January 26th, 2017
Can Medical Professionals Ask Patients About Guns?
A student recently asked me if clinicians can talk to patients about gun ownership and safety. Her question triggered my month-long search for data to provide a solid evidence-based response.
Alas, my research did not unearth such an answer. But I did find endless writing that discussed this increasingly contentious question in terms of rights, ideology, law, politics, ethics, and medicine.
I realized that if we are to have an honest discussion about the relevance of gun safety to medical practice, it is essential to study the major conundrums that have caused polarization among patients, providers, state legislatures, and medical organizations. The American Medical Association (AMA), the American Academy of Pediatrics, and the Society of Adolescent Medicine are examples of organizations that encourage clinicians to counsel patients about gun safety; they oppose legislative action that limits or obstructs such discussions. Florida and Montana are examples of states that have passed legislation that limits questions by physicians about gun ownership, a stance supported by gun lobby groups.
Can we legitimately call gun violence an epidemic like polio, measles, and HIV?
According to gun lobby groups, gun violence is not an epidemic. Epidemics refer to diseases; more specifically, to surges in infectious disease. The use of the word epidemic is a misnomer aimed at creating an emotional response. Some dismiss such language as rhetoric and hyperbole, lacking in caliber and sincerity.
Undeniably, epidemic in the past was limited to infectious diseases. Today, the scope is much broader: an epidemic refers to a condition, disease, or undesirable phenomenon that affects a disproportionately large number of the population. Such new definitions can be seen in dictionaries like Merriam-Webster and the Oxford English dictionary: “the practice had reached epidemic proportions” or “an epidemic of crime.” Given this change, it is reasonable to refer to gun violence as an epidemic.
If we look at an epidemic as “a surge” or disproportionate increase, such terminology becomes questionable. Firearm mortality rates have generally remained stable over the past 30 years. The agency defines an epidemic as “a recent increase in amount or virulence of [an] agent.” I am not sure we can say gun violence is virulent, although it may feel so at times. If we consider gun violence in terms of type, then we can see America has had a stark increase in mass shootings — namely an epidemic. Precision in the language of medicine matters.
What about the data?
According to the CDC, the total number of firearm-related deaths in 2015 was 36,252; of these, 2824 affected individuals aged 0-19 years. Mortality data can be subdivided into suicide, homicide, legal, and unintentional. Whether or not you consider these numbers to be disproportionately large is somewhat subjective: how many deaths from firearms are too many? Gun lobby groups cite that few of these deaths are accidental; some are related to gang violence or are suicides, but this surely leaves us making value judgments according to intent, mechanism, or ideology. Are deaths from suicide any less preventable or tragic?
How do we define a “public health issue,” and are guns a threat to public health?
Gun groups contend gun violence is not a public health issue, as most injuries and deaths occur from the negligent or malicious use of a firearm. It is neither a disease nor a medical problem. Thus, questions regarding gun control and measures to ensure public safety should be under the jurisdiction of the legal system. The National Rifle Association sees the public health approach as an attempt by medical organizations at gun control.
Public health is defined by the CDC Foundation as “the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention.” Given the number of injuries caused by firearms, it is legitimate to consider gun violence a public health issue. Merriam-Webster also includes “preventive medicine” as part of its definition of public health. Talking to patients about gun ownership and safety is preventive medicine.
Are questions about gun ownership an invasion of privacy or violation of the Second Amendment?
Gun lobby groups and gun owners see questions about ownership of firearms as a value judgment. Some worry that documentation of gun ownership in medical records might be accessed by the federal government to create databases. Others consider clinician questions about guns as a challenge to their Second Amendment rights. They cite fears that the information will be used to discriminate against gun owners or discourage gun ownership. They consider these discussions to be an underhanded means of promoting an anti-gun political agenda.
Medical organizations argue that personal questions are an essential part of medical practice inherent to the clinician-patient relationship. Pediatricians ask about guns just as they would car seats, swimming pool fences, and safe storage of noxious chemicals. Patients have the right to decline to answer such questions. Additionally, the AMA suggests that “physician gag laws” violate the First Amendment rights of clinicians.
Reconciling rights and ideology with the Hippocratic Oath (duty to protect) is difficult. In response to my student’s question: yes, medical professionals can ask about gun ownership and safety, but they need to be attentive to state legislation that sets parameters for such questions and cognizant of the patient’s right not to answer. A reasonable approach is to ask such questions in situations where gun ownership and gun safety are relevant to the context of the encounter: a well-child check, gun-related injuries, or when patients are at risk of suicide or homicide.