Patient Case

A 62-year-old Caucasian male presented for a low-vision evaluation on referral from his ophthalmologists. He had recently been diagnosed with a sudden onset optic neuropathy and complained that his vision in both eyes had been getting progressively worse over the last month. He also described visual phenomena suggestive of Charles Bonnet syndrome. His diagnosis was complicated by longstanding pseudoexfoliative glaucoma for which he was using brimonidine. His medical history was significant for type 2 diabetes, hypertension and leukemia, which had been in remission for four years.

Upon examination, his best-corrected vision measured 20/2400 in his right eye and counting fingers at 6 inches in his left eye. Visual field testing was inconclusive because of the patient’s inability to fixate. Despite qualifying as legally blind based on his visual acuity, the patient had not yet been registered with the Massachusetts Commission for the Blind (MCB), but he stated that he had given up driving voluntarily because he no longer felt safe doing so. As a father of four and the sole wage earner in his household, he expressed concern that his visual impairment was limiting his ability to work. In spite of the difficulty he was experiencing at work, he disclosed that he could not afford to lose his job and that he feared dismissal if the extent of his visual impairment was made public. The patient reported that he was an engineer at a nuclear power plant.

Ethical Quandary

With a single statement, this patient’s case went from being relatively straightforward to ethically complex. While often a source of ethical dilemmas, the loss of driver’s license was not this patient’s primary concern as he had already voluntarily given up driving. More problematic in this case was the patient’s fear of losing his job because of his impairment. As someone in a very specialized profession whose family depended on his ability to provide for them, he found himself facing a potentially life-altering decision, which he brought to the optometrist’s attention. From the optometrist’s perspective, what are the legal and ethical obligations in a case like this?

As with most ethical dilemmas, this case falls in a gray area. Unlike the well-defined visual requirements needed to legally obtain a driver’s license,³ most employers do not have specific visual criteria that must be met. In fact, with very few exceptions, employers are not legally allowed to inquire about or base employment decisions on knowledge of a disability such as visual impairment. In the United States, this protection is afforded to disabled individuals under the federal Americans with Disabilities Act (ADA).⁶ This law exists for obvious reasons to protect the rights and privacy of disabled individuals whose performance on the job is often a better indication of their abilities than an eye examination might be. It is not until such time that job performance is affected or there is an indication that the employee is unable to safely perform the essential functions of his/her job that an employer can even ask about a disability. Without a much more specific job description, it is impossible to tell in this case whether this patient’s job performance has been affected or if he is a safety risk.

In addition to the uncertainty surrounding this patient’s ability to safely perform his job and the employer’s right to be informed about an employee’s visual impairment, the optometrist’s role in protecting privacy is ambiguous. In general, the federal Health Insurance Portability and Accountability Act (HIPAA) prohibits disclosure of protected health information without patient consent except when required by state law.⁵ Disclosure of protected health information is also allowed, but not required, under other limited circumstances, which include measures to protect public health.⁵ Unlike the mandated reporting of legal blindness to the MCB and consequently to the Registry of Motor Vehicles (RMV),^3,4 there is no specific legal guidance to help an optometrist decide if visual impairment should be reported to a patient’s employer in a high-risk case such as this.

While release of protected health information may be legally allowed in this case, the optometrist has an ethical obligation to act in the best interest of his or patient. As defined by the Code of Ethics published by the American Optometric Association (AOA), “It shall be the ideal, resolve, and duty of all optometrists to keep their patients’ eye, vision, and general health paramount at all times; to respect the rights and dignity of patients regarding their health care decisions [and] to ensure confidentiality and privacy of patients’ protected health and other personal information.”¹ This code of ethics and the AOA’s Standards of Professional Conduct indicate that the optometrist should protect his or her patient’s confidentiality and autonomy at all costs.^1,2

From a societal point of view, however, and in light of highly publicized accidents at nuclear power plants in places like Chernobyl, Three Mile Island and Fukushima,⁷ it is reasonable and necessary to consider the potential public health impact of a visually impaired individual in a high-risk job with no margin for error. While the World Nuclear Association considers nuclear reactor accidents to be “the epitome of low-probability but high-consequence risks,”⁷ it is important to mitigate the risks, including the potential for operator error due to visual impairment. After all, the optometrist has an ethical obligation to protect the interests of both his or her patient and the general public. As stated in the Code of Ethics referenced above, “It shall be the ideal, resolve, and duty of all optometrists … to recognize their obligation to protect the health and welfare of society.”¹

When the interests of various stakeholders are so clearly in opposition, there is inherently an ethical dilemma. On one hand there is the patient’s right to autonomy and on the other is the optometrist’s obligation to society and to do good (beneficence).²

Management and Resolution

After consideration of the ethical and legal obligations in this case, an appropriate management strategy, which included a variety of low-vision aids and significant patient education, was devised. Due to the severity of vision loss, the computer application ZoomText and both a desktop and a handheld CCTV were recommended for this patient’s use. The patient also expressed interested in white cane training and was referred to an orientation and mobility specialist for this.

In addition, the patient was reported as legally blind to the MCB as required in Massachusetts and allowed by a clause in HIPAA.^3,5 One consequence of this registration is an automatic loss of driver’s license, which the patient was resigned to and willing to accept.⁴ With the optometrist’s legal obligation fulfilled and the ethical dilemma carefully considered, it was decided that it would be unethical to report the patient’s visual impairment to his employer. Instead of breaking confidentiality, the patient was provided with the information he needed to make a fully informed decision about continuing to work. He was educated regarding his rights as a legally blind individual and his employer’s responsibility to make reasonable accommodations under the law.⁶ In the interest of public safety, the patient was encouraged to communicate openly with his employer about his impairment. It was believed that as a highly educated man, the patient knew best what the visual demands of his job were and what the implications of his decision to keep working might be. By educating this patient regarding his visual impairment, his rights under the law, and asking difficult questions of him, the optometrist was able to promote beneficence while also allowing the patient to retain his autonomy.

References

1. American Optometric Association. Code of Ethics. Accessed 5 Feb 2015. https://www.aoa.org/about-the-aoa/ethics-and-values/code-of-ethics?sso=y.
2. American Optometric Association. Standards of Professional Conduct. Accessed 5 Feb 2015. https://www.aoa.org/documents/Standards-of-ProfessionalConduct_Adopted-June-2011.pdf.
3. Commonwealth of Massachusetts. MCB Registration Information for Eye Care Providers. Accessed 5 Feb 15. https://www.mass.gov/eohhs/provider/training-and-edu/vg/mcb-registration-info-for-eye-care-provider.html.
4. Commonwealth of Massachusetts. Vision Policy Statement. Accessed 5 Feb 2015. https://www.massrmv.com/rmv/medical/policies/vision.htm.
5. Department of Health and Human Services. Summary of the HIPAA Privacy Rule. Accessed 5 Feb 2015. https://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/.
6. Equal Opportunity Employment Commission. Questions & Answers about Blindness and Vision Impairments in the Workplace and the ADA. Accessed 5 Feb 2015. https://www.eeoc.gov/eeoc/publications/qa_vision.cfm.
7. World Nuclear Association. Safety of Nuclear Power Reactors. Accessed 5 Feb 2015. https://www.world-nuclear.org/info/Safety-and-Security/Safety-of-Plants/Safety-of-Nuclear-Power-Reactors/.

 Save article as PDF