” todrive. Licensing and physician-reporting requirementsfor epileptic drivers now vary considerably from state tostate.2,3 Six states (California, Delaware, Nevada, NewJersey, Oregon, and Pennsylvania) require mandatoryphysician reporting of patients with seizures to regula-tory authorities.4 Three of these states specifically men-tion epilepsy in their statutes, and the other 3 require thatany condition resulting in “lapses of consciousness” bereported to the licensing agency. The remaining statestypically require the patient to self-report or face civil lia-bility, criminal liability, or both. Table 1 summarizes eachstate’s licensing requirements for patients with seizures.

Although regulating driving privileges of epilepticpatients may seem beneficial, it actually hinders optimalmedical management and may increase the risk of trafficaccidents.1,5-10 This article contrasts the relative risk ofMVCs for epileptic drivers versus other less regulatedconditions, discusses the negative effect reporting statuteshave on epileptic patients and society, and recommendseliminating physician reporting of epileptic patients todriver-licensing authorities.

The reported relative risk for MVC among epilepticdrivers ranges from no difference to almost twice the riskof nonseizure cohorts.11-16 These rates are comparable

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or markedly less than those of other medical conditionsthat are not under the same regulatory guidelines (Table2).9,13,15-37 For example, drivers younger than 25 yearsof age and those with sleep apnea, dementia (Alzheimer’stype), visual impairment, cardiac arrhythmias, Parkinson’sdisease, and migraine headaches all have a higher relativerisk of an MVC than epileptic drivers.15-26,34 Of personalinterest to emergency physicians, shift work and cellulartelephone use both result in higher relative risks of MVCsand fatal crashes.27-29,35-37

The overall percentage of MVCs attributed to seizures isunknown. Estimates range from 0.01% to 0.1% for all vehi-cle crashes, which may be low given reporting limita-tions.11,12,14,15,38 However, this rate is similar to that of nat-ural death at the wheel.39 According to the 1999 NationalHighway Traffic Safety Administration database, 0.7% of alltraffic fatalities were a result of “passed out/blackout.”40

Although seizure was not listed as a specific driver-relatedfactor, it is likely a subcategory. The “passed out/blackout”rate is 2 to 4 times less than the fatality rate caused by driversleepiness (1% to 3%) and 54 times less than the National

Highway Traffic Safety Administration–reported fatality rateinvolving alcohol (38%).40,41

Of MVCs involving epileptic drivers, only about 11%are seizure related.1,16 The major risk factors for MVCsinvolving epileptic patients are the same risk factorsfound in the general population: male sex, age less than25 years, unmarried status, and abuse of alcohol ordrugs.12,20,42 Notably, women with epilepsy have loweraccident rates than men without epilepsy.43,44

If mandatory reporting actually improves safety forepileptic drivers and society, invasion of the physician-patient relationship might be warranted. However, evi-dence suggests otherwise. Epileptic patients with drivingrestrictions report a compromised quality of life, as wellas employability.1,7,10,45-47 Patients with driving restric-tions often lose their independence, have difficulty main-taining social contacts, and experience reduced self-esteem. As a consequence, physician-controlled drivingrestrictions discourage honest patient-physician commu-

Table 1.Individual state requirements for driving and epilepsy.2

Seizure-Free Interval

6 12 18 24 None3 mo mo mo mo mo Specified

California* Alaska Alabama Rhode Island Vermont ColoradoKentucky Florida Arizona ConnecticutMaryland Iowa Arkansas DelawareNevada Kansas District of IllinoisUtah Maine Columbia IndianaWisconsin Massachusetts Georgia Ohio

Michigan HawaiiMinnesota IdahoMontana LouisianaOregon MississippiPennsylvania MissouriSouth Carolina NebraskaTennessee New HampshireVirginia New JerseyWashington New Mexico

New YorkNorth CarolinaNorth DakotaOklahomaSouth DakotaWest VirginiaWyoming

States with mandatory physician reporting are in boldface.*Three months to 1 year.

Table 2.Relative risk of MVC.

Relative RiskDriver Condition of MVC Reference

Epilepsy 1.0–1.95 Taylor et al,9 Waller,30 Popkin andWaller,13 Hansotia and Broste,16

Fisher et al15

Alcohol, 20–40 mg/dL 1.4 (fatal crash) Alcohol Alert31

(1 drink)Smoking 1.5 Brison32

Cardiac arrhythmia 1.63 Gresset and Meyer,26 Waller30

Alcoholism 1.66 Waller30

Diabetes 1.32–1.78 Hansotia and Broste,16 Fisher et al15

<25 y 1.93 Hansotia and Broste20

Mental illness 2.12 Hansotia and Broste,20 Fisher et al15

Migraine headache 2.3 Norton et al,22 Lerman et al19

Elderly cyclic anti- 2.3 Leveille et al33

depressant useVisual impairmentVisual acuity worse 1.45 Owsley et al25

than 20/40>40%/>60% reduction 2.2/13.6 Owsley et al24

in useful field of viewCataracts 2.5 Owsley et al21

Cellular telephone 4.3 Redelmeier and Tibshirani27

2.0 (fatal crash) Violanti and Mashall,28 Violanti29

Sleep apnea 6.3 Teran-Santos et al,17 Horstmann et al23

Dementia (Alzheimer’s 7.9 Friedland et al18

type)Alcohol, mg/dL50–90 11.1 (fatal crash) Alcohol Alert31

100–140 48 (fatal crash) Alcohol Alert31

>150 380 (fatal crash) Alcohol Alert31

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3. Epilepsy Foundation of America. Epilepsy Foundation position statement on driver licensingand mandatory physician reporting. Available at: http://www.efa.org. Accessed July 2, 2001.

4. Finucane AK. Legal aspects of epilepsy. Neurol Clin. 1999;17:235-243.

5. Harvey P, Hopkins A. Views of British neurologists on epilepsy, driving, and the law. Lancet.1983;1:401-404.

6. Salinsky MC, Wegener K, Sinnema F. Epilepsy, driving laws, and patient disclosure tophysicians. Epilepsia. 1992;33:469-472.

7. Bornemann MT. Viewpoint of a driver with epilepsy. Epilepsia. 1994;35:665-667.

8. Dickey W, Morrow JI. Epilepsy and driving: attitudes and practices among patients attend-ing a seizure clinic. J R Soc Med. 1993;86:566-568.

9. Taylor J, Chadwick DW, Johnson T. Accident experience and notification rates in peoplewith recent seizures, epilepsy or undiagnosed episodes of loss of consciousness. QJM.1995;88:733-740.

10. Dalrymple J, Appleby J. Cross sectional study of reporting of epileptic seizures to generalpractitioners. BMJ. 2000;320:94-97.

11. van der Lugt PJ. Traffic accidents caused by epilepsy. Epilepsia. 1975;16:747-751.

12. Taylor J, Chadwick D, Johnson T. Risk of accidents in drivers with epilepsy. J NeurolNeurosurg Psychiatry. 1996;60:621-627.

13. Popkin CL, Waller PF. Epilepsy and driving in North Carolina: an exploratory study. AccidAnal Prev. 1989;21:389-393.

14. Fountain AJ Jr, Lewis JA, Heck AF. Driving with epilepsy: a contemporary perspective.South Med J. 1983;76:481-484.

15. Fisher RS, Parsonage M, Beaussart M, et al. Epilepsy and driving: an international perspec-tive. Joint Commission on Drivers’ Licensing of the International Bureau for Epilepsy and theInternational League Against Epilepsy. Epilepsia. 1994;35:675-684.

16. Hansotia P, Broste SK. The effect of epilepsy or diabetes mellitus on the risk of automobileaccidents. N Engl J Med. 1991;324:22-26.

17. Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association between sleepapnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med.1999;340:847-851.

18. Friedland RP, Koss E, Kumar A, et al. Motor vehicle crashes in dementia of the Alzheimertype. Ann Neurol. 1988;24:782-786.

19. Lerman Y, Matar M, Lavie B, et al. Effect of valvular heart diseases, migraine headaches,and perianal diseases on the risk of involvement in motor vehicle crashes. J Trauma.1995;39:1058-1062.

20. Hansotia P, Broste SK. Epilepsy and traffic safety. Epilepsia. 1993;34:852-858.

21. Owsley C, Stalvey B, Wells J, et al. Older drivers and cataract: driving habits and crash risk.J Gerontol A Biol Sci Med Sci. 1999;54:M203-M211.

22. Norton R, Vander Hoorn S, Roberts I, et al. Migraine: a risk factor for motor vehicle driverinjury? Accid Anal Prev. 1997;29:699-701.

23. Horstmann S, Hess CW, Bassetti C, et al. Sleepiness-related accidents in sleep apneapatients. Sleep. 2000;23:383-389.

24. Owsley C, McGwin G Jr, Ball K. Vision impairment, eye disease, and injurious motor vehiclecrashes in the elderly. Ophthalmic Epidemiol. 1998;5:101-113.

25. Owsley C, Ball K, McGwin G Jr, et al. Visual processing impairment and risk of motor vehi-cle crash among older adults. JAMA. 1998;279:1083-1088.

26. Gresset J, Meyer F. Risk of automobile accidents among elderly drivers with impairmentsor chronic diseases. Can J Public Health. 1994;85:282-285.

27. Redelmeier DA, Tibshirani RJ. Association between cellular-telephone calls and motor vehi-cle collisions. N Engl J Med. 1997;336:453-458.

28. Violanti JM, Marshall JR. Cellular phones and traffic accidents: an epidemiologicalapproach. Accid Anal Prev. 1996;28:265-270.

29. Violanti JM. Cellular phones and fatal traffic collisions. Accid Anal Prev. 1998;30:519-524.

30. Waller JA. Chronic medical conditions and traffic safety: review of the California experi-ence. N Engl J Med. 1965;273:1413-1420.

31. National Institute on Alcohol Abuse and Alcoholism. Alcohol and trauma. Alcohol Alert. Vol.3. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 1989.

nication with regard to their seizure activity. Of epilepticdrivers experiencing a seizure in the last year, only 25% to28% reported the episode to their physician for fear ofbeing reported to the licensing authorities.6,8,10 Further-more, 90% of patients with epilepsy would not self-reporttheir illness to licensing authorities.5,6,8-11 Even aftercounseling and encouragement from a neurologist, only27.1% of drivers reported their condition to the licensingagency.9 Finally, when questioned regarding what theywould do if their licenses were revoked, a substantialnumber admitted they would continue to drive.6,8,10

Because of the current reporting laws, epileptic patientsfail to obtain appropriate care for their condition, whichmay inadvertently increase their MVC risk. Bornemann,7

an epileptic driver, summarized the issue as follows:“When the practice of medicine or law creates a regula-tion without full regard for its consequences in the lives ofthose affected, more harm may result than the good whichwas intended.”

Because of this conflict, the Epilepsy Foundation ofAmerica has firmly opposed mandatory reporting lawssince 1974.3 They argue that epilepsy is “not a communi-cable disease, …poses no threat to public health,” andthat physician reporting “violates and destroys the physi-cian-patient relationship.” They conclude the following:“Proper diagnosis and treatment of epilepsy dependsgreatly upon the development of an honest, trusting rela-tionship between an individual and his physician. Accurateinformation concerning seizure activity is of critical im-portance. If a patient knows or fears that his physician isobligated to report him to the state, he may withhold cru-cial information with potentially fatal consequences.”The Epilepsy Foundation of America does recognize thatthere may be situations in which the immediate risk to thepatient and public outweigh the consequences of report-ing.45 They support voluntary reporting in these limitedsituations and “good faith” immunity for the physician.

Physician reporting of epileptic patients is ineffectiveand unnecessary. Only a small percentage of MVCs in-volving epileptic drivers are a result of seizures. The relativerisk for MVCs involving epileptic drivers is comparable orlower than those of more prevalent conditions that are notsubject to similar mandatory reporting requirements.These reporting statutes are discriminatory and destruc-tive to patient-physician confidentiality and should berepealed.1. Krumholz A, Fisher RS, Lesser RP, et al. Driving and epilepsy. A review and reappraisal.JAMA. 1991;265:622-626.

2. Krumholz A. Driving and epilepsy: a historical perspective and review of current regulations.Epilepsia. 1994;35:668-674.

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32. Brison RJ. Risk of automobile accidents in cigarette smokers. Can J Public Health.1990;81:102-106.

33. Leveille SG, Buchner DM, Koepsell TD, et al. Psychoactive medications and injurious motorvehicle collisions involving older drivers. Epidemiology. 1994;5:591-598.

34. Heikkila VM, Turkka J, Korpelainen J, et al. Decreased driving ability in people withParkinson’s disease. J Neurol Neurosurg Psychiatry. 1998;64:325-330.

35. Gold DR, Rogacz S, Bock N, et al. Rotating shift work, sleep, and accidents related tosleepiness in hospital nurses. Am J Public Health. 1992;82:1011-1014.

36. Steele MT, Ma OJ, Watson WA, et al. The occupational risk of motor vehicle collisions foremergency medicine residents. Acad Emerg Med. 1999;6:1050-1053.

37. Lyznicki JM, Doege TC, Davis RM, et al. Sleepiness, driving, and motor vehicle crashes.Council on Scientific Affairs, American Medical Association. JAMA. 1998;279:1908-1913.

38. Maxwell RD, Leyshon GE. Epilepsy and driving. BMJ. 1971;3:12-15.

39. Baker SP, Spitz WU. An evaluation of the hazard created by natural death at the wheel. NEngl J Med. 1970;283:405-409.

40. Fatality Analysis Reporting System (FARS) Web-Based Encyclopedia. National HighwayTraffic Safety Administration, Fatality Analysis Reporting System Web Site. Available at:http://www-fars.nhtsa.dot.gov. Accessed July 9, 2001.

41. Traffic Safety Facts 1999. National Highway Traffic Safety Administration Web Site.Available at: http://www.nhtsa.dot.gov. Accessed July 9, 2001.

42. Gislason T, Tomasson K, Reynisdottir H, et al. Medical risk factors amongst drivers in sin-gle-car accidents. J Intern Med. 1997;241:213-219.

43. Crancer A Jr, O’Neall PA. A record analysis of Washington drivers with license restrictionsfor heart disease. Northwest Med. 1970;69:409-416.

44. Masland RL. The physician’s responsibility for epileptic drivers. Ann Neurol. 1978;4:485-486.

45. Berger JT, Rosner F, Kark P, et al. Reporting by physicians of impaired drivers and poten-tially impaired drivers. The Committee on Bioethical Issues of the Medical Society of the Stateof New York. J Gen Intern Med. 2000;15:667-672.

46. Fisher RS, Vickrey BG, Gibson P, et al. The impact of epilepsy from the patient’s perspec-tive. I. Descriptions and subjective perceptions. Epilepsy Res. 2000;41:39-51.

47. Social aspects of epilepsy in the adult in seven European countries. The RESt-1 Group.Epilepsia. 2000;41:998-1004.