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INTENT
The intention of all the laws and regulations regarding epilepsy (re: driving) is to protect the driver, other motorists, and pedestrians. The balance between risk and personal freedoms has favored the risk side (often in a punitive fashion). Although the laws and regulations are strict, enforcement is non-existent, and depends on reporting by patients, or in a few states, mandatory reporting by doctors.
Neurologic disorders constitute dangers through alteration of consciousness, alteration in cognition, or loss of motor control. Either type can impair one's driving ability. The PRIVILEGE (not right) to drive is predicated on existing abilities, or risk for transient or permanent disability. Therefore, a demented patient, stroke patient with hemiparesis, etc would be precluded from driving. Uncontrolled TIA's, uncontrolled seizures (and pseudoseizures), recurring syncope would constitute unacceptable future risk to retain a license.
Risk Assessment
Do drivers with uncontrolled seizures pose a risk on the road? Yes.
But the real question is how much risk. Until 20 yrs ago, no studies were performed to measure this. Subsequently, epidemiology in the US and other countries (notably Israel and Scandinavian countries) have shown either no increased risk compared to the general population, or up to double the risk of accidents. Refinements have come in trying to assess risk based on type of epilepsy, past history of control, type of vehicle being driven. Unfortunately, this has produced marginal results. Scientific evidence is usually ignored in favor of strong political voices. Fortunately, the lobbying effort by physicians and patients has produced a gradual reduction in the period needed to be seizure free, and the exceptions for driving have been liberalized. Seizure free period in the U.S. ranges from 3 months (many states) to 2 years (Vermont). Many states have no seizure free interval defined and leave it discretionary. Some states require periodical medical re-evaluation.
Interstate Trucking
A bit of a loop hole, in that individual States have no say here, it is Federally regulated, and little attention is often paid to it.
Law versus Regulation
Each state has it's own laws about driving. They are all vague with regards to epilepsy and other medical conditions.
Regulations are the detailed implementation of the laws by the Dept. of Public Safety (DPS), Dept. of Transportation (DOT), Department of Motor Vehicles (DMV), or whatever it is called in that state.
Your license is valid until DPS knows you have epilepsy and sends you a letter revoking your license. Legally, unless you get a letter you can still drive. However, your civil responsibility applies, and lawsuits against you for accidents can be filed.
Medical Advisory Boards (MAB) exist in some states to assist the Departments. These boards often have formal guidelines.
Appeal Processes
The ability to appeal the decision of the drivers licensing division is sanctioned in some states with an appeals process spelled out through the Department of Motor Vehicles. Others are at the mercy of the courts and the judicial system.
Physician Obligation
Mandatory reporting is in effect in a few states. Physicians are given legal immunity ONLY if they reports patient. Failure to report puts the physician at risk and several lawsuits have ruled in favor of the patient (and against the physician for NOT reporting).
In states without mandatory reporting, the physician's refusal to report the patient's condition to the State is protected by the patient-physician contract. However, do not confuse this privileged status with a mandate that you must not or can not report the patient's medical condition to the State. The physician can report patients as a concerned citizen. The patient may then be requested to re-apply for license. The patient will then be asked if they have seizures. The legal onus is on the patient, not physician.
In all states, physicians should inform patients of the law.
Well meaning Physicians
Physicians CAN NOT tell the patient whether they can drive, that is the State's function. Some States are supportive (such as Oklahoma) of physician guidelines for their individual patients, but only if the recommendations are sensible. Physicians should be careful making recommendations such as "be careful" "only drive a short distance" "only drive in the daytime" "oh, it's ok, you only have a seizure disorder (not epilepsy)". You've put yourself in an untenable legal situation unnecessarily. If the physician is really concerned for the safety and welfare of his patient (and the community at risk to this unsafe driver), and but is unwilling to report (or inform) their patient, they can refer the patient to an Epilepsy Center!
Patient Obligation
Patients lie on their applications which ask if they have seizures or medical disorders.
Patients drive without licenses.
Patients drive when drunk and with uncontrolled seizures.
Patients will complain that they MUST drive. As inconvenient as it might be, driving is a privilege, not a right. And they have no "right" to kill someone else in an accident. They may go on to say that although they have seizures, they have never had an accident, implying they will remain safe drivers. I tell them it only takes one seizure to change that record, and no patients of mine has ever come back to clinic to tell me I was right after they had a fatal accident.
Insurance
Patients driving illegally have financial risk, as their insurance carrier no longer need pay claims, even if they are unrelated to seizures.
Photo ID
Patients may obtain a photo ID to replace their driver's license in all states.
Debate on Mandatory Reporting
The number of States requiring this is deceasing. [ CA, DE, NV, NJ, OR, PA ]
Pro - like communicable disease, physician is obliged to the common good.
Con- interferes with patient/physician relationship.