Medical certificate for older drivers – an analysis of the Norwegian parliamentary debate

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    Abstract
    BACKGROUND

    BACKGROUND

    In February 2021, the Storting decided to abolish the mandatory medical certificate required for driving licence renewals for drivers over the age of 80. The decision will affect older drivers, traffic safety in general, and the everyday work of GPs in particular.

    MATERIALS AND METHODS

    MATERIALS AND METHODS

    A content analysis was performed of the parliamentary debates and supporting documentation on the issue of medical certificates for older drivers, from the time of the motion in December 2020 up to the debate on when to implement the decision in May 2021.

    RESULTS

    RESULTS

    The majority decision was founded on an anti-discrimination argument with undertones of district politics, in which the traffic safety element was relativised. A minority argued for a traffic safety policy based on a health authority decision and with an emphasis on the added overall health value. Cognitive screening tests were unanimously rejected.

    INTERPRETATION

    INTERPRETATION

    The parties that represent the majority decision framed cognitive testing in a way that suggests the decision is a reaction to these tests rather than to the medical certificate requirement as such. There was little discussion on how the decision will affect GPs' ability to identify impaired fitness to drive among the older population.

    Main findings

    Main findings

    In a majority decision, the Norwegian parliament (the Storting) voted to abolish the requirement for a medical certificate for drivers over the age of 80, on the grounds that their mobility should not be limited by an unfounded fear of traffic accidents.

    A minority argued for the precautionary principle to be applied to traffic safety on the basis of a health authority decision, and an emphasis on the added health policy value of medical certificates.

    The decision appears to be founded on objections to the cognitive test rather than to the use of a medical certificate as such.

    Article
    Introduction

    Measured by road traffic death rate per 100 000 population, Norway is one of the safest countries in the world to be a road user (1). Where accidents do occur, however, the driver is most likely to be in either the youngest or the oldest age group. Older drivers face the highest risk of being killed or seriously injured in traffic (2).

    In order to reduce age-related risks of traffic accidents, new drivers have been given twice as many points on their licence for traffic violations since 2011 (3). The oldest drivers have been required to submit a medical certificate from their GP in order to renew their driving licence (4). GPs have thus served as a control mechanism for the oldest drivers.

    In 2019, the age at which drivers become subject to the requirement for a medical certificate was increased to 80 (5). The main purpose of the medical certificate is to identify drivers' cognitive abilities, as patients with dementia are often not aware of their cognitive limitations (6). In 2019, the Ministry of Health and Care Services stressed that GPs should only test drivers' cognitive abilities where cognitive impairment was already suspected (7). The Norwegian Association of General Practitioners and the Norwegian Health Association were highly critical of the fact that the test was not carried out routinely in relation to driving licences, as it is particularly suitable for identifying incipient cognitive impairment when this is not suspected a priori (8).

    I was one of those who "raised an eyebrow", as Storting representative Arne Nævra put it when his party, the Socialist Left Party, proposed a motion to abolish the requirement for a medical certificate for older drivers in December 2020 (9). In this study, I examine the Storting's majority decision to abolish this medical certificate requirement on 1 August 2021 (9-11). The outcome of the parliamentary debate was determined by the opposition's controlling majority. However, the Minister responsible warned that the ramifications of the legislative amendment and alternative control mechanisms would have to be investigated before implementation (12). Impact assessments were performed, and based on their findings, the Minister made it clear that he would not be implementing the majority decision during his term in office (13, 14).

    Materials and methods

    Materials and methods

    The article is based on a qualitative analysis of the content and arguments of the parliamentary debate. The documentation includes the motion to abolish the requirement for older people to present a medical certificate that testifies to their fitness to drive (15), the relevant Minister's written assessment and recommendation to the Transport and Communications Committee of the Parliament (16), the committee's recommendation to the Storting (10), and transcripts of the parliamentary debates on the abolition of the medical certificate requirement (herein referred to as 'the parliamentary debate') and on the timing of the implementation of the decision (herein referred to as 'the implementation debate') (17, 18).

    Qualitative content analysis is a social science method for interpreting the meaning of texts by systematically identifying, coding, and categorising themes and patterns in context (19). Combined with argument analysis, the purpose here is to identify and assess the arguments and ideas on which relevant actors' views and decisions are based, i.e. to 'capture' the essence of the politics (20). The texts were first read and coded according to primary claims and rhetorical main points, and the justifications used by representatives to support these (research/analysis, emotional conviction, anecdotal experience, and/or relativisation) (20, 21). The arguments were then categorised under four headings or cross-party interests that permeated the debate: health policy, district policies, traffic safety, and unwarranted discrimination. These are presented according to their prominence in the lines of argumentation of the majority and the minority respectively.

    It is an important part of the principle of disclosure and transparency in public administration that parliamentary debates and the supporting material are published on the Storting's website. The Norwegian Centre for Research Data considers the processing of personal data in this analysis to be in accordance with ethical guidelines.

    Results

    Results

    When the parties representing the majority decision (the Socialist Left Party (SV), Labour Party (Ap), Progress Party (FrP), and Red Party (Rødt), herein referred to as 'the majority') voted to abolish the requirement for a medical certificate for drivers over the age of 80, their decision was founded on an anti-discrimination argument with undertones of district politics, where traffic safety was relativised. The parties representing the minority in this case (the Conservative Party (Høyre), Liberal Party (Venstre), Centre Party (Senterpartiet), Christian Democrats (KrF), and Green Party (MDG)) argued for a traffic safety policy based on a health authority decision and added value for health policy. The Red Party and the Green Party chose not to speak in the parliamentary debates.

    Arguments for abolishing the medical certificate requirement

    Arguments for abolishing the medical certificate requirement

    Unwarranted discrimination. One of the main arguments for abolishing the requirement for a medical certificate was the prevention of age discrimination against older people. One of the proposers from the Socialist Left Party emphasised that the motion was about 'stigmatisation of a group that we have tended to stigmatise in recent years [and] the decreasing respect that society is showing its elders' compared to young people (17). In the parliamentary debate, a representative of the Labour Party made reference to older drivers who had said that 'as a group, they are stigmatised and treated with suspicion' (17). The spokesperson from the Socialist Left Party further compared older drivers to high-risk groups who 'perhaps should have been screened a bit sooner: those who take drugs, are mentally ill, or have epilepsy or diabetes, etc.' (17). The Labour Party's representative followed suit in the implementation debate (18):

    'Obviously, if we were to check all drivers under the age of 25, we would probably find some that should not have been given a driving licence. But why don't we do that? Because we don't think of younger people as one group. They're individuals, and that's how we also need to think of older people.'

    However, the discrimination argument was largely about the indignity of cognitive testing, as the Socialist Left Party describes it in their motion (15):

    '… performing these tests is disrespectful to older people, and seems degrading. These tests are also biased towards well-educated people due to the theoretical and logical nature of some of the tasks.'

    Parallel to this, several representatives pointed out that the tests were not suitable for assessing driving skills and that GPs performed them on autopilot – not on the grounds of suspected cognitive impairment, as was the intention following the parliamentary debate in 2019. Several representatives made the point that doctors have a duty to report patients to the county governor if they do not meet the health requirements for driving licences, regardless of age, and that special checks are not therefore needed for older drivers (10, 15, 17).

    The representative for the Socialist Left Party stressed that their party line was based on expert reports on traffic safety from countries with no requirement for a medical certificate for older drivers (15). Several of the unwarranted discrimination arguments nevertheless appeared to be based on anecdotes and unsubstantiated claims.

    Risk assessment. The motion states that about 60 000 drivers were over the age of 80 in Norway, and that in 2019 six drivers over the age of 75 died in traffic (15). A representative from the Centre Party also highlighted how 'the number of older drivers killed or injured [has] decreased' despite the rising number of drivers in this age group (17). Against this backdrop, a representative from the Progress Party criticised the minority for 'playing the traffic safety card' and said that he felt he was being portrayed as someone who did not care about traffic safety because of his support for the motion (18).

    The spokesperson for the Socialist Left Party referred to a study conducted by the Swedish Transport Agency (22), which concluded that 'the results do not support the introduction of mandatory health checks for older drivers, because […] the probability of being involved in an accident is the same whether someone has dementia or not' (17). In the motion, the Socialist Left Party also refers to a SINTEF report from 2010 which found that drivers over the age of 65 were not more at risk than other age groups. The proposers of the motion acknowledged that the very oldest age group is 'slightly overrepresented in the accident statistics compared to average', but claimed that it is the 'youngest who are really overrepresented' (15).

    Representatives from both the Socialist Left Party and the Labour Party pointed out that the oldest drivers, by comparison, drive fewer kilometres, do less night driving, and adapt their driving to their skill level (17). A Labour Party representative further made the point that despite the requirement for a medical certificate, the fact that there are still some older drivers on the road who should not be driving shows that the measure does not work (17). One of the representatives from the Progress Party framed the opposing argument in the debate as if it was about a general fear of older drivers and about whether they should be allowed to drive or not (17):

    'There is […] nothing to indicate that the number of accidents will rise sharply (…) even if older people continue to drive. In the Progress Party, we feel that this fear is probably a bit more theoretical than it is based on reality.'

    In summary, the majority pointed out that the impact of the medical certificate requirement on road safety is undocumented, and that therefore 'the road safety argument provides insufficient grounds for special treatment [of older people] in terms of a mandatory medical certificate', as stipulated in the committee's recommendation (10).

    Rural district and health policy arguments. The majority stressed the importance of a car for mobility in more rural areas. The committee's recommendation cited the motion by stating that cars are 'the link between the home, municipal services, work, leisure activities, and shops. Older people in particular experience a drastic change in quality of life when they lose their driving licence' (10). The argument was that where the alternative to driving is an expensive taxi as opposed to a well-developed public transport infrastructure, the loss of the driving licence leads to isolation (10, 15, 18).

    The argument was linked to broader health policy considerations than the mobility of older people. A representative of the Progress Party stated that the issue 'affects several hundred thousand (sic!) people who depend on having a driving licence […] to maintain their quality of life', and added that 'we have received countless enquiries from very many older people who feel discriminated against and unfairly treated, those who have been isolated, or lost their spark, or who are frustrated and depressed' (17). During the implementation debate, this same representative appealed to the Minister of Transport and Communications (Transport Minister) as 'a person who cares a lot […] and has a big heart […] and who loves his fellow human beings very much', before talking about older people who die because they are not allowed to drive: 'older people who have simply taken their own life' because their driving licence was taken away from them (18).

    The majority also pointed to the GPs' workload and the societal costs of burdening the health service with 'checking large numbers of healthy, capable people because of their age and not their health', in the words of the Labour Party's representative in the implementation debate (18). The representative suggested rhetorically that an alternative could be to test all drivers, so that 'we can weed out even more [drivers who should not have a driving licence]'.

    In summary, the rural-oriented rhetoric was based on anecdotes, some exaggerations, and emotional pressure. None of the socioeconomic, health policy arguments were based on evidence.

    Arguments against abolishing the medical certificate requirement

    Arguments against abolishing the medical certificate requirement

    Road safety weighting. The minority was clear that their opposition to the decision related to traffic safety. The Transport Minister, Knut Arild Hareide (the Christian Democrats), pointed out that drivers over the age of 75 have a 'markedly higher risk of being killed or seriously injured' (16), according to analyses by the Institute of Transport Economics (2). He further highlighted how the documented reduced accident risk in recent years did not apply to the oldest drivers. The Minister also criticised the Socialist Left Party's use of the Swedish Transport Agency's report as a basis for claiming that dementia does not increase the risk of accidents, as one of the selection criteria for participants in the study was a dementia diagnosis given in hospital. As the Minister pointed out: 'Most people who are diagnosed with dementia at hospitals have already reached the stage […] where they are driving less, and it is therefore not surprising that no difference was found in accident risk' (17). The Conservatives also stressed that 'if the expert advice is not unambiguous, it is at least quite clear that abolishing the medical certificate requirement is not recommended' (17).

    In a letter to the Storting's Transport and Communications Committee, the Minister also criticised the use of the SINTEF report in the motion (16). He made the point that although drivers over the age of 65 are not more at risk than other age groups, the authors also state that this changes when drivers pass the age of 75, and that the difference increases as they age further (23). Hareide warned in the parliamentary debate that 'Norway is [not] a world leader in terms of road safety […] for no reason: we have chosen to maintain a regime. We have had a vision of zero accidents, but with the mindset we are seeing today from the majority, we are in many ways choosing to break with this [vision]' (17).

    For most representatives of the minority, the road safety issue was about the risk of the older drivers themselves being injured or killed. Only a few of the representatives raised the more general issue of road safety: the risk of older drivers injuring others. However, the Liberal Party's representative was clear in the parliamentary debate (17): 'It should be remembered that one person's freedom ends where another person's freedom begins. Traffic safety is such a freedom.' He used the report from the Institute of Transport Economics to support this, and summarised it as follows:

    '[Drivers] over the age of 75 [have not only] a greater chance of injuring themselves, but also others. The figures are completely unambiguous and should frighten those who are now proposing to dilute the opportunity to keep a close eye on the health of this age group.'

    The minority critically addressed the majority's use and understanding of sources in the traffic safety discussion. They explicitly referred to and cited sources for their own argument.

    Warranted differential treatment. The traffic safety argument was linked to expert knowledge about the incidence of health conditions that can make older motorists' driving unsafe. In his letter to the Transport and Communications Committee, the Transport Minister stressed the following (16):

    'Failing health poses a risk to the driver as well as their fellow road users. As people age, physiological changes mean that many older drivers face different challenges to younger drivers, including impairments in vision, cognitive function, responsiveness, and manoeuvrability.'

    He made the point that dementia develops without the person being aware of their deteriorating condition (16), and emphasised in the parliamentary debate that the very purpose of the medical certificate is 'to identify […] those in the initial stages of dementia' (17). The Minister referred to specific reports on the age distributed prevalence of dementia, including a report by the Norwegian National Centre for Ageing and Health from 2020, which shows that the prevalence of dementia rises sharply for those in the age group over 80 years (24). In his letter to the Storting, he stated that the increase in the age limit for a medical certificate requirement for driving licence renewals, from 75 years to 80 years in 2019 made the measure even more targeted than before (16).

    One of the Conservative Party's representatives also clarified 'that this is not a debate about whether older people should be allowed to drive or not. Rather, it is a debate about the requirements we set to define fitness to drive' (17). The Minister also rejected accusations that older people are treated less favourably than other groups associated with a high accident risk. He supported this by giving the example of people with epilepsy who receive special follow-up, and new drivers who incur double points on their licence for traffic offences (17).

    The Conservative Party further addressed the majority's emphasis on the mobility of older people in rural districts as follows (17):

    '[…] traffic safety is no less important in rural Norway than in urban areas. […] There are other ways to help older people get to and from the shops, cultural events, and such like.'

    Both the Minister and representatives from the Centre Party stressed that the cognitive test should only be used if cognitive impairment is already suspected (17, 18). In response to claims that GPs still used the test routinely, it was proposed that the Norwegian Directorate of Health update the driving licence guidelines for GPs. The Centre Party's members of the Transport and Communications Committee emphasised in the recommendation to the Storting that it was crucial for them that cognitive tests were only performed on prior suspicion of cognitive impairment, and not based on age (10). A representative of the Centre Party considered the cognitive tests to be degrading and stated that they 'are not well suited for measuring fitness to drive or driving skills', but did not produce any evidence of this (17). The Conservative Party's representative commented at one point on the focus on cognitive testing in the debate (17):

    'I feel that much of this discussion is really about the cognitive tests […] which should only be used when absolutely necessary. I think scrapping the entire arrangement […] on the basis of opposition to the cognitive tests seems peculiar.'

    In summary, the Transport Minister was specific as he referenced sources on the incidence of relevant health conditions in the older population, while the minority's comments on whether practices were discriminatory were based on unsubstantiated claims. The minority – like the majority – rejected screening-based cognitive testing as a valid practice.

    Value to health policy. The minority's opposition was also based on the workload of GPs, considerations for family members, and the opportunity to identify other health challenges. A representative from the Conservative Party acknowledged that the medical certificate scheme required GP resources at the municipal level, but did not believe that an alternative control mechanism would be any less bureaucratic (17). Another Conservative politician stated that GPs do 'important preventive work' with older people who are required to obtain a medical certificate, and asked if the majority expected 'the doctor to think about their patient's driving licence when their visit concerns some unrelated issue' (17).

    One of the Centre Party's representatives suggested that practical driving tests could be weighted more in renewal assessments for older drivers (17). A representative of the Liberal Party said that several doctors found that 'one of their most difficult tasks is to contribute to older people having their driving licence taken away for necessary reasons'. The representative stressed in the parliamentary debate that mandatory tests therefore simplify GPs' work (17):

    'A mandatory medical certificate can help doctors raise the subject of fitness to drive in patient appointments before fatal accidents occur. It could also make agonising family disputes […] easier to bear for everyone concerned.'

    The role of relatives was a recurring theme, often with anecdotal examples of how difficult it could be for family members to get older drivers who were unwilling or unable to recognise their own limitations to listen to them. The Socialist Left Party's representative acknowledged that this was a strong argument in the implementation debate, but nevertheless believed that the duty of healthcare professionals to report fitness to drive issues was enough to identify motorists who should not have a driving licence (18).

    In order to substantiate their health policy position, the representatives on both sides relied on anecdotes from their own lives, or from people who had contacted them in connection with the debate.

    Discussion

    Discussion

    This article shows that the Storting decided to abolish the requirement for a medical certificate for older drivers so that their mobility, integrity, and quality of life should not be limited by what the majority regarded as an unfounded fear of traffic accidents. The minority's arguments were based on the precautionary principle and traffic safety considerations founded on expert advice, in addition to the added value to health policy that could emerge from the medical certificate regime.

    The arguments in the parliamentary debate were characterised by anecdotal 'evidence' and selective use of reports and report findings, and the majority did not explain the relevance of the studies cited. For example, the findings in the Swedish Transport Agency's report (22) were incorrectly cited as if they relate to the same age group that was the subject of political debate in Norway. The Swedish report, however, concerned all drivers over the age of 65, and did not address drivers over the age of 80 as a separate group. This distinction is crucial both when it comes to the prevalence of dementia and the general risk of traffic accidents. Findings in the SINTEF report that were used as a basis in the motion (23) were also selectively presented.

    The Swedish Transport Agency's report was further used to back up the claim that a dementia diagnosis does not increase the risk of traffic accidents. The Minister criticised the report for basing its assertions on dementia diagnoses given in hospitals, i.e. to patients who are already driving less than normal. However, it is not a dementia diagnosis per se that constitutes a traffic risk, but unidentified dementia. The Swedish Transport Agency refers to international research (25) that documents how people diagnosed with dementia were almost twice as likely to be involved in a traffic accident in the three years preceding the diagnosis compared to after being diagnosed. A dementia diagnosis reduces the number of accidents because those who have been diagnosed drive less (and possibly in a different way). This finding supports an argument for cognitive testing without prior suspicion, but was not introduced to the debate.

    The review of the parliamentary debate shows the challenge of dealing with the age imbalance in accident statistics when targeted measures aimed at a specific age group are consistently referred to as discriminatory, even though the age limit is justified by the prevalence of cognitive impairment and documented accident risk. The majority problematised the cognitive test in particular – from GPs' screening practices to the alleged irrelevance of the test as a measure of driving skills, the indignity, and the age discrimination that healthy older people experience because of it, as well as the stress that the test situation creates, which implicitly can lead to a false positive conclusion about cognitive impairment. The Norwegian Association of General Practitioners and the Norwegian Health Association objected to the majority decision to the Ministry of Health and Care Services (8):

    'GPs occasionally meet patients who we do not initially suspect [of having] a cognitive impairment, but when we test them, we find that their understanding, sense of orientation or other factors necessary for them being fit to drive are impaired. This problem is not uncommon at Norwegian GP practices.'

    As a control mechanism, the medical certificate procedure is established to identify insidious signs of illness in a group that is particularly vulnerable to factors that can expose themselves and others to risk if they get behind the wheel. The fact that the health check is mandatory gives the GP an opportunity to perform an assessment of the patient's fitness to drive, which neither the patient nor the GP can down-prioritise. The motion that triggered the debate proposed abolishing this requirement without first investigating or introducing alternative control mechanisms to identify drivers with age-related health challenges that affect their driving skills. The Transport Minister therefore commissioned an investigation into possible alternative measures in response to the Storting's decision.

    The resulting report (13) showed that driving licence renewals are subject to medical screening in many European countries (26). A recent comparison of traffic safety in Norway and Sweden showed that relative traffic fatality rates have been lower in Norway than in Sweden since Norway introduced the age-related medical certificate requirement in 2013 (27). The comparison only looks at fatalities, not the age of the driver at fault, and therefore has limited relevance. The report concludes that 'there are no alternative measures that [identify] people who do not meet the health requirements as effectively as the mandatory age-specific medical certificate'.

    Consequently, the Minister did not abolish the requirement for the oldest drivers to obtain a medical certificate for driving licence renewals, as had been decided by the Storting, and left it 'to the new government to decide how this should be followed up further' (14). The new minority government consists of two parties that were on opposing sides of the parliamentary debate, and the government's political platform does not mention the medical certificate requirement (28). It therefore remains to be seen if, and how, the present Transport Minister follows up the decision.

    I would like to thank Andreas Hessen Schei, the Journal of the Norwegian Medical Association's reviewers, and also the Norwegian Pensioners' Association, the Norwegian Council for Road Safety and the Norwegian Medical Association for providing useful information for this article.

    The article has been peer-reviewed.

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