Gun Laws May Allow Docs to Counsel Patients, Report Ownership

Laird Harrison

May 16, 2016

Physicians legally can and should report concerns about their patients' gun ownership to law enforcement, among others, researchers say.

Physicians should weigh their patients' age and ethnicity along with such factors as mental health, substance abuse, and history of violence in deciding whether to counsel patients about firearm safety, according to Garen J. Wintemute, MD, MPH, from the Violence Prevention Research Program at the University of California Davis Medical Center in Sacramento, and colleagues.

"Depending on the circumstances, interventions may include education; counseling in support of behavior change; or more direct efforts, such as disclosure to others, to prevent death or serious injury," they write.

The review appeared online May 16 in the Annals of Internal Medicine.

When asked to comment on the review, a spokesperson for Doctors for Responsible Gun Ownership, which opposes the treatment of gun use as a public health issue, was highly critical. "You are labeling these perfectly ordinary demographic groups as people who should not have weapons," Robert Young, MD, a clinical associate professor of psychiatry at the University of Rochester Medical School in New York, told Medscape Medical News.

The review authors contend that some physicians are not asking patients about access to guns because of concerns that such questions may be illegal. In fact, "no federal or state statute prohibits physicians from asking about firearms when such information is relevant to the health of the patient or others," write Dr Wintemute and colleagues.

They note that the American Bar Association has opined that the Second Amendment does not prohibit physicians from asking such questions. Meanwhile, the Affordable Care Act prohibits any requirement that physicians collect information about firearms but does not prohibit the collection of this information.

A Florida statue says physicians "should refrain" from asking about firearms, and "may not intentionally" record the information in medical records, but it makes an exception for circumstances in which the physician "in good faith believes that this information is relevant to the patient's medical care or safety, or the safety of others," write Dr Wintemute and colleagues.

Moreover, they note that physicians have challenged the Florida statute in court on First Amendment grounds, prevailing in US District Court. That decision remains in effect, although it is being reviewed by the US Court of Appeals for the Eleventh Circuit.

Montana, Missouri, and Minnesota have prohibited any requirement that physicians collect information about firearms, but they have not generally prohibited physicians from asking, according to the review authors. Minnesota also prohibits its state health commission and insurance exchange from collecting firearm information.

More restrictive bills have been introduced, for example, in North Carolina and Ohio, but so far they have not passed, the researchers write.

Likewise, no law prohibits disclosing information about patients' firearms to people concerned, such as caregivers, psychiatric services, and law enforcement, the writers say.

In addition, physicians may have a moral obligation to disclose the information, they write, citing the American Medical Association Code of Medical Ethics, which says "therapeutic privilege does not refer to withholding medical information in emergency situations."

The researchers list three instances in which physicians should act on information about their patients' access to guns:

  • When patients say or do something indicating a risk for violence, such as expressing a wish to commit suicide or murder, physicians should take emergency actions to secure such patients' weapons, if necessary by disclosing the risk to others.

  • When patients have "individual-level risk factors for violence," such as a mental health disorder or a history of violence or abuse drugs or alcohol, physicians should give advice about securing the weapons, and "when capacity is diminished consider disclosure to others who are able to lessen risk."

  • Third, when patients belong to "demographic groups that are at increased risk for firearm-related injury," physicians should give advice about securing the weapons and, in the case of minors, talk to the parents.

Demographic categories at risk for violence include middle-aged white men, because they have a high incidence of suicide, and young black men, because they have an increased risk of dying from homicide, Dr Wintemute and colleagues write, citing statistics from the Centers for Disease Control and Prevention.

The review lists resources physicians can use in discussing firearms with patients.

Physicians should indeed intervene when patients express a desire to commit violence, Dr Young agreed. He has advised families of some of his patients to secure firearms along with other dangerous items. But in most cases, taking action on the basis of the other criteria would be violating patients' privacy, he said.

"Most psychiatric illnesses have nothing to do with dangerousness," he argued. "This is a broad brush indictment of many people with many conditions and many situations. These are not reasons consistently to assume that these people are likely to be dangerous, and there is no reason to assume these people should not possess a gun."

Taking the opposite tack, Steven E. Weinberger, MD, executive vice president and chief executive officer of the American College of Physicians, argues in an editorial accompanying the review that physicians should ask about patients' guns for the same reason they ask about immunization, smoking, and seatbelt use.

"[T]hey should not shirk their responsibility to seek information about gun ownership when appropriate or to counsel, educate, and take other actions if necessary to mitigate the risk for firearm-related injury or death," he concludes.

Dr Wintemute disclosed grants from the California Wellness Foundation. The other coauthors and Dr Weinberger and Dr Young have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 16, 2016.

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