Shooting Underlines Need to Ask About Guns, Doctors Say

December 21, 2012

Some 6 weeks before Adam Lanza shot to death 20 children and 6 adults at Sandy Hook Elementary School in Newtown, Connecticut, organized medicine made a point in a federal lawsuit that seems prescient today: "A physician is well positioned to warn a parent...that a teenager who shows symptoms of depression or impulsivity could harm himself or others if given access to a firearm," the American Medical Association, the American Academy of Pediatrics (AAP), and 7 other medical societies wrote in an amicus (friend-of-the-court) brief.

The lawsuit, underway in a federal appeals court in Atlanta, Georgia, concerns a Florida law that prohibits physicians from asking patients or family members whether they own guns. The law allows for disciplinary action by the Florida Board of Medicine if physicians violate any of its provisions, "including causing a patient to feel harassed because questions about gun ownership were posed," according to a commentary published online today in the Archives of Pediatrics & Adolescent Medicine.

Supporters of the law, including the National Rifle Association (NRA), view such questions as hostile to the Second Amendment right to bear arms. They say physicians have harassed gun owners and dropped their children as patients when they refused to answer the gun question. Medical societies such as the AAP counter that inquiries about gun ownership simply set the stage for conversations about gun safety, particularly proper storage, and avoid the tragedy of a toddler who discovers a loaded pistol in a closet.

Or a disturbed young man who picks up and loads his mother's military-style assault rifle.

Along with several individual physicians, Florida chapters of the AAP, the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP) sued the state of Florida in a federal district court in Miami, challenging the law as an infringement of the First Amendment right to free speech. US District Judge Marcia Cooke struck down the law as unconstitutional, a ruling that the state — and the NRA — is now contesting at the appellate level.

The legal battle has gained more prominence in the wake of the Newtown mass murder on December 14, in which 20-year-old Adam Lanza also shot his mother and himself to death. It is widely reported that Lanza's mother, Nancy Lanza, owned and stored guns in their home, although the Connecticut State Police has not disclosed how she stored them. The 3 guns that Lanza brought into the elementary school — 2 handguns and a Bushmaster AR-15 assault rifle — allegedly belonged to Nancy Lanza. The federal Bureau of Alcohol, Tobacco, Firearms and Explosives confirms that mother and son visited shooting ranges together, although not in the previous 6 months.

The Connecticut State Police said in a press release yesterday that it is continuing to investigate the crime with the help of other law enforcement agencies and that a final report is several months away.

Leaders of organized medicine this week responded to the incomplete narrative of the shooting by reiterating the need for physicians to ask patients about gun ownership.

"Part of my professional and ethical duty is to identify those things that can harm kids and their families," said M. Denise Dowd, MD, MPH, who coauthored the most recent AAP position paper on firearm-related injuries. Last week's massacre "underscored that point completely," Dr. Dowd told Medscape Medical News.

AAFP President Jeffrey Cain, MD, said the Newtown shooting has reopened the dialogue about gun violence — a dialogue that physicians and patients also must have.

"What Florida did was appalling," Dr. Cain told Medscape Medical News. "What they were doing in the legislature was getting between patients and physicians and inhibiting a conversation about personal health."

In his society's response to the Newtown shooting, ACP President David Bronson, MD, said in a press release yesterday that "government must not impose any restrictions on physicians being able to counsel their patients on reducing injuries and deaths from firearms in the home, as some state legislatures have attempted to do." American Medical Association President Jeremy Lazarus, MD also affirmed physician free speech in a blog entry on the shooting.

"We Don't Have Beds for Those Kids"

Organized medicine's stance on gun violence goes beyond unfettered conversations in the exam room. The ACP, AAP, and AAFP all support banning the sale of assault weapons like the kind used by Adam Lanza. Such a ban, which once existed from 1994 to 2004, is quickly gathering political tailwinds. At the same time, medical society leaders say that preventing mass murders like those in Newtown, or Aurora Columbine in Colorado, will require a holistic approach, not just gun control legislation.

"It's also about mental health," said Dr. Cain. "And violence in the media."

The ACP's Dr. Bronson sounds a similar note. He said that the nation needs to do more to help people with mental health and substance abuse problems, most of whom pose no danger.

"It is especially urgent that the system provide affordable and effective treatment options for persons who may be at greater risk of inflicting violence on themselves and others," said Dr. Bronson.

Dr. Dowd said she witnesses unmet mental health needs that augur violence in the emergency department at Children's Mercy Hospital in Kansas City, Missouri, where she works.

"I can't tell you the number of parents, especially mothers, who bring in their out-of-control teenager who [weighs] 170 pounds," said Dr. Dowd. "They're scared. They've had altercations with them. They can't get proper mental healthcare.

We have plenty of beds for kids with gunshot wounds, but a kid with a mental health problem, that's another issue. We don't have beds for those kids. M. Denise Dowd, MD, MPH

"We have plenty of beds for kids with gunshot wounds, but a kid with a mental health problem, that's another issue. We don't have beds for those kids."

"We Have Not Touched the Second Amendment With a Single Word"

While citizens of Newtown mourn their dead and lawmakers debate the merits of banning assault weapons, the appellate case on the Florida "gun gag" law grinds forward. Oral arguments have not been scheduled. When lawyers for the opposing sides eventually square off before the bench, one of the issues they will likely discuss is a much-debated loophole in the Florida law. It states that clinicians can inquire about gun ownership if they believe that "this information is relevant to the patient's medical care or safety, or the safety of others."

In their brief in the appellate case, Florida Governor Rick Scott and other state officials maintain that this relevancy exception preserves the right of physicians to ask about gun ownership. The law, therefore, does not infringe on anyone's right to free speech, and US District Judge Marcia Cooke erred in declaring the measure unconstitutional, they contend. The NRA made the same argument in an amicus brief.

From the beginning, the medical societies and physicians who sued the state have claimed that the relevancy loophole is too vague to give clinicians any confidence that they will not get into legal trouble if they ask, "Do you own a gun?" Cooke concurred.

The plaintiffs in the Florida case, along with the national medical societies who filed an amicus brief in the appellate court, continue to pick apart the relevancy loophole. "Issues of firearm ownership may appear irrelevant at the onset of the physician-patient relationship, but they may become relevant later," the national societies argued in their brief.

Bernd Wollschlaeger, MD, a family physician in Miami and one of the individual plaintiffs, sums up the loophole conundrum, as he sees it, in simpler language. "You can only determine the relevance of the question once you have the answer," he told Medscape Medical News.

Dr. Wollschlaeger, who carries a concealed handgun under a state permit, said that Florida officials have mischaracterized him and other physician plaintiffs.

"They say we are radical and politicized," he said. "We are not. We have not touched the Second Amendment with a single word."

He called the shooting at Sandy Hook Elementary School "horrific."

"It horrifies me that we don't learn from these events," he said.

If through my questions I can address gun safety, I'm part of the solution. Bernd Wollschlaeger, MD

Like others, Dr. Wollschlaeger said the solution to gun violence is more complicated than gun control laws. The problem will requires collective action by parents, teachers, physicians, clergy, and others to prevent people such as Adam Lanza and their families from falling through the cracks.

"If through my questions I can address gun safety," he said, "I'm part of the solution."

Arch Pediatr Adolesc Med. Published online December 21, 2012. Full text