Hypoglycemia, driving and licensing standards

Hypoglycemia leads to a decline in neurocognitive function and impairment in judgment and complex task handling.15 16 Driving standards in the UK in relation to diabetes are defined by the Driver and Vehicle Licensing Agency (DVLA),17 and are largely based on the European Commission Directive (2006/126/EC)18 and the 2009/113/EC Amending Annex III to Directive 2006/126/EC,19 the overarching legal guidance for European Union (EU) member states. Details of restrictions in relation to hypoglycemia in the above directives are summarized in table 1. In response to submissions to relax licensing restrictions, some of these have been amended recently in Directive 2016/1106/EC20 and were implemented in the UK in January 2018.17 The latest EU Directive has advocated specific relaxation of some licensing regulations for drivers of group 1 vehicles. The key changes were reviewed recently by Graveling and Frier.21 These changes include stating ‘inadequate awareness’ rather than ‘impaired’ hypoglycemia, reduction in the length of time of revocation of a driving license from 12 to 3 months, and restricting the relevance of severe hypoglycemia to waking hours.21 Globally, there is a wide variation between different countries and regions in the statutory requirements and policies used to regulate and assess drivers with diabetes.22

Insulin-treated diabetes and driving

In the UK, the DVLA details comprehensive recommendations and requirements for group 1 (car and motorcycle) and group 2 (bus and lorry) drivers who are treated with insulin, and these are summarized in table 2.17 23 24 It is noteworthy that modern insulin analogs are potentially safer and have been shown to carry a lower risk of hypoglycemia during fasting.25 Previous research demonstrates that there is delayed recovery of neurocognitive function following hypoglycemic episodes, giving a strong biomedical basis for this advice.26 27 The guidance also advocates that ‘particular care should be taken during changes of insulin regimens, change of lifestyle, exercise, travel and pregnancy’.17 Such details are currently not included in the European Commission Directive, with individual countries having their own standards and recommendations. In a recent international study, no restrictions on drivers with insulin-treated diabetes existed in 59 out of 82 surveyed countries (69.4%).22 Lack of restrictions on licenses in drivers on insulin was evident in less developed countries, indicated by geographic basis and by using an established national social/political/economic index (gross domestic product).22

Implications for driving and fasting for people with diabetes on insulin and tablets carrying a hypoglycemic risk

Fasting during Ramadan with insulin-treated and secretagogue-treated diabetes constitutes a significant change in lifestyle and presents an increased risk of hypoglycemia. This requires particular care when driving. Current DVLA guidance, European Commission Directive on driving licenses, and Ramadan and diabetes guidelines do not specifically address the issue of driving and fasting with insulin-treated or secretagogue-treated diabetes during Ramadan. From a biomedical perspective, the twofold to sevenfold increase in risk of hypoglycemia with diabetes and fasting9 10 requires strict adherence to DVLA precautions if driving.

Religious considerations on matters specifically relating to fasting and secular legal aspects of driving for Muslims intending to fast

Current thinking highlights situations in which people with diabetes may be exempted from fasting, particularly when it comes to longer fasts, and is derived directly from the Qur’an, the holy book of Muslims.1 4 7 The guidance explicitly states that Islam permits, and indeed supports, those with appropriate ailments to be exempted from fasting.1 In such situations, non-fasting Muslims have two main options:

1. Making up the missed fast when health permits them to do so—either when the illness is no longer present, such as an acute illness, or when the illness is not worsened by fasting at another point in time in relation to chronic illness.

2. A perpetual exemption from fasting in those whose illness will not permit them to keeping fasts indefinitely, this being replaced by a requirement to feed the poor, known as ‘Fidyah’. Even after considering the aforementioned general Islamic principles, there may be a need for healthcare professionals or people with diabetes to explore further considerations when deciding if fasting is appropriate, or indeed to maintain the fast once started, if mitigating circumstances arise.

Within religious traditions, the process of developing cardinal religious virtues, such as patience and servitude to God, requires a devotee to undertake certain practices that will entail varying degrees of difficulty in order to effect a desired change in habits perceived as detrimental to the human soul. However, the Islamic tradition explicitly recognizes the danger that, for certain people, this will lead to not just normal difficulty, but perceptible harm or damage. In light of this, Islamic law, otherwise known as Shari’ah, seeks to pre-empt the onset of harm to the individual by providing guidelines that allow a person to take a dispensation to opt out of certain practices, either for a short period of time or indefinitely. If it is established, however, that this will lead to an observable onset or worsening of an illness that limits normal human functions, this emphasizes prioritizing one’s health over fasting.26

The Shari’ah also recognizes the secular legal requirements of public good, that is, care or safety for others, for example, other road users. As these are based on current understandings of risk, it would not be permitted to encroach on such restrictions by attempting or continuing to fast because of the general legal maxim that ‘harm is to be alleviated’.27 Ultimately, however, the final decision to fast or not rests with the individual, and they have the right to fast even if the medical or religious opinion states otherwise. This does not, however, absolve the person from their personal and civic responsibilities in terms of maintaining their health appropriately, in terms of medical fitness to drive.

In the Shari’ah, exemptions or dispensations are applied when a necessity (dhurura) or need (haajat) arises.28 29 It is worthwhile appreciating these two terms used when it comes to classifying situations that may arise. A ‘necessity’ arises when a person needs to break the Shari’ah due to dire circumstances to directly safeguard one of the essential benefits of Shari’ah (ie, religion, life, intellect, lineage or property/wealth). In this situation, the person acts in a manner that is otherwise unlawful to secure existence. ‘Needs’ are subordinate to necessities and are things, often of a personal nature, deemed to be of importance because they remove severity and hardship in day-to-day life in relation to promoting and protecting the essential benefits. For example, a healthy person would not be permitted to break a fast except in a situation where there is a more pronounced hardship to their fast than is normally to be experienced, such that it impairs their capacity to work safely. Therefore, a need for one person may not be a need for another as circumstances may vary. If an individual has been stratified as having high risk or very high risk of harm from fasting due to their diabetes, then from this perspective alone, there is sufficient reasoning for them not to fast because of the magnitude of risk of personal harm.1 4

Potential interplay between Shari’ah and secular laws—considerations for the healthcare professional and patient (using UK driving legislation as an example)

The Shari’ah therefore includes a concept of driving being undertaken owing to a necessity, need or choice. This contrasts with national laws and guidelines, as no national guideline or law makes any distinction based on the purpose for which driving is undertaken. However, the underlying reason for driving may make reaching a decision easier especially when a person with diabetes is already stratified as having higher risk of harm from fasting. Resolving such contemporary incidents cannot be based on literal interpretation but rather by analogy similar to the exemption of those who have obligations to undertake hard types of physical labor included in the 2009 Fatwa by the International Fiqh Academy and incorporated in recent risk stratifications.1,4

If a healthcare professional advises that it is safe for a person with diabetes to fast, or if the person with diabetes chooses to fast despite contrary advice, the following scenarios (listed in Box 1) should also be considered to help guide both parties when deciding: (1) how the act of driving is viewed under the Shari’ah law; and (2) what, if any, advice is needed to maintain safety, including driving cessation. In all circumstances local legislation must be followed.

What are the ramifications if a person chooses to drive despite not being allowed to drive or strongly advised not to do so?

• The ramifications are based on considerations on personal welfare and duty of care for others.27 Any individual taking insulin who informs the DVLA signs an agreement which includes a statement that they will ‘comply with the directions of the doctors treating my diabetes’.22 Such a written contract, both in Islamic law and in the UK, can result in prosecution if it transpires that a mishap has occurred as a result of neglecting any relevant advice given by the healthcare professional.

• In the context of driving by a fasting individual during Ramadan, the same level of commitment to the contract is required. Seeking professionals’ advice, attending an educational program, altering doses and timing of diabetic drugs, and undertaking regular glucose monitoring have all been shown to reduce acute complications during Ramadan.11

A person with diabetes may wish to try undertaking trial (voluntary) fasts in the month preceding Ramadan as these experiences could provide useful evidence to support decision making during Ramadan. This practice has been suggested in the most recent international guidance and has been adopted by several of the authors of this paper, particularly in recent years as the fasts have become longer.4 Table 3 and figure 2 can serve as a useful patient-centered guide for healthcare professionals when discussing fasting with people with diabetes, incorporating and highlighting the importance of pre-Ramadan and post-Ramadan review, risk stratification, driving guidance and emphasis on documenting outcomes of such discussions.34 In all cases, healthcare professionals should not overlook their patients’ words and driving habits (if they become known) if they are compromising driving standards. Although professionally challenging to many healthcare professionals, if there is a need to report an individual to the driving authority, then this should be undertaken in the standard manner.

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Table 3

Suggested pathway for discussions between healthcare professionals and people with diabetes intending to drive and fast during Ramadan (adapted from Beshyah e t al 34)

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Figure 2

Suggested pathway for discussions between healthcare professionals and people with diabetes intending to fast during Ramadan. CBG, capillary blood glucose; DVLA,  Driver and Vehicle Licensing Agency; HCP, health care professional.

As with all doctor–patient encounters involving religious beliefs and practices, discussion of Ramadan fasting is not complete without a bioethical consideration despite the claimed differences between Western and Islamic ethics.35 All the Georgetown mantra principles of bioethics apply very well to this situation. For instance, physicians have to respect autonomy of the patients and his/her choice of observing the fast. However, ‘non-maleficence’ is manifested in the physicians’ knowledge and application of the conditions and when people are exempted temporarily or permanently and avoidance of any harm to himself and other road users. Individuals with diabetes who are not classed at the higher risk categories who strictly observe Ramadan fasting may benefit in terms of weight reduction and quitting smoking (beneficence). Finally, ‘justice’ will be seen by balancing between the individual’s right to observe Ramadan fasts and the right to public safety, with the scenarios discussed providing solutions which do not lead to the need to prioritize one individual over the public.

Conclusions

The tetrad of diabetes, fasting during Ramadan, hypoglycemia and safe driving stimulates a challenging discussion with potential legal ramifications. Islamic law provides logical and practical framework to facilitate the decision-making process through the concepts of necessities and needs, and the healthcare professional may benefit in using the suggestions discussed when raising and facilitating discussion with people with diabetes on fasting in the context of safeguarding health. Given that for many Muslims fasting is an important part of their individual life as well as in engendering community spirit and bonding, healthcare professionals should continue to adopt a patient-centered approach when engaging in discussion, asking their patients about their goals, and touching on the spiritual, emotional, clinical, physical, social and legal aspects, such as driving when planning on fasting for the month.

Thus, it is hoped that over time as healthcare professionals, people with diabetes and influential community members such as Imams become more aware of the evolving and dynamic issues, coupled with research that generates key relevant outcomes, stakeholders’ dialogue on this topic and further guidance come out in a timely manner. Finally, this may also require the need for legal and authoritative bodies to work with such parties in providing clear and explicit guidance for people with diabetes, but in a sensitive and relevant manner. The roles of Imams, in particular in the dissemination of evolving guidance, will be key to reaching Muslims who give the highest importance to fulfilling their religious obligations. The issue of driving and Ramadan is a matter of relevance for any country that has secular legislation on driving and diabetes, as well for public safety; therefore, healthcare professionals in these countries must also consider having such discussions with people with diabetes.