The 2009 Giller Prize winning The Bishop’s Man by Linden MacInytre is a detailed study of the trials and tribulations of being, as one reviewer put it, an enforcer. In this fictional tale, the enforcer is an ecclesiastic whose character, intelligence and unique experiences at the outset of his vocational life render him suitable for carrying out the delicate task of dealing with pervasive wickedness within his organization, while bolstering the public reputation of the institution as an agency of goodness.
While there are many occupations more obviously aligned with an ‘enforcer’ role, the police and crown prosecutors for example, the complexity of the ‘enforcer’ portrait in this novel came to mind in reading about the role that Canada’s cardiovascular medical doctors say they are being asked to play—and their distaste for it—with respect to patients whose medical condition may render them unfit to drive.
When the facts are clearly established and the risks quantifiable, at least the purposefulness of an enforcer’s task is unquestionable. The suitability of the ‘solution’ is the main difficulty. And so say the doctors who are required by law in seven Canadian provinces to report to the motor vehicle licensing authority patients whose physical condition may render them unfit to drive.
The most common reportable physical ailments include cardiovascular disease with the potential for heart attack or stroke, heart arrhythmias with the potential for loss of consciousness or stroke, and neurological disorders with the potential for seizures or fainting. In Alberta, Quebec, and Nova Scotia a doctor’s duty to report is discretionary.
This issue was a matter of debate at the Canadian Cardiovascular Society annual meeting in late October of this year. Physicians who oppose these stringent reporting requirements argue that the consequences of their compliance can be unfair to their patients and harmful to the doctor-patient relationship. Patients become reluctant to disclose their symptoms, distrustful and angry.
Some go so far as to question whether this ‘solution’ is an answer to the problem. Dr. Chris Simpson, Professor of Medicine and Chief of Cardiology at Queen’s University in Ontario and Medical Director of the Cardiac Program at Kingston General Hospital (Ontario) was quoted as saying, “We all have this sinking feeling that we’re reporting all these patients and causing them all this distress and hardship, and there’s no proof it is doing any good. … Most of the people we’re removing from the road, never would have had a problem. … It’s really very difficult for us to try to predict who is destined to have a medical illness behind the wheel.”
Dr. Simpson, who lists medical fitness to drive as one of his key areas of research interest, said he reports as many as 150 patients per year to the Ontario Ministry of Transportation. The real risk may come not from patients under treatment but from others. One report indicated that, “95% of drivers who lose control of a vehicle because of a heart condition did not even know they had a problem.”