Imagine that your 16-year-old daughter has been bullied mercilessly in school, but hasn’t talked to you about it, or spoken about her suicidal impulses. One day, she is brought by ambulance to your local hospital emergency room, having made superficial cuts on her arms while in school. The emergency room physician tries to call you at work, but your cell phone isn’t picking up. The doctor begins her evaluation of your daughter, including an assessment of all relevant risk factors for suicide. Now imagine that the doctor believes she is forbidden by law from asking your daughter whether there are guns in your home — despite the fact that firearms in the home markedly increase the risk of gun-related suicide.1
You needn’t use much imagination. In Florida, Gov. Rick Scott is expected to sign a bill (SB-432) that will prohibit doctors from asking patients if they own guns, except when “…the information is relevant to the patient’s medical care or safety or the safety of others…”
The Florida bill was written with the help of — no surprise here — the National Rifle Association, which insists that this legislation is designed to prevent doctors from intruding on a patient’s privacy; “harassing” gun owners; and interfering with the patient’s second amendment “right to bear arms.” Similar bills are being considered in North Carolina and Alabama.
Now, the “relevance exception” clause may sound quite reasonable, at first blush. Evidently, it persuaded the Florida Medical Association, who ultimately went along with the bill. But the exception clause has not persuaded many Florida pediatricians, who believe such a law would have a chilling effect on the doctor’s evaluation. According to a report on National Public Radio2, one specialist in adolescent medicine recently told a Florida Senate committee, “What if I have an adolescent who’s been bullied, [but] who’s not suicidal? I don’t think, under the current bill, I’m entitled to ask him if there’s a gun in the home, or if he’s carried a gun to school, or if he’s thinking of harming someone else with a gun.”
Indeed, the newly-added “relevance” clause may actually put the physician — and perhaps other clinicians — in a medico-legal “double bind”. If he or she fails to inquire about gun possession because it is not deemed “relevant”, and the patient goes on to commit some act of gun-related violence, the physician may be held liable for failing to ask the “relevant” questions. On the other hand, if the physician decides that a query about gun possession is relevant; but the patient believes otherwise, and becomes angry about the “invasion of privacy”, he or she could initiate a suit against the doctor, on the grounds that the gun possession query was not clinically “relevant” as per state law.
There are, of course, important constitutional issues raised by bills of this sort, not least of which is the physician’s right to freedom of speech, under the first amendment. Since when is it the role of government to control what may or may not be said, in the supposedly confidential relationship between physician and patient? Since when are such communications subject to monitoring and muzzling by a state government? And, by the way — how, exactly, is the second amendment’s right to bear arms infringed upon by a doctor’s mere inquiry, regarding guns in the home? Is the idea that the doctor is going to lead a group of left-wing, anti-gun zealots out to the patient’s house, and confiscate legally-owned firearms?
But these are questions best left in the hands of constitutional scholars and jurists. As a psychiatrist, I have a more direct interest in protecting the safety of patients, their families, and society. In fact, I am professionally obligated to inquire about firearms (and many other risk factors) whenever I believe there is a potential danger to the patient or others. As a therapist, in many jurisdictions, I am legally obligated by either case law or state statutes to consider notifying police or a third party who may be the target of violence on the part of a patient I have evaluated; for example, a distraught, angry patient in psychotherapy who reveals his intent to shoot a particular individual. What effect would a Florida-style law have on assessing the risk of gun-related violence, if the physician fears legal sanctions for stepping across the line of “relevance” specified in the exception clause?
These are hardly academic issues. Recently, a three-year-old South Carolina girl fatally shot herself in the head, using a pistol that was left loaded on a windowsill in her parent’s bedroom. In another case from California, reported in the May 11, 2011 New York Times, a 10-year-old boy shot his father to death, at home, using a handgun. Of course, lax firearms regulations in the U.S. contribute to such tragedies. Indeed, according to data from UCLA and Harvard researchers, the U.S. firearm-related suicide rate is almost six times higher than in comparison countries, and unintentional firearm-related deaths are about five times higher in this country.1
Some proponents of the Florida bill respond to critics with a classic reductio ad absurdum argument. They ask, “If doctors need to inquire about guns in the home, why don’t they ask about poisonous snakes or dangerous dogs in the neighborhood? Why don’t they ask about tall buildings with unprotected balconies, open sewers, etc?” The emptiness of this argument should be evident to any clinician with a modicum of forensic experience. Obviously, there are infinite risks a physician, psychologist, or social worker could inquire about, but our time with the patient is finite — and few domestic dangers pack the lethality of a loaded gun in the house. Moreover, the possession of firearms in the home is a professionally-recognized risk factor for both gun-related homicide and suicide. As noted by Garen J. Wintemute, M.D., M.P.H. (Professor of Emergency Medicine and director of the Violence Prevention Research Program at the University of California, Davis, School of Medicine):
“Gun violence is often an unintended consequence of gun ownership. Americans have purchased millions of guns, predominantly handguns, believing that having a gun at home makes them safer. In fact, handgun purchasers substantially increase their risk of a violent death. This increase begins the moment the gun is acquired — suicide is the leading cause of death among handgun owners in the first year after purchase — and lasts for years. The risks associated with household exposure to guns apply not only to the people who buy them; epidemiologically, there can be said to be “passive” gun owners who are analogous to passive smokers. Living in a home where there are guns increases the risk of homicide by 40 to 170% and the risk of suicide by 90 to 460%.1
These facts confer a very high degree of responsibility on the part of the physician. As Norris and Price have pointed out:
“Access to firearms is an important factor for clinicians to consider in any risk assessment of suicidal patients. Miller and Hemenway report that “in 2005, an average of 46 Americans a day committed suicide with a firearm, accounting for 53% of all completed suicides.”… All discussions with the patient and his or her family regarding firearms should be documented. When clinicians are doing a psychiatric examination of suicidal patients, they should inquire about the availability of firearms in the household. If a firearm is available, concerns about safety should be raised with the family and police. This is particularly true when children and adolescents reside in the household.”2
Obviously, the “gun possession” question will rarely be raised when a patient goes to the ER with a sore throat — any more than an astute physician would do a rectal exam under such circumstances. Furthermore, patients who decline to answer a physician’s questions about gun possession should never be harassed, disparaged or denied care — but doctors do not need a law to instruct them in such basic medical ethics. More important: the physician should not be looking over his or her shoulder at the question of how much legal risk is entailed in asking clinically-indicated questions about firearms.
These judgments should be guided by the physician’s medical training and clinical evaluation — not by misbegotten legislation that intrudes on the physician’s freedom of speech, and on the privacy of the doctor-patient relationship.
Acknowledgments: The author wishes to thank Michael P. Hirsh, MD, FACS, FAAP; and James L. Knoll IV, MD, for their helpful comments on earlier drafts of this piece.
1. Wintemute GJ. Guns, fear, the Constitution, and the public’s health. N Engl J Med. 2008 Apr 3;358(14):1421-4. Epub 2008 Mar 19.
2. Allen G: Florida Bill Could Muzzle Doctors On Gun Safety. National Public Radio, May 7, 2011. Accessed at: http://www.npr.org/2011/05/07/136063523/florida-bill-could-muzzle-doctors-on-gun-safety
3. Norris D, Price M: “Firearms and Mental Illness” Psychiatric Times, Oct. 30, 2009