In the United States,a driver's license is a passport to adulthood. In both rural and suburban areas, access to a motor vehicle is often essential for independence and employment. Even in many urban areas, driving is required for some jobs or to reach certain locations for work or pleasure.
Driving applicants must meet the criteria set forth by their state to qualify for a driver's license. Applicants in all states must be older than a minimum age (usually 16 or 17 years), must not have a medical disorder that would make driving dangerous, and must pass a written test, a vision test, and a driving test.
The laws determining which medical conditions disqualify someone from obtaining a driver's license vary from state to state. In many states, the laws have become more liberal in recent years, resulting in fewer restrictions for people with epilepsy. The laws are written to protect public safety and to grant the privilege of driving to people who are the least likely to have an accident. Compared with those of most European nations, however, our driving restrictions are quite liberal. In some European countries, for example, a single tonic-clonic seizure in adulthood prohibits holding a license for the rest of the person's life.
Many people do not recognize that absence or complex partial seizures while driving can be just as dangerous as tonic-clonic seizures. Furthermore, the risk of injury or death is not restricted to the driver and passengers but applies to pedestrians and people in other vehicles. Studies have shown that the rate of motor vehicle accidents for people with epilepsy is higher than the average rate, but nowhere near the rate for those who drink and drive. In some cases, accidents involving epilepsy are caused by people, especially men, who are driving without a license or who fail to report their epilepsy when applying for a license.
To obtain a driver's license in most states, a person with epilepsy must be free of seizures that affect consciousness for a certain period of time and may be required to submit a doctor's statement of opinion that the person can drive safely. The seizure-free period varies from state to state. The recent trend is away from requiring an "absolute period" of being seizure-free toward a shorter interval of freedom from seizures. Although some states still require a period of at least 1 year during which the person with epilepsy is seizure-free, most consider exceptions that would permit someone to drive after a shorter seizure-free interval. A recent conference of professional and lay epilepsy organizations recommended a seizure-free period of 3 months for driving privileges. In some states, the doctor who cares for the person with epilepsy must fill out a form stating that it is safe for the person to drive and recommending licensure. This recommendation is used as one of several factors in making a decision. In states that do not require a specific seizure-free period, the doctor's recommendation often carries considerable weight.
In most states, the medical information submitted by the applicant and the doctor is reviewed by personnel in the state's department of motor vehicles (or equivalent department). In complex cases, or those in which the decision is uncertain, the information is usually forwarded to a consulting doctor or the state's medical advisory board. Most states have such a board, which may also hear appeals concerning decisions to deny or revoke drivers' licenses.
Decisions made by the motor vehicle department can be appealed by requesting an administrative hearing before the medical advisory board or another designated body. If the administrative decision is not favorable, the applicant can request a review by a judge. Such requests must be made within a specified period.
In some states, someone with persistent seizures may be allowed to drive if the seizures do not impair consciousness or control of movement, occur only during sleep, are consistently preceded by an aura, are restricted to a certain time of the day (such as within an hour after awakening), or occur only when the antiepileptic medications are reduced or stopped on the advice of a doctor. A letter from the doctor confirming the presence and consistency of these features is often required by the state motor vehicle agency. If a driver's license is revoked because of a breakthrough seizure surrounded by extenuating circumstances (reduction of medication on a doctor's advice or unusual stress such as the death of a loved one, for instance) the driver may appeal the decision, as described earlier. Evidence that the person takes the prescribed medications is often required, and the level of the antiepileptic drug in the blood is usually provided as confirmation of compliance. In many states, persons who do not meet the requirements for a regular driver's license may be granted a restricted license. This license may allow a person with epilepsy or other disabilities to drive under certain conditions, such as during daytime only, to and from work within a certain distance from the home, or only during an emergency.
The U.S. Department of Transportation (DOT) prohibits anyone with a history of epilepsy from driving a truck between states. These regulations are currently under review, however. For advice about the current rules, a person with epilepsy should contact the DOT.
Regulations for driving a truck or bus within one state vary from state to state. Some states have restrictive policies that prohibit any person with a history of epilepsy from driving a commercial vehicle. Others review each case individually.
Most states that grant drivers licenses to people with epilepsy require periodic medical reports. These reports document that seizure control has not deteriorated and that the person is taking or does not need to take medications. If the seizures have stopped or have been controlled for more than 3 to 5 years, most states will no longer require periodic medical reports.
Regardless of the reporting requirements, if seizures recur and impair consciousness or control of movement, it is imperative to stop driving and consult the doctor, who may be able to suggest changes in lifestyle (such as more sleep) or adjustments in medications that may restore seizure control.
A person with epilepsy may be civilly or criminally liable for a motor vehicle accident caused by seizures. Liability may occur when a person drives against medical advice, without a valid license, without notifying the state department of motor vehicles of the medical condition, or with the knowledge that he or she is prohibited from driving.
A small number of states have "mandatory reporting laws" requiring that doctors report persons with epilepsy and other disorders that may make driving hazardous. These laws generally order the doctor to notify the department of motor vehicles of the person's name, age, and address. In these states, doctors may be liable for negligence if they fail to report a person with epilepsy who is later involved in a motor vehicle accident. In states without such laws, however, the question of whether a doctor should report a patient who may be driving unsafely presents a difficult conflict between public safety and the doctor's need to respect the privacy of the relationship with the patient. In theory, a physician who reports a patient's condition could be sued for disclosing confidential information. As discussed later, the state of Connecticut has attempted to establish a middle ground in this conflict. In states that do have mandatory reporting laws, the specifics of when a doctor must report someone can be vague. In New Jersey, for example, the law states that the doctor will report any person 16 years of age or older for recurrent convulsive seizures or for recurrent periods of unconsciousness or for impairment or loss of motor coordination due to conditions such as, but not limited to, epilepsy in any of its forms when such conditions persist or recur despite medical treatments. This law is open to some interpretation. For example, it remains unclear what constitutes "medical treatments." The plural usage indicates that more than one treatment has failed to control the seizures but does not specify how many dosage adjustments or medications must have been tried.
Mandatory reporting laws were repealed in Connecticut in 1990. However, if a physician in Connecticut cares for a person whose seizures are so poorly controlled that driving would present a serious risk to public safety, and there is evidence that the person continues to drive, the doctor can report the person with immunity from lawsuit by the patient. Such cases are rare. Connecticut's approach to mandatory reporting strikes a balance between the rights of the individual and the public's safety.
The chief problem with mandatory reporting is that it can interfere with the doctor-patient relationship. In many cases, those who believe that they "must" drive will lie to the doctor about their condition in order to avoid mandatory reporting and potential loss of the driver's license. This is the worst of both worlds: the person is not receiving the best medical care and is driving. If the doctor and patient can work together, the seizures are likely to be better controlled, and the person can drive more safely.
The most common penalty for a physician's failure to report a patient under mandatory reporting laws is a fine, usually ranging from $5 to $50. However, an accident can lead to a lawsuit charging wrongful death or injury, with a large judgment against the doctor. In states that require mandatory reporting, compliance varies widely among doctors.
Doctors who state that it is safe for a person with epilepsy to drive and recommend licensure could also face some liability in case of an accident, although it appears to be minimal. Very few cases have been brought against a doctor by a third party who was injured in a motor vehicle accident allegedly caused by a person with epilepsy. Doctors should not be liable for recommendations made to the department of motor vehicles if their opinions are reasonable and consistent with good medical care. Some states grant immunity from liability to doctors who make recommendations about driving privileges.
Topic Editor: Steven C. Schachter, M.D.
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