Rideshare Dilemma

The attending is considering reporting the alcohol abuse to the patient’s employer but calls for an ethics consult since she is unsure if it is the right move. It’s a public hazard to have a driver potentially operating a passenger vehicle while intoxicated; however, reporting may violate confidentiality standards and could cost the man his livelihood. Should the patient be reported to the ride-share company?

Physicians and other medical professionals operate under the principles of beneficence and non-maleficence, meaning they are charged with weighing the benefits and risks of procedures to “do good” for the patient and to avoid harm at all costs.

The physician must also respect patient autonomy and find a way to advise him without taking away his decision-making power. This case questions patient autonomy outside of the examination room. It asks whether it’s ethical for a physician to inform a patient’s employer of a health issue, thereby taking away the patient’s autonomy to make that disclosure, but acting for the benefit of the public.

So, how do we respect autonomy and confidentiality when there is a risk of harm to the patient and/or others? Mental health providers are required to warn any intended victims of threats of serious harm from their patients—should this idea be expanded outside of mental health? This type of mandatory reporting is already controversial and requires that the provider has a certain amount of evidence that indicates a serious threat.

In the case of our ride-share driver, the identified risk is based on the potential for an overlap between working hours and drinking activity, not on concrete evidence of drunk driving behavior. It may be problematic to report a patient without any verification of wrongdoing, but it may also be unethical to wait for a disaster to happen.

Disclosure of this type of information to an employer could conceivably prevent damage to the individual and others. But it could also lead to job loss and other consequences that further harm the patient and perpetuate the alcohol abuse. As a physician, whose well-being do you prioritize?

There is also the question of consistency and avoiding discrimination. How do we decide which professions should be held to this standard? It is likely that most companies have rules—spoken or unspoken—prohibiting intoxication at work. But when should a physician get involved and report behavior that could potentially be occurring during work time? And how do physicians avoid letting discrimination and bias influence who and at what point they report?

The two options are:

1. Look out for the common good: Report the patient’s alcohol abuse to his employer, breaking confidentiality and risking the patient’s loss of a job and subsequent consequences, but diminishing the likelihood of serious harm to the patient, riders, and pedestrians.
2. Maintain complete patient-provider confidentiality: Don’t report the alcohol abuse, but work with the patient to address the issue and make them aware of the risk they are posing to the community.

Ultimately, upon the recommendation of ethics consultants, the provider did not report the patient, because of a lack of sufficient evidence to prove a serious and imminent threat, but did counsel him.