We Are Only Human

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Loaded Question

Should states restrict doctors from asking patients about gun ownership?
The recent efforts of three states (Florida, North Carolina, and Alabama) to consider laws that restrict doctors from asking patients or parents about whether they own a gun is an alarming direction. The bill in Florida was prompted by gun rights groups who felt doctors' direct questioning about guns in the home goes too far and that the proposed law is necessary to protect the Second Amendment rights.

Boy with speech bubbles of gun and question mark

Although guns make up only one percent of suicide attempts, they comprise 50 percent of completed suicides. At times a person has carefully planned how to die by suicide yet many suicide attempts occur during an acute emotional crisis fueled by underlying mental illness and lubricated by drugs or alcohol. Easy access to a weapon can transform a temporary suicidal impulse into a tragic death.

I am a practicing child psychiatrist so I also appreciate the devastation a suicide can cause for those left behind. I often talk with teenagers, who may struggle with depression, substance abuse or impulsivity. They may have taken an overdose, tried to hang themselves or contemplated shooting themselves. I am fortunate enough to intervene when there is an opportunity to ask guiding questions to help teenagers and families take the time to be reflective. There is a chance to avert disaster by families taking life saving precautions that may include protective measures, therapy and/or medication.  Routine questions in an assessment may range from asking How do you think your mother would feel at your funeral? to Do you have a gun in your home? . On a recent clinic visit, after the routine question to a guarded teenager as to whether he had access to a gun, he confided that if he left our clinic he would either be killed or he would kill himself. He had access to a gun and we took the necessary measures to keep him safe. To avoid asking questions like these is bordering on negligence to adequately assess safety.

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The "success rate" or risk of completion of suicide is enhanced in a macabre way when a patient has access to a gun. A teenager who lives in a home with a gun is twice as likely to kill himself than those in gun free homes. Even if a parent thinks the gun is safely locked in a cabinet, this may provide a false security, as the teenager often knows the "secret" hiding place of the key. (How many of you were deterred by your parents' efforts at security when you were teenagers?)  In the heat of the moment, with the news of his parents' divorce or rejection by a girlfriend and feeling like a failure- a teenager can temporarily lose perspective. If a teenager pulls the trigger, he has made an irreversible decision.

Physicians have a privileged position to ask questions that may seem intrusive and up to this point are legal.   For example, if a patient has a sexually transmitted disease, in order to curtail the risk of spreading infection, a doctor may ask him to reveal their other sexual partners. A doctor will ask about alcohol use or eating fatty foods and helmet use in sports as a way to encourage safe habits. A question to a depressed patient about access to guns is not political as much as a protective inquiry. A physician may not have anything against responsible gun use by teenagers (hunting, target shooting etc.) rather than having guns in the house along with teenagers is highly risky and the providers need accurate information to keep their patients safe.  

If it is true that certain states may consider legislature to penalize physicians for asking questions about ownership of guns in the home, it is interesting to speculate how this might be enforced. Would it be required to videotape interviews in an emergency room and then a certified inspector review the tape to note infractions? What would this mean about patient confidentiality laws and the right to privacy? Would colleagues start to police each other? Would there be clandestine efforts to catch a doctor by having fake patients feign suicidality? These scenarios all sound ludicrous and undermine doctors' practice of sound clinical judgment. If these laws are not challenged, we lose critical opportunities to ask life saving questions.

 

Nancy Rappaport is associate professor of psychiatry at Harvard Medical School.

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