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Controversies in Internal Medicine
October 13, 2003

Rebuttal by Dr Fitten

Arch Intern Med. 2003;163(18):2132. doi:10.1001/archinte.163.18.2132-a

CONGRATULATIONS to Dr Fain on her excellent contribution to this debate. She makes several good points, for example, the ease with which statistics can be used to support one position or another. Furthermore, she underscores the competing ethical standards of respect for individual autonomy vs benefit or good for the collectivity that are at the heart of this debate, and she argues forcefully in clear favor of the virtues of individual autonomy.

From my perspective, I see this confrontation of values on which the debate hinges as much more dilemmatic and difficult to resolve. I differ from Dr Fain in that I believe that she fails to adequately consider the impact on driving ability of the exponentially increasing vulnerability of elders to diseases that impair cognition, mobility, and vision such as Alzheimer, Parkinson, and cerebrovascular disease, severe osteoarthritis, macular degeneration, and others. These conditions can have a profound negative effect on driving ability and safety. It is, however, critical to distinguish healthier older persons, certainly the majority among the elderly, from those who are clearly affected by these conditions that could impact driving. It is also very important to distinguish those with problematic diagnoses who can still drive safely from those who cannot. I agree with Dr Fain that we do not yet have adequate screening tests that are effective and practical to administer, but this does not mean we should abandon our efforts to develop them. Good tests will allow us to identify the minority of older drivers who are at greatest risk for collisions and who may unfortunately be causing a bias against and fear of all older drivers, most of whom are really safe on the road.

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