Medical Exemptions to the Auto Seat Belt Mandates:

A Review and Some Observations
from Robert S Hattner MD*

Background: Auto seat belts have been around a long time, but only relatively recently, since the 1960's, have they been required equipment in new cars. Most physicians, including me, recommend their use even though a benefit in decreasing fatalities from vehicular traffic misadventures is controversial - in spite of the contention of the NHTSA. When the multiple-variable controlled gold standard statistic, fatalities per 100 million miles driven, is examined relative to seat belt use, no significant effect is apparent. In fact there may be a negative effect, but that's a topic for another day.

State laws mandating seat belt use now prevail - only excluding New Hampshire, which ironically has had the greatest reduction of any state in the nation in traffic fatalities per 100 million miles driven over the past twenty years. And Massachusetts, the state with the lowest prevailing seat belt use in the USA, had the lowest fatality per hundred million miles driven until it passed a seat belt law.

The latest illiberal incursion in this vein is the so-called primary enforcement law, which enables police to stop and penalize a seat belt eschewer for no other reason than an unbuckled belt. Washington passed one in 2002, and for fiscal prudence, enforces it fanatically. Since then seat belt use has risen from 55% to 90%, and the fatality rate has increased. And so it goes.

Medical Exemptions: Although not common knowledge, in every state there are health related reasons for exempting individuals from the seat belt laws. These are primarily based on a medical finding that for some, seat belt deployment is less safe than not. The basis is often that symptoms caused by contact with the belt impair the attentiveness required to otherwise drive as safely as possible.

Reasons for this may be temporary, related to post traumatic regional tenderness after accidental or post surgical trauma, a fractured left shoulder, or mastectomy for example. Other causes may be more chronic, prominently including a variety of sensory neuropathies. These nervous system disorders of variegate causation share inappropriate perception of any tactile sensation, including hyperaesthesia, heightened perception; allodynia, pain, and; dysaesthesia, local anesthetic numbness or electric shock-like tingling.

Even though sensory neuropathies themselves are uncommon, the spectrum of entities causing them is so broad careful questioning of almost anyone by a knowledgeable physician can reveal a potential culprit for one. Since physical examination findings of sensory neuropathies are largely subjective requiring the patients confirmation, e.g. "Does this hurt?" the diagnosis is also subjective, and requires a truthful patient. In fact, diagnosis of a sensory neuropathy can be made by phone or even from a questionnaire.

State Medical Exemption Regulations: I have reviewed all of the states' codes and found they're mostly similar. They require a written statement from a physician licensed in any state with the exception of Oregon, which specifies Oregon licensure. The statement is carried in some form, and shown to an arresting officer - negating issuance of a citation. I am aware of many instances in which use of these exemptions saved the onerous cost of the ticket, $101 in WA, and more than $200 in some TX municipalities - subsequent tickets' fines increase like compound interest. Also the federal agency NHTSA awards grants to states to pay traffic officers extra overtime to use state vehicles to issue seat belt tickets on their off-work hours, the states pocketing the treasure gleaned from the fines.

Most physicians are unaware of these regulations to say nothing of patients who may be fitting candidates for medical exemptions. Also physicians are often unwilling to issue seat belt exemptions stemming from fear of legal reprisals from government authorities, or a misplaced trust in the apparent added safety from their use.

Conclusions: In spite of the prevailing wisdom that auto seat belt deployment is effective in limiting injury and fatality in motoring misadventures advantages are controversial and convincing evidence is not apparent. In some cases seat belt use may evoke symptoms sufficiently distracting from a driver's attentiveness to negate any safety benefit. These drivers and their physicians should be aware of the availability of legal medical exemptions to seat belt use.

(* Dr. Hattner participates in an internet web site, www.buckleoff.com, which issues medical seat belt exemptions following a fee based evaluation.)