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Although there is no doubt that the aftermath of guns—injury and death—is indeed a healthcare issue, there is considerable controversy as to whether preventing these injuries is within the purview of the healthcare community. What, after all, do healthcare professionals know about gun safety? And among those who do have the knowledge to adequately instruct patients and families, who has the time?
Medscape polled our readers to see what they thought. We offer this summary of the issues and the range of opinions expressed by our members.
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Healthcare providers and facilities often encounter the associated effects of guns: suicide, homicide, and injury. Guns are used in more than 31,000 deaths annually,[1] and suicide by gun is more common than homicide.[2] Yet the number of gun homicides is approximately the same as that of vehicle fatalities, and unintentional trauma caused by guns results in more deaths than other accidental causes, such as poisoning or falls.
Gun injuries result in at least 40,000 medical visits, and that number is considered by many experts to be a significant underestimate. In 2009, there were over 7000 hospitalizations in children and adolescents as a result of a firearm-related injury; the rate was highest among teenage males.[3]
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Statistics on injuries and death prevented by firearms are much harder to come by. A randomized trial in which half of the population is provided guns and the other half denied access, would allow a definitive answer, but it is clearly neither practical nor ethical. And study of trends in and patterns of injury by governmental bodies is limited because of language included in the 1996 Omnibus Consolidated Appropriations Bill for Fiscal Year 1997 that is still in effect: "None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention [CDC] may be used to advocate or promote gun control."[4] Although this language does not preclude spending money on research, it has been interpreted as a de facto ban, especially because the CDC was stripped of funding by an amount identical to the sum spent on gun violence research that same year.[5] There are certainly instances of injuries that were prevented through the use of firearms—including the well-publicized incident of a physician who shot an armed psychiatric patient at a hospital in Pennsylvania in 2014[6]—but overall, the evidence remains anecdotal.
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Are the effects of firearm injury and violence felt equally across the country? Or is this an urban phenomenon? According to an analysis of data provided by the CDC in 2008, almost 60% of gun homicides occurred in 62 cities based in the nation's 50 largest metropolitan regions, but only 27% of gun suicides occurred in these same areas.[7] On the basis of these same data, gun suicides appeared to be a primarily suburban phenomenon. The seminal study[8] that sparked the language on gun research in the 1996 CDC appropriations bill identified a relationship between the presence of guns in the home and suicide. Subsequent analysis of state-level data has suggested that rural areas with higher rates of gun ownership do not have higher rates of suicide attempts,[9] but they do have higher rates of completed suicide by firearm.[10]
It would therefore appear that clinicians in all areas of the country are indeed likely to encounter the potential aftereffects of gun use, raising the question: What can, and should, healthcare providers do about it?
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Numerous professional associations have weighed in on the issue. The American Academy of Pediatrics first detailed the role of pediatricians in preventing firearm injury in 1992[11] and most recently reaffirmed and updated that recommendation in 2012.[12] The American College of Physicians (ACP) issued a position paper in April 2014 asserting that "the medical profession has a special responsibility to speak out on prevention of firearm-related injuries and deaths, just as physicians have spoken out on other public health issues".[13] Earlier this year, eight medical societies teamed up with the American Bar Association (ABA) to issue a call for action to reduce firearm-related injury and death without violating the Second Amendment.[14]
During ACP's 2015 annual meeting, the organization announced that an additional two dozen groups have signed on in support of the joint statement. Several are medical organizations, but other endorsers include non-healthcare–related groups like the National Urban League, Sandy Hook Promise, and the Violence Prevention Center.
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In contrast to the position of medical professional societies reiterating the need for physicians to discuss gun ownership with patients and families, some states preclude exactly this kind of conversation. A Florida law passed in 2011 prohibits asking patients about gun ownership in most routine encounters. Exceptions include circumstances in which the physician "in good faith believes this information is relevant to the patient's medical care or safety or to the safety of others."[15] Physician groups sued, arguing that the bill infringed on their First Amendment rights. The law was initially put on hold, but in July 2014, a three-judge panel of the 11th Circuit ruled that the Florida law is "a valid regulation of professional conduct that has only an incidental effect on physicians' speech." The physician groups have asked all nine judges of the 11th Circuit to review the decision, and a final ruling is expected this summer.
In the meantime, several other states have proposed bills that would, to varying degrees, restrict discussions of gun ownership by healthcare professionals. Minnesota, Missouri, and Montana have passed much less restrictive versions[15]; Indiana[16] and Texas[17,18] are considering bills with language similar to the Florida law.
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Vivek Murthy, MD, was confirmed as surgeon general in December 2014 in a lame duck session of Congress and sworn in on April 22, 2015. Although his nomination had been opposed by Senate Republicans and the National Rifle Association branded his position on gun control as radical, Dr Murthy asserted during his confirmation hearings that he did "not intend to use the Surgeon General's office as a bully pulpit for gun control." In an interview with National Public Radio after his confirmation, Dr Murthy, without singling out gun violence, affirmed that "violence of all kinds is a public health issue. When you have large numbers of people dying from preventable causes, that's a healthcare issue. That's a public health issue."[19]
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Given the many disparate views on the issue, from professional societies to state legislatures, Medscape conducted a poll to ask our readers which of the recommendations included in the call to action from the consortium of medical societies and the ABA should be enforced. The recommendations ranged from those directly affecting physicians, such as a recommendation to eliminate state and federal mandates that interfere with physician free speech and the patient/physician relationship, to those less clearly linked to healthcare, such as a recommendation that background checks be a universal requirement for gun purchase. None of the five specific suggestions detailed in the paper garnered support from more than 20% of Medscape readers. Discussion was heated on both sides of the issue.
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The argument of readers who support the role of healthcare professionals in advocating gun safety is encapsulated in comments from one family physician: "Why should physicians not be allowed to discuss gun safety with parents, like car seats, household poisons, and bike helmets, unless you do not believe in preventive medicine? This is not 'liberal,' but common sense!" Another reader argued that given that most firearm deaths are the result of suicide and not homicide, gun safety was more of a public health issue than a criminal issue.
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The arguments against healthcare professionals' role in gun safety are numerous and equally compelling—and equally vehemently held positions. Are healthcare professionals qualified to discuss gun safety? Even if they are qualified, do they have the time? What about the myriad other potential risks in life, such as pools, automobiles, and pedestrian accidents? Are those also the responsibility of healthcare professionals? And does counseling potentially open the door to legal liability if done incorrectly or if the patient or family subsequently sustains a gun injury?
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In a commentary on Medscape, Arthur Caplan, PhD, a nationally recognized ethicist, argued that doctors and nurses should promote safe gun ownership, particularly in families with children. Hundreds of readers commented, with a solid majority noting that healthcare professionals may not have the necessary skill or knowledge to correctly educate patients and families about gun safety. Although concern was voiced about the legal liability of a healthcare professional providing safety education that did not meet an objective standard, what about legal concerns for a professional who identifies that a patient or family has access to a gun and does not then provide safety education? Is the provider potentially liable if the identified gun later is used to cause an injury or death?
Readers on both sides of the argument voiced strong support for the importance of adequate education in the safe handling of guns and ammunition. Many readers suggested that the appropriate response was to refer patients to legitimate gun-safety educational programs. Many attested to the Eddie Eagle Gunsafe® Program provided by the National Rifle Association as a comprehensive and well-done program for children.
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