Winning Clinical Ethics Essay
Addresses Familiar Tough Topic
ASCO and its Ethics Educators Special Interest Group are pleased to announce Negar Sohbati as the winner of the 2019 Student Award in Clinical Ethics. Negar is a member of the Illinois College of Optometry’s Class of 2020. Her winning essay, “Optometrist as Mandatory Reporter: What is Our Obligation to Keep the Roads Safe for All?” appears below.
The award competition, sponsored by Alcon, is open to optometry students during any point in their professional program at an ASCO-affiliated school or college of optometry. The winner receives an engraved plaque and $1,000. ASCO thanks all the students who submitted essays.
Optometrists as Mandatory Reporters:
What is Our Obligation to Keep the Roads Safe for All?
By Negar Sohbati
Given that driving is a highly visual task, the role of vision in road safety requires careful consideration.1 In Illinois, it is a driver’s responsibility to report any vision deterioration to the Secretary of State within 10 days of becoming aware or being notified.2 Optometrists are not required to report any changes in a patient’s visual acuity or visual field to the Department of Motor Vehicles (DMV) because Illinois is not a mandatory reporting state.2
Researchers have found that older drivers with cataract have restriction in driving mobility, a decrease in safety on the road, and a higher rate of crash involvement than those without cataract.3,4 Because driving is directly linked to mobility and independence, individuals may not fulfill their duty to report vision impairment for fear of receiving a license restriction or revocation.5 In light of this, optometrists should carefully consider how driving restrictions are discussed with patients. First, they must consider reporting procedures in their jurisdiction, as the criteria for restricted licenses are often set by state DMVs. Second, optometrists should consider how to best discuss driving limitations with their patients with special attention to impact on the patients’ quality of life. Currently, only 12% of states require mandatory reporting.6
One could argue it may be safer for all states to require reporting by optometrists. Perhaps optometrists should be asking about patients’ driving habits and confirming driving eligibility at each visit. In caring for these patients, optometrists may face moral and ethical dilemmas, aspects of which are considered in this case report.
Older Drivers on the Road
Older individuals make up a large percentage of drivers on the road.7 Given that cataract is the leading cause of vision impairment in adults older than 60, it is important to consider its associations with road safety.4 Cataract can cause deficits in visual acuity and contrast sensitivity and problems with glare in older individuals.8 These factors are associated with difficulty driving in the rain, at night, during rush hours, alone, and making left turns in traffic.4 Several studies have found a statistically significant association between cataract and at-fault crash involvement.3,4 Elderly drivers may have a hard time accepting their visual impairment as it is directly tied to their independence. Sarkin et al. showed that among 376 pre-cataract-surgery patients, only 12.3% reported stopping nighttime driving due to visual impairment.9 This demonstrates that, although cataract surgery can improve vision, some patients may choose to ignore their visual limitations.
Patient Reports Cloudy Vision, Difficulty with Glare while Driving
Patient RT presented to the Illinois Eye Institute in December 2018 with a chief complaint of cloudy vision including difficulty with glare when driving. These symptoms, however, did not prevent her from driving daily. She worked in a cafeteria for a catering company and reported driving herself to and from work, often in the dark during the winter months. She had entering best-corrected visual acuity of 20/70 OD, 20/100 OS, and 20/70 OU. Her suprathreshold driving visual field test results (Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA) showed greater than 140° of peripheral visual field. Vision was not improved with refraction in either eye. Slit lamp evaluation revealed bilateral 2+ nuclear sclerotic and 3+ cortical cataracts.
Per the state’s DMV guidelines, drivers require a minimum binocular visual acuity of 20/40 and 140° of peripheral vision.2 Drivers with binocular visual acuity between 20/41 and 20/70 are limited to daylight driving only.2 Drivers with monocular visual acuity of 20/100 or worse in one eye are permitted to operate only vehicles that have both outside rearview mirrors.2 According to these standards, this patient required a restriction: daytime only driving and both rearview mirrors. With her borderline visual acuity, it was stressed that at a future visit she may no longer meet the cut-off to drive at all.
Contrast sensitivity also plays a significant role in safe driving; reduced levels put older drivers with cataract at an elevated risk for accidents.7 Specifically, drivers with a history of crash involvement are six times more likely to have severe contrast sensitivity impairment in both eyes when compared to their crash-free counterparts.7 Bal et al. evaluated cataractous eyes and found that 31% of individuals with visual acuity meeting driving requirements would be considered unfit to drive based on a contrast sensitivity cut-off value of below 1.25 log.8 Moreover, this patient population is at risk of being involved in car accidents, even if decreased contrast sensitivity is present in only one eye.9 These study results suggest states should consider not only visual acuity but also decreased contrast sensitivity in determining driving fitness.
Because contrast sensitivity is not one of the required tests for driving certification in Illinois, it wasn’t included in RT’s initial workup. However, it could be a consideration at a follow-up visit should the patient continue to drive. If the DMV were to consider revising current requirements to undertake a more comprehensive assessment of safety, adding contrast sensitivity testing may be a simple addition. Validated contrast sensitivity tests such as the Pelli-Robson, MARS or Vistech chart could be administered to drivers older than 60 with visual acuity worse than 20/40. Further research would be necessary to determine precise cut-offs for any test implemented.
Mandatory Reporting for All States?
Legal and ethical quandaries surround the discussion of the safety of elderly motorists. Optometrists who practice in non-mandatory reporting states may strive to find a balance between protecting themselves from legal action, while also protecting their patients and those with whom they share the road. Conversations with patients are challenging because driving cessation can lead to a loss of independence and an overall decrease in general well-being.1,5 In Illinois, optometrists cannot be included in any lawsuit filed by victims of a car accident in the event the at-fault party had continued to drive against their recommendation to cease driving or to self-report.2 However, being proactive and mandating reporting for all states could spur the creation of infrastructure to connect patients to social services or transportation options, while also preserving public safety.
Patient RT was educated on her vision changes and the nature of her cataract. She was informed that, contrary to her personal beliefs, her vision couldn’t be corrected with an updated spectacle prescription. Surgical intervention would be required to improve her vision for safe driving at night. As is the case with many patients, she was hesitant about surgery and did not think it was an immediate necessity. However, she did agree to schedule a cataract consultation for February 2019. The Illinois Vision Report Form was completed to demonstrate to the patient her driving limitations and exact restrictions. Although the need for her to self-report to the DMV was emphasized, when my attending faculty left the room, the patient repeatedly asked, “You will not be submitting any forms to the DMV, right?” Given the explanation of the situation, the patient felt a sense of loss of independence and automatically verbalized her dissatisfaction. She continued to be in denial of the information given to her and to ask questions such as “How am I to get back home from work every night?” She expressed that she did not want to burden her daughter with driving her around.
As outlined in the code of ethics published by the American Optometric Association, “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.”12 Thus, it is an optometrist’s duty to understand the patient’s living situation and the availability of any support system. Other options for these patients may include requesting leave through the Family and Medical Leave Act, if their condition is disabling. The law provides employees with up to 12 weeks of unpaid, job-protected leave per year.11 Those who are willing to undergo surgery in the short-term may not feel the need to self-report nor acquire a restricted license, only to get it re-instated after surgery; therefore, careful discussions and documentation of recommended limitations should occur with each patient, including his or her obligations with the DMV.
Considering the statistics on elderly driving accidents, current reporting procedures as well as criteria for a restricted license in Illinois could be deemed insufficient. Furthermore, if optometrists were mandated to report vision changes such as those in this case study to the DMV, patients might be more willing to cease driving when recommended knowing they are legally bound to do so. In addition, given the symptoms of cataract, the DMV could require additional information about drivers’ contrast sensitivity to better determine driving eligibility, especially for nighttime driving. These measures could help remedy the alarming rates at which older drivers with deteriorating vision are involved in at-fault motor vehicle accidents. Road safety cannot be overlooked, and these preventative measures could help optometrists lead the way toward much needed improvements in public safety.
- Wood JM, Owsley C. Vision and driving: a look at the research road ahead. Clin Exp Optom. 2016 Sep;99(5):393-4.
- Illinois rules of the road 2019 [Internet]. Springfield, IL: State of Illinois. Available from: https://www.cyberdriveillinois.com/publications/pdf_publications/dsd_a112.pdf
- Owsley C, McGwin G Jr, Sloane M, Wells J, Stalvey BT, Gauthreaux S. Impact of cataract surgery on motor vehicle crash involvement by older adults. JAMA. 2002 Aug 21;288(7):841-9.
- Owsley C, Stalvey B, Wells J, Sloane ME. Older drivers and cataract: driving habits and crash risk. J Gerontol A Biol Sci Med Sci. 1999 Apr;54(4):M203-11.
- Edwards JD, Lunsman M, Perkins M, Rebok GW, Roth DL. (2009). Driving cessation and health trajectories in older adults. J Gerontol A Biol Sci Med Sci. 2009 Dec;64(12):1290-5.
- Current screening and assessment practices. State policy affecting community mobility: variability across the country [Internet]. Washington, DC: National Highway Traffic Safety Administration; [cited Jan 16, 2019]. Available from: https://one.nhtsa.gov/people/injury/olddrive/CommMobilityDementia/pages/CurrentScr-StatePolicy.htm
- Owsley C, Stalvey BT, Wells J, Sloane ME, McGwin G Jr. Visual risk factors for crash involvement in older drivers with cataract. Arch Ophthalmol. 2001 Jun;119(6):881-7.
- Bal T, Coeckelbergh T, Van Looveren J, Rozema JJ, Tassignon MJ. Influence of cataract morphology on straylight and contrast sensitivity and its relevance to fitness to drive. Ophthalmologica. 2011;225(2):105-1.
- Rubin GS, Adamsons IA, Stark WJ. Comparison of acuity, contrast sensitivity, and disability glare before and after cataract surgery. Arch Ophthalmol. 1993 Jan;111(1):56-61.
- Sarkin AJ, Tally SR, Wooldridge JS, Choi K, Shieh M, Kaplan RM. Gender differences in adapting driving behavior to accommodate visual health limitations. J Community Health. 2013 Dec;38(6):1175-81.
- Family and Medical Leave Act [Internet]. Washington, DC: U.S. Department of Labor. [cited Jan 7, 2019]. Available from: https://www.dol.gov/whd/fmla/.
- Code of Ethics [Internet]. St. Louis, MO: American Optometric Association; c2019 [cited Jan 7, 2019]. Available from: https://www.aoa.org/about-the-aoa/ethics-and-values/code-of-ethics