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Postgraduate Education Corner: CONTEMPORARY REVIEWS IN SLEEP MEDICINE |

Legal Issues Encountered When Treating the Patient With a Sleep Disorder FREE TO VIEW

Vidya Krishnan, MD, MHS, FCCP; Ziad Shaman, MD, FCCP
Author and Funding Information

From the Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Cleveland, OH.

Correspondence to: Vidya Krishnan, MD, MHS, FCCP, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109; e-mail: vkrishnan@metrohealth.org


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(1):200-207. doi:10.1378/chest.09-1962
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As our understanding of sleep medicine grows, so does our obligation to protect patients and society from the potential harms of sleep disorders. Harm to self and others can take the form of violent behaviors during sleep or from sleep arousals, or from errors in judgment and motor skills due to excessive daytime sleepiness. Motor vehicle accidents and industrial accidents represent the majority of deaths and injuries due to sleep disorders. Errors in judgment and mental capacity can also lead to significant problems in terms of financial costs to businesses, inefficiencies in the workplace, and harm to others (as in the case of medical errors). Sleepiness can be so debilitating to an individual that he or she may qualify for disability compensation. The sleep specialist plays three basic roles in the interaction between the medical and legal fields: the educator, the medical examiner, and the expert witness. The education of the public, court officials, and patients is necessary to increase awareness of sleep disorders and their risks. The medical examination of the patient and subsequent treatment of the sleep disorder can help to minimize the risks of sleep disorders. Finally, if necessary, the sleep specialist may be called upon to provide expert testimony about the medical evidence provided and the likelihood that a sleep disorder contributed to an alleged criminal act.

In 1846, a man in Massachusetts was acquitted of charges of murder and felony on the grounds that he was sleepwalking during the events. This case marked the first time in American legal history that a sleep disorder was accepted as a plausible defense against a crime.1 Since then, many other sleep disorders have been identified that potentially could be implicated in legal offenses involving errors, accidents, losses, and injuries. Behaviors that arise directly from sleep can cause injury to self or others. Pathologic sleepiness due to any cause, including sleep deprivation, sleep apnea, or narcolepsy, results in reduced psychomotor performance, which in turn can result in poor outcomes. Society’s expectation is to hold individuals legally accountable for these predictable errors and accidents.2 Because sleepiness is known to increase errors, an individual who commits an offense while subjectively sleepy may be disregarding the known risks of his or her behaviors. It is therefore imperative that health-care professionals understand the legal implications of sleep disorders and fully appreciate what their role is in the medical-legal system.

There have been several reviews of particular legal issues in sleep.2-5 In this review, we explore the facets of the legal system with a primary focus on understanding criminal liability. Next, we highlight particular sleep issues that have high likelihoods of legal implications. Finally, we address the slippery slope of disclosure, discussing the balance of the rights of an individual vs the rights of society.

Legal issues in medicine rarely are broached in medical education, and yet an understanding of these principles is necessary for clinical management of patients with sleep disorders. Some basic definitions of legal terms will help with understanding how they are applied. Of course, variances in laws by jurisdiction create an additional layer of complexity. The FindLaw Web site (www.FindLaw.com) is a good resource for more information on all aspects of the law, including federal and state law.

Culpability

The legal issue of culpability addresses the blameworthiness of an individual for a behavior. Criminal liability in the United States is considered in four degrees of mental state: (1) purposeful, (2) knowing, (3) reckless, or (4) negligent (Table 1).6 Behaviors related to sleepiness may not be intentional but may be done knowingly, with the individual aware of the actions and potentially with knowledge of the consequences of the actions. Behaviors that arise during sleep or from sleep-related arousals generally are not knowingly performed but involve a question of whether the risk of such actions is substantial and unjustifiable and whether the individual was aware of these risks. Actions that are performed while an individual is sleepy are more of a gray area, requiring insight as to the awareness of the state of sleepiness and the consequences of the sleepiness.

Table Graphic Jump Location
Table 1 —Degrees of Culpability: Elements of Definition of Culpability of a Person’s Action With Respect to the Material Element of an Offense

From the American Law Institute’s Model Penal Code.6

Culpability relies on the necessary mens rea, or mental state. The standard common-law test of criminal liability usually is expressed by the Latin phrase “actus non facit reum nisi mens sit rea,” which translates to “the act does not make a person guilty unless the mind is also guilty.” For criminal liability, the guilty mental state must be present at the time of the action.7 In cases involving sleep-related behaviors, the mental state of the accused party is a key component to a criminal case. If the actions are performed during sleep, then the individual was not conscious of the actions or the consequences thereof. However, determination of the actual mental state at the time of the action only can be speculated. Supporting evidence and expert testimony is relied on to ascertain the mental state of the individual at the time of the alleged crime.

Legal Differences by Jurisdiction

Laws that govern American society come from five basic sources: the Constitution (including the Bill of Rights and other amendments), statutory law, administrative law, federal and state law, and common law (which includes case law). Although the Constitution applies to all Americans, the others may vary by state or region, resulting in differences in laws by jurisdiction. It is the physician’s responsibility to know the laws in the jurisdiction he or she practices. In many states, the state medical board offers literature in print or online regarding rules and statutes that govern medical-legal issues. In addition, the medical board may offer position statements, which are not legally enforceable but guide practitioners on recommended conduct and obligation. In Texas, for example, physicians must pass a medical jurisprudence examination in order to obtain a state medical license. Although not a comprehensive medical-legal examination, such requirements are being implemented with increasing frequency in an attempt to improve physician awareness of local medical-legal issues.

Variations in laws and precedent cases have resulted in differences in acceptable defenses from state to state. The differences in laws by jurisdiction also result in differences in the manner in which sentences are applied. For example, drivers causing a sleep-related motor vehicle accident that results in a fatality cannot be charged of a crime in four out of the 44 states that responded to the 2007 State of States Report on Drowsy Driving by the National Sleep Foundation.8 Of the states that have existing statutes addressing fatal sleep-related crashes, charges can be at the discretion of the law enforcement officer or prosecutor in two states and range from improper lane usage or failure to reduce speed to avoid an accident to negligent homicide or manslaughter. Consultation with a criminal attorney is advised to fully understand how the laws are enforced in each region.

Sleep-Related Violence

Although the term sleep-related violence (SRV) may conjure images of sensational or dramatic murders, violence against others related to sleep includes many different behaviors. SRV has a reported prevalence of 2% among adults,5 but this may be an underestimation because of underreporting of these behaviors. SRV has been reported in the form of kicking, punching, hitting, or sexual activity (sexsomnias) during sleep, which may not be reported by the bed partner to a physician. Case reports have documented criminal charges that have been brought against patients suspected of SRV in the form of murders, assaults, and felonies.1,9-11

In legal cases involving SRV, although the actions often are not in doubt, the mental state of the patient is called into question. SRV acts may also be confused for volitional violence for which the contribution of a sleep disorder may not have been considered. By definition, behaviors that occur during sleep are done during a state of unconsciousness. Without conscious wakefulness, acts of SRV may not meet the legal standards of negligent culpability in a criminal action.

Parasomnias is the general medical term for behaviors or experiences that occur during onset of sleep, during sleep, or during arousals from sleep.12 Mahowald and Schenck3 have proposed five categories for the conditions that have been implicated in SRV. Sleep disorders that can result in SRV are (1) disorders of arousal, (2) rapid eye movement sleep behavior disorders, (3) nocturnal seizures, (4) compelling hypnagogic hallucinations, and (5) sleep talking. The International Classification of Sleep Disorders, Second Edition, provides guidelines for diagnosing each of these disorders on the basis of history, physical examination, and laboratory testing.12

Although typical behaviors and history may strongly suggest a diagnosis of an arousal disorder that may explain unusual behaviors, a definitive explanation of prior acts rarely can be determined. Even if diagnostic testing can demonstrate movements and behaviors during sleep, whether the sleep disorder contributed to a previous violent act can still be in doubt. The role of a sleep specialist in evaluating cases of SRV is twofold: to establish the diagnosis of a sleep-related disorder and to educate the general public about the pathophysiology, prevalence, triggers, and treatments of sleep-related behaviors. Cramer Bornemann5 recently published a review of the role of expert witness testimony in SRV trials. He emphasizes the need for published, clinically based evidence and peer-reviewed medical literature in the field of SRV in order to effectively render an expert opinion. However, in the absence of sufficient evidence-based knowledge in the field of SRV, Pressman13,14 proposed guidelines for determining the presence of SRV. These guidelines provide some structure to the approach of assessing the likelihood that an SRV occurred.

Sleep-Related Accidents and Errors

Sleep deprivation, like many sleep disorders, negatively affects psychomotor performance, decreasing the speed and cognitive performance of individuals with this condition.1516 This reduction in physical and mental capacity may lead to personal injury, loss of property, and loss of life. The wide prevalence of sleep disorders and the pervasiveness of sleep deprivation in modern society affect the public through transportation accidents; industrial accidents; and reduced performance in the workplace, including medical education and errors in medical judgment.17

Transportation Accidents

Drowsy driving is an underreported and underrecognized public safety issue.8 The role of sleepiness in the overall number of transportation accidents is not fully appreciated. It is estimated that in the United States there are approximately 4,800 fatal truck crashes each year, and many more nonfatal crashes. In one study, the National Transportation Safety Board (NTSB) found that fatigue plus alcohol or drugs accounted for a large proportion of fatal-to-the-driver accidents.18 The NTSB also reported a probable cause of fatigue in 57% of accidents that led to a truck driver’s death, although this figure is not widely accepted. It must be noted that the NTSB use of the word fatigue is most consistent with what sleep specialists mean by the term sleepiness. To better estimate the effect of sleepiness on transportation accidents, it is essential that documentation of vehicular accident reports reflect that. As of November 2008, in the United States, all but one state have a code for fatigue or sleepiness on their police crash report form; however, < 40% of law enforcement agencies educate their officers on the impact of fatigue on driving performance or proper countermeasures.8

Driving while sleepy carries the same consequences as driving under the influence of alcohol and other substances. In fact, if a driver’s impairment is determined to be due to sleep deprivation, the driver may be considered negligent, or even reckless, and can be held liable for civil and criminal penalties. However, sleepiness has no reliable objective measurement that can be performed at the site of an accident. Thus, the status of a patient’s sleep deprivation must be inferred from the nature of the accident and the operator’s prior sleep-wake schedule.19 In common law, for an individual to be put on trial, there has to be a law under which the person can be prosecuted. As of 2008, the National Sleep Foundation reported that no state had a law that addresses nonfatal, sleep-related motor-vehicle crashes.8 However, the only state with a specific law under which a sleepy driver can be charged in a fatal crash is New Jersey.20 This legislation was the first to allow law enforcement officials to charge individuals with vehicular homicide if, after not sleeping for ≥ 24 h, they cause a fatal accident. This law, known as Maggie’s Law, was enacted in 2003 and named after Maggie McDonnell, who was killed in a head-on collision in 1997 by a driver who had gone without sleep for 30 h.

On the national level and in response to a congressional mandate in 1995, a revised hours-of-service rule for commercial truck drivers was announced by the Department of Transportation’s Federal Motor Carrier Safety Administration in April 2003.21 This legislation allows long-haul drivers to drive a maximum of 11 h per day after 10 consecutive off-duty hours, and drivers are prohibited from driving after 14 h on duty during a single shift. Although the effectiveness of these regulations have not been proven yet, Maggie’s Law and the hours-of-service rules represent small, but positive steps toward establishing and enforcing a comprehensive set of drowsy driving laws. The National Sleep Foundation continues to call for more action in this regard.

The Expert Panel Recommendations on Obstructive Sleep Apnea and Commercial Motor Vehicle Driver Safety, which were presented to the Federal Motor Carrier Safety Administration on January 14, 2008, contains the most comprehensive information available on screening, diagnosing, and treating commercial motor vehicle drivers for sleep apnea. It also lists the standards and guidelines for sleep apnea from other US government transportation and safety agencies as well as from select countries other than the United States.22

Industrial Accidents

The advent of a highly 24/7 society has made inadequate daily sleep and substandard levels of alertness commonplace for many working individuals. The majority (60%-90%) of industrial accidents are caused by human error,23,24 although the proportion that is directly related to sleepiness is unknown. The economic and human impact has been substantial. The accidents in Chernobyl and at the Three Mile Island nuclear power plant and the grounding of the Exxon Valdez oil tanker are a few well-publicized examples of large-scale industrial disasters partially attributed to sleep loss and shift work-related performance failures.25

Although industrial accidents can result in large-scale public losses, there have been no guilty verdicts attributed directly to sleep disorders or to sleep deprivation. The Report of the Presidential Commission on the Space Shuttle Challenger Accident stated that working “excessive hours, while admirable, raises serious questions when it jeopardizes job performance, particularly when critical management decisions are at stake.”26 Our evolving understanding of the impact of sleepiness and reduced psychomotor performance should allow for more definitive statements regarding the effect of sleepiness on industrial accidents and to improve the education of the public on this safety hazard.

Medical Errors and Medical Education

Medical errors related to sleep deprivation have been on the forefront of public opinion since the release of the Institute of Medicine report on preventing medical errors in 1999.27 However, there are no accurate prevalence estimates of the impact of sleep deprivation and sleep disorders on reduced performance in the workplace and on education (including medical errors and the effect of sleep deprivation on medical training).

In 1984, Libby Zion, an 18-year-old college freshman, died in a hospital in New York City. A grand jury found that her death was due to an undiagnosed infection and blamed inadequate supervision of residents and resident fatigue for the failure to institute proper treatment.28 As a result, New York enacted laws to reduce the total number of hours that residents are permitted to work (section 405 of the New York State Health Code). The state of New Jersey followed in 2002 with a bill that limits residents’ work hours. Subsequently, the Accreditation Council for Graduate Medical Education implemented standard requirements for work hours for all resident physicians. Furthermore, it requires that faculty and residents must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract the potential negative effects of fatigue on patient care and learning.29,30 This move toward shorter work hours in order to reduce fatigue-related medical errors has been positively supported by research. In two studies comparing traditional vs abbreviated schedules, shorter shifts worked by interns in ICUs result in more sleep, substantially fewer serious medical errors, and fewer attentional failures.31,32 However, the association of long work hours and fatigue leading to medical errors has not been completely clarified.

Outside of medical training, it is conceivable that medical professionals may be held liable in courts or have their licenses revoked by medical boards for gross negligence, professional incompetence, or similar acts as a result of practice while impaired due to a lack of adequate sleep. To our knowledge, however, no criminal or civil lawsuits have been successful so far in incriminating a physician for poor performance resulting in injury solely due to sleepiness.

Sleep-Related Disability

Sleep disorders may result in significant daytime dysfunction and can limit a patient’s ability to work. Although many sleep disorders can be adequately diagnosed and treated with behavioral modification, medical therapy, or psychotherapy, there is a clear subset of patients who suffer from incapacitating symptoms, despite aggressive and appropriate therapy. For example, despite optimal therapy with medications and behavioral modifications, patients with narcolepsy may still experience severe daytime sleepiness.

Under the Americans with Disabilities Act, businesses with > 15 employees are required to accept requests from employees with disabilities for work accommodations.33 Patients with excessive daytime sleepiness may benefit from altered work hours or from short scheduled naps. Patients with sleep disabilities also may be eligible for disability insurance payments. Federal, state, and private disability insurances may offer compensation based on the severity and duration of disability. The role of sleep disorders in causing disability or inability to work should be evaluated by a sleep specialist. The sleep physician should perform a thorough clinical evaluation, and all therapies and responses to therapy need to be documented in the medical chart of the patient. Laws to protect patients with disabilities are meant to defend the rights of those with temporary or permanent incapacities. Although some sleep disorders can be disabling, these laws may not be applicable to patients who have treatable sleep disorders and, therefore, deserve a full and continuing evaluation by a sleep specialist.

In medical-legal issues related to sleep disorders, the physician plays a key role in the interplay between the patient and the legal community. There are three major roles of the physician in this situation: (1) educator for the patient and the public, (2) medical examiner of the patient (which includes the privileged physician-patient relationship), and (3) expert witness. These roles may not necessarily be served by the same physician, but they are by no means mutually exclusive. Although physicians are ultimately the advocates of their patients, they also should follow ethical principles and use objective data to guide their actions.

Educator

One of the primary roles of a physician in general is to educate the patient, colleagues, and the public. The sleep specialist should have expertise in all the facets of sleep disorders: the pathophysiology, the clinical manifestations, and the treatment. Patients with sleep disorders must understand their disease, its implications, and treatment. Recklessness and negligence standards of law can be met only if the sleepy person is aware of the risks of behaviors (Table 1). In most states, physicians are not mandated to report drowsy driving of patients. Therefore it is imperative to counsel the patients on the potential risks to self and others and, as always, to document this discussion. The documentation should not only reflect that the appropriate counseling was provided but also that the patient understood the discussion.

Education of colleagues and the public may not be a legal obligation but certainly a public health obligation. Primary-care physicians and other specialists often are the first to encounter patients with sleep disorders, and a basic understanding of wake and sleep is essential. Non-sleep physicians should still identify patients at risk for sleep disorders, inform patients of prescription medications that can induce sleepiness, counsel patients regarding the risks of sleepiness, and potentially refer management to a sleep specialist. The education of the public is another ethical obligation of the sleep specialist. Although this clearly entails educating the patients about risks associated with their sleep disorder, it also should include informing the public of the implications of sleep disorders so that in a criminal case, the officers of the court and a jury of peers can effectively evaluate the evidence of what the patient (perpetrator) understood relative to risks and reach a verdict based on all relevant evidence.

Medical Examiner

Physicians are responsible for receiving and interpreting the information that is available to them. A thorough history and physical examination are the cornerstones of every medical evaluation, and the information obtained from this process, along with review of medical records, is essential in the diagnosis and management of any medical disorder. The sleep specialist is expected to identify risks of sleep disorders on the basis of the available history, medications, and physical examination. Although sleep physicians are responsible for identifying sleep disorders and formulating plans to minimize their risks to the patient,34 the physicians cannot interpret information that is not readily available to them. Information that is not disclosed by the patient or medical records that are not readily available, after all necessary and reasonable measures are taken on the part of the physician to acquire the information, should not be the responsibility of the sleep examiner. However, the absence of these data may hinder the accurate evaluation of the patient with a sleep disorder.

Objective testing may be performed based on the available data but needs to be ordered in an informed manner. Patients suspected of parasomnias may require extended monitoring, with additional electroencephalogram and electromyogram monitoring to gather data to support such a diagnosis. Commercial driver’s licenses are regulated by federal and state legislation, and licensure requires a medical examiner to review the applicant’s fitness to drive. If a sleep disorder is suspected, the candidate must undergo a clinical evaluation. A joint task force of three major medical professional societies has published recommendations for obstructive sleep apnea evaluation for commercial driver licensure.35 However, these recommendations address only obstructive sleep apnea and no other sleep disorders. Guidelines for the evaluation of sleep disorders for commercial driver’s license evaluations have been recommended36 but not widely accepted.

The requirement to report drowsy drivers in the United States differs by state. In general, a physician concerned about the safety of the patient also has the safety of the public in mind. The physician’s response must be constructed in the context of the Health Insurance Portability and Accountability Act, federal legislation that includes regulations on the use and disclosure of protected health information. In addition, there may be genuine disagreement between the patient and the physician regarding the nature of the risk that is posed by a sleep disorder. In these situations, the physicians must decide whether divulging confidential patient information is outweighed by the benefit to society, and often, this decision is best made with consultation of a legal expert. In the case Tarasoff v Regents of the University of California in 1976, the Supreme Court of California held that health professionals have a duty to protect individuals who are being threatened by bodily harm by a patient by means of notifying the police, warning the intended victim, and taking other reasonable steps to protect the threatened individual.37 How this translates to the public and to a particular individual was not addressed in this case. Mandatory reporting laws of some states (which tend to be only a small subset of sleep disorders) may obviate this dilemma but may have the unintended consequence of discouraging patients from sharing important medical information with their physician. Voluntary reporting programs exist in most states but put the physician at risk for litigation for divulging confidential patient information. The American Thoracic Society provides guidelines for reporting sleepy drivers, but these guidelines are not legally enforceable and are limited by lack of support from the scientific literature.15 In Canada, eight of the 12 provinces and territories require medical practitioners to report patients who have medical conditions that would make it dangerous for them to operate a motor vehicle.16 This variability in reporting regulations begs for a consensus statement between public agencies and medical professional societies to negotiate a fair policy to protect both the safety of the public and the right to privacy of the patient.

Expert Testimony

Once a criminal action is prosecuted, the sleep physician may be asked to provide expert testimony. Physicians may be asked to provide expert testimony in many ways, such as in the process of discovery, during depositions, and as an expert witness. The sleep expert usually is retained by either the defense or the prosecution, which may taint the equipoise that the testimony should provide. The testimony provided should be based on objective data of the patient, available medical knowledge, peer-reviewed published evidence, and the standard of care at the time of the incident in question. Beyond these, expert opinion can be subject to personal biases. The duty of the expert witness is not to win the case but to educate the court about the sleep disorder of interest.

Most physicians have had minimal, if any, training in providing expert testimony for a court. In order to provide expert testimony, one must have knowledge of the pathophysiology and etiology of the sleep disorder in question. In most cases of sleep-related crimes, a specific sleep-related diagnosis can be inferred only from the available data through formal testing. This usually is complicated by the fact that the sleep/wake state of the patient at the time of the event only can be speculated. Therefore, the best that an expert can provide is a balanced evaluation of the data available. Cramer Bornemann,5 in his review of the topic, recommends providing an opinion of high, medium, or low likelihood of the sleep disorder being present at the time of the event or an opinion of insufficient data to make such a conclusion.

It is clear that as the field of sleep medicine evolves, the legal implications of sleep disorders become more apparent. Sleep-related behaviors, errors, and accidents can seriously affect individuals and society in terms of harm, cost, and efficiency. The liability of the patient with a sleep disorder depends on his or her cognizance of the implications of the sleep disorder. The role of the physician as the educator, the medical provider, and the expert comes to center stage to elucidate the implications of sleep disorders. As our knowledge in the field of sleep medicine evolves, so does our obligation to protect the safety of our patients and society.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank Mary Legerski, RN, JD, MPA, MBA, and Steve Legerski, JD, for their help in the editing of this manuscript.

Knappman EW. Great American Trials. 1994; Detroit, MI Visible Ink Press:101-104
 
Strohl KP. Keeping sleepy people off the road: the responsibility of drivers, doctors, and the DMV. Virtual Mentor. 2008;109:578-584
 
Mahowald MW, Schenck CH. Medical-legal aspects of sleep medicine. Neurol Clin. 1999;172:215-234. [CrossRef] [PubMed]
 
Berger JT, Rosner F, Kark P, Bennett AJ.The Committee on Bioethical Issues of the Medical Society of the State of New YorkBerger JT.Rosner F.Kark P.Bennett AJ. The Committee on Bioethical Issues of the Medical Society of the State of New York Reporting by physicians of impaired drivers and potentially impaired drivers. J Gen Intern Med. 2000;159:667-672. [CrossRef] [PubMed]
 
Cramer Bornemann MA. Role of the expert witness in sleep-related violence trials. Virtual Mentor. 2008;109:571-577
 
Dubber MD. Criminal Law: Model Penal Code (Turning Point Series). 2002; New York, NY Foundation Press
 
Feinman JM. Law 101: Everything You Need to Know About the American Legal System. 2000; New York, NY Oxford University Press
 
National Sleep FoundationNational Sleep Foundation State of the States Report on Drowsy Driving: Summary of Findings. 2008; Washington, DC National Sleep Foundation
 
The Age. ‘Sexsomnia’ case sparks law change. 2009; http://www.theage.com.au/national/sexsomnia-case-sparks-law-change-20090508-axqx.htmlAccessed June 25, 2010.
 
Citynews.ca Staff. Man acquitted of sleepwalking murder running for school trustee in Durham. 2006; http://www.citytv.com/toronto/citynews/news/local/article/24162–man-acquitted-of-sleepwalking-murder-running-for-school-trustee-in-durhamAccessed June 25, 2010.
 
Martin L. Can sleepwalking be a murder defense? Lakeside Press http://www.lakesidepress.com/pulmonary/Sleep/sleep-murder.htm. Accessed April 26, 2009.
 
American Academy of Sleep MedicineAmerican Academy of Sleep Medicine The International Classification of Sleep Disorders. 2005;2nd ed Westchester, IL American Academy of Sleep Medicine
 
Pressman MR. Disorders of arousal from sleep and violent behavior: the role of physical contact and proximity. Sleep. 2007;308:1039-1047. [PubMed]
 
Cartwright R. Re: Pressman, M. Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications.Sleep Med. Rev. 2007;11:5-30. Sleep Med Rev. 2007;114:327-329. [CrossRef] [PubMed]
 
Koslowsky M, Babkoff H. Meta-analysis of the relationship between total sleep deprivation and performance. Chronobiol Int. 1992;92:132-136. [CrossRef] [PubMed]
 
Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep. 1996;194:318-326. [PubMed]
 
National Sleep FoundationNational Sleep Foundation Sleep in America Poll 2002. 2002; Washington, DC National Sleep Foundation
 
National Transportation Safety BoardNational Transportation Safety Board Safety Study: Fatigue Alcohol, Other Drugs, and Medical Factors in Fatal-to-the-Driver Heavy Truck Crashes. 1990; Washington, DC National Transportation Safety Board
 
Walsh JK, Dement WC, Dinges DF.Kryger MH, Roth T, Dement W. Sleep Medicine, Public policy, and public health. Principles and Practice of Sleep Medicine. 2009;4th ed Philadelphia, PA Elsevier:648-656
 
Maggie’s Law: National Drowsy Driving Act of 2003, NJS.2C:11-5 210th Legislature (2003).
 
Department of TransportationDepartment of TransportationFederal Motor Carrier Safety Administration Hours of service of drivers; driver rest and sleep for safe operations. Fed Regist. 2003;6881:22456-22517
 
US Department of TransportationUS Department of TransportationFederal Motor Carrier Safety Administration Expert panel recommendation: obstructive sleep apnea and commercial motor vehicle driver safety. http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdf.Accessed May 5, 2010.
 
Shappell SA, Wiegmann DA. A Human Error Analysis of General Aviation Controlled Flight Into Terrain Accidents Occurring Between 1990-1998. DOT/FAA/AM-03/4. 2003; Washington, DC Office of Aerospace Medicine
 
Dinges DF. An overview of sleepiness and accidents. J Sleep Res. 1995;4S2:4-14. [CrossRef] [PubMed]
 
Colten HR, Altevogt BM. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. 2006; Washington, DC National Academies Press:20
 
Presidential CommissionPresidential Commission Appendix G: human factors analysis. Report of the Presidential Commission on the Space Shuttle Challenger Accident. 1986;Vol 2 Washington, DC US Government Printing Office
 
Committee on Quality Health Care in America IoMCommittee on Quality Health Care in America IoMKohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. 1999; Washington, DC National Academy Press
 
Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;31812:771-775. [CrossRef] [PubMed]
 
Accreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education ACGME duty hour standards fact sheet. http://www.acgme.org/acWebsite/newsRoom/ACGMEdutyHoursfactsheet.pdf.Accessed August 13, 2009.
 
Accreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education Common program requirements. http://acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf. Accessed October 14, 2010.
 
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;35118:1838-1848. [CrossRef] [PubMed]
 
Lockley SW, Cronin JW, Evans EE, et al; Harvard Work Hours, Health and Safety Group Harvard Work Hours, Health and Safety Group Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;35118:1829-1837. [CrossRef] [PubMed]
 
US Department of JusticeUS Department of Justice Americans with Disabilities Act. http://www.ada.gov. Accessed August 13, 2009.
 
Brown DB.Kushida CA. Legal implications of obstructive sleep apnea. Obstructive Sleep Apnea. 2007; New York, NY CRC Press:405-423
 
Hartenbaum N, Collop NA, Rosen IM, et al; American College of Chest Physicians American College of Chest Physicians American College of Occupational and Environmental Medicine National Sleep Foundation Sleep apnea and commercial motor vehicle operators: statement from the joint task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation. Chest. 2006;1303:902-905. [CrossRef] [PubMed]
 
Miller CM, Khanna A, Strohl KP. Assessment and policy for commercial driver license referrals. J Clin Sleep Med. 2007;34:417-423. [PubMed]
 
 Tarasoff v Regents of the University of California. 17 Cal 3d 425,551 P2d 334, 131 Cal Rptr 14 (Cal 1976).
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Degrees of Culpability: Elements of Definition of Culpability of a Person’s Action With Respect to the Material Element of an Offense

From the American Law Institute’s Model Penal Code.6

References

Knappman EW. Great American Trials. 1994; Detroit, MI Visible Ink Press:101-104
 
Strohl KP. Keeping sleepy people off the road: the responsibility of drivers, doctors, and the DMV. Virtual Mentor. 2008;109:578-584
 
Mahowald MW, Schenck CH. Medical-legal aspects of sleep medicine. Neurol Clin. 1999;172:215-234. [CrossRef] [PubMed]
 
Berger JT, Rosner F, Kark P, Bennett AJ.The Committee on Bioethical Issues of the Medical Society of the State of New YorkBerger JT.Rosner F.Kark P.Bennett AJ. The Committee on Bioethical Issues of the Medical Society of the State of New York Reporting by physicians of impaired drivers and potentially impaired drivers. J Gen Intern Med. 2000;159:667-672. [CrossRef] [PubMed]
 
Cramer Bornemann MA. Role of the expert witness in sleep-related violence trials. Virtual Mentor. 2008;109:571-577
 
Dubber MD. Criminal Law: Model Penal Code (Turning Point Series). 2002; New York, NY Foundation Press
 
Feinman JM. Law 101: Everything You Need to Know About the American Legal System. 2000; New York, NY Oxford University Press
 
National Sleep FoundationNational Sleep Foundation State of the States Report on Drowsy Driving: Summary of Findings. 2008; Washington, DC National Sleep Foundation
 
The Age. ‘Sexsomnia’ case sparks law change. 2009; http://www.theage.com.au/national/sexsomnia-case-sparks-law-change-20090508-axqx.htmlAccessed June 25, 2010.
 
Citynews.ca Staff. Man acquitted of sleepwalking murder running for school trustee in Durham. 2006; http://www.citytv.com/toronto/citynews/news/local/article/24162–man-acquitted-of-sleepwalking-murder-running-for-school-trustee-in-durhamAccessed June 25, 2010.
 
Martin L. Can sleepwalking be a murder defense? Lakeside Press http://www.lakesidepress.com/pulmonary/Sleep/sleep-murder.htm. Accessed April 26, 2009.
 
American Academy of Sleep MedicineAmerican Academy of Sleep Medicine The International Classification of Sleep Disorders. 2005;2nd ed Westchester, IL American Academy of Sleep Medicine
 
Pressman MR. Disorders of arousal from sleep and violent behavior: the role of physical contact and proximity. Sleep. 2007;308:1039-1047. [PubMed]
 
Cartwright R. Re: Pressman, M. Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications.Sleep Med. Rev. 2007;11:5-30. Sleep Med Rev. 2007;114:327-329. [CrossRef] [PubMed]
 
Koslowsky M, Babkoff H. Meta-analysis of the relationship between total sleep deprivation and performance. Chronobiol Int. 1992;92:132-136. [CrossRef] [PubMed]
 
Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep. 1996;194:318-326. [PubMed]
 
National Sleep FoundationNational Sleep Foundation Sleep in America Poll 2002. 2002; Washington, DC National Sleep Foundation
 
National Transportation Safety BoardNational Transportation Safety Board Safety Study: Fatigue Alcohol, Other Drugs, and Medical Factors in Fatal-to-the-Driver Heavy Truck Crashes. 1990; Washington, DC National Transportation Safety Board
 
Walsh JK, Dement WC, Dinges DF.Kryger MH, Roth T, Dement W. Sleep Medicine, Public policy, and public health. Principles and Practice of Sleep Medicine. 2009;4th ed Philadelphia, PA Elsevier:648-656
 
Maggie’s Law: National Drowsy Driving Act of 2003, NJS.2C:11-5 210th Legislature (2003).
 
Department of TransportationDepartment of TransportationFederal Motor Carrier Safety Administration Hours of service of drivers; driver rest and sleep for safe operations. Fed Regist. 2003;6881:22456-22517
 
US Department of TransportationUS Department of TransportationFederal Motor Carrier Safety Administration Expert panel recommendation: obstructive sleep apnea and commercial motor vehicle driver safety. http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdf.Accessed May 5, 2010.
 
Shappell SA, Wiegmann DA. A Human Error Analysis of General Aviation Controlled Flight Into Terrain Accidents Occurring Between 1990-1998. DOT/FAA/AM-03/4. 2003; Washington, DC Office of Aerospace Medicine
 
Dinges DF. An overview of sleepiness and accidents. J Sleep Res. 1995;4S2:4-14. [CrossRef] [PubMed]
 
Colten HR, Altevogt BM. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. 2006; Washington, DC National Academies Press:20
 
Presidential CommissionPresidential Commission Appendix G: human factors analysis. Report of the Presidential Commission on the Space Shuttle Challenger Accident. 1986;Vol 2 Washington, DC US Government Printing Office
 
Committee on Quality Health Care in America IoMCommittee on Quality Health Care in America IoMKohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. 1999; Washington, DC National Academy Press
 
Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;31812:771-775. [CrossRef] [PubMed]
 
Accreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education ACGME duty hour standards fact sheet. http://www.acgme.org/acWebsite/newsRoom/ACGMEdutyHoursfactsheet.pdf.Accessed August 13, 2009.
 
Accreditation Council for Graduate Medical EducationAccreditation Council for Graduate Medical Education Common program requirements. http://acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf. Accessed October 14, 2010.
 
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;35118:1838-1848. [CrossRef] [PubMed]
 
Lockley SW, Cronin JW, Evans EE, et al; Harvard Work Hours, Health and Safety Group Harvard Work Hours, Health and Safety Group Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;35118:1829-1837. [CrossRef] [PubMed]
 
US Department of JusticeUS Department of Justice Americans with Disabilities Act. http://www.ada.gov. Accessed August 13, 2009.
 
Brown DB.Kushida CA. Legal implications of obstructive sleep apnea. Obstructive Sleep Apnea. 2007; New York, NY CRC Press:405-423
 
Hartenbaum N, Collop NA, Rosen IM, et al; American College of Chest Physicians American College of Chest Physicians American College of Occupational and Environmental Medicine National Sleep Foundation Sleep apnea and commercial motor vehicle operators: statement from the joint task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation. Chest. 2006;1303:902-905. [CrossRef] [PubMed]
 
Miller CM, Khanna A, Strohl KP. Assessment and policy for commercial driver license referrals. J Clin Sleep Med. 2007;34:417-423. [PubMed]
 
 Tarasoff v Regents of the University of California. 17 Cal 3d 425,551 P2d 334, 131 Cal Rptr 14 (Cal 1976).
 
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