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Gun control: Medical ethics issue, public health concern, or political bias?
VA Tech shootings fuel debate on MD's role in curbing violence
The mass shootings at Virginia Tech in April fueled the national debate over gun control, and physicians treating those killed and injured in the rampage expressed shock at the extent of the violence.
But is gun violence a health care issue?
"I don't think there are many people who would say people with holes in them aren't a public health problem," says Mike McCally, MD, PhD, executive director of physicians for social responsibility in Washington, DC.
Or is simply violence the health care issue, with guns brought into the equation for political purposes?
"Well-intentioned physicians are confusing violence with guns; oppose the violence, but not the guns," says Miguel A. Faria, Jr., MD, a retired Macon, GA, neurosurgeon and professor of neurosurgery, who has written extensively on the subject of gun control and public health.
McCally, a public health physician professor in the department of community and preventive medicine at Mount Sinai School of Medicine in New York, says while few in the medical community dispute that gun violence and violence in general are a public health problem, there is less clear evidence of a medical ethical argument for that assertion.
In 2004, 29,569 people in the United States died from firearm-related deaths — 11,624 (39%) homicides; 16,750 (57%) suicides; 649 (2.2%) accidents; and 235 (0.8%) of unknown cause/intent. In all, the death rate from accident and injury in 2004 was 167,184.1
Physicians on all sides of the gun violence debate agree that's too many — just like the statistics on drunk driving deaths, child abuse, and domestic violence are too high. Where opinions diverge is over the role guns play, and the role physicians should have in advocating for gun control.
Fighting a 'Wild West mentality'
Gregory Luke Larkin, MD, MS, who practices trauma and emergency medicine at Yale-New Haven Hospital in Connecticut, is squarely in favor of physicians doing anything they can to deter gun violence. He's stitched up and resuscitated more gunshot-wounded patients than he can count; he's been shot at himself, twice, in the emergency department. And he doesn't think the Virginia Tech shootings will change the number of guns and gunshot wounds he sees.
"I think when the news dies down, people will stick their heads in the sand, and will pretend it will go away, and it won't," he says. "I think it's important that people understand and not be surprised when [mass killings] happen again."
The former rifle team sharpshooter says there is a place for guns, but in the hands of so much of the population is not that place.
"Given that we've tried this experiment, where people can buy guns openly, with limited restrictions and short wait times — it doesn't work," Larkin insists. "As an emergency physician in a trauma center, who has been shot at twice by patients, the evidence is clear: There is a very small part of the population that can responsibly carry a firearm and handle the implications of a semiautomatic weapon. The vast majority can't."
Larkin says America maintains a "Wild West mentality" when it comes to the right of the individual above the good of society. Privacy restrictions afforded by the federal Health Insurance Portability and Accountability Act (HIPAA) can add additional risk in some cases, he adds.
"HIPAA restrictions prohibit us from sharing mental health information that would have helped in the Virginia incident," he suggests. "We are butchering safety on the altar of the rights of the individual."
While Faria adamantly opposes asking patients if they own firearms, Larkin says he often does.
"I ask people if they have access to firearms, if they have firearms in their house, and I can admit them [to the hospital] for a short stay against their will if I think they could be a threat to themselves or others," he says. "Only recently have we realized how many patients are suicidal. We reported that of patients who come into the ED for routine stuff — headaches, asthma, sprains — about 8% have suicidal thoughts, and about 2% actually have a plan, but that's not routinely picked up by staff because they're focusing on the complaint they come in with."2
Larkin says it's not unusual for him to see patients come in with gunshot wounds, have their injuries treated — and sometimes their lives saved, only to return again a month or year later with another gun-related injury.
"As a physician I feel ineffective," says Larkin. "We are closing the barn door after the horses run free — we don't seem to want to invest in prevention to control injuries, but we're willing to spend millions of dollars on trauma centers to treat the consequences."
Doctors ask about guns, 'violate boundaries'
"I think the gun control issue is a political and constitutional issue, and it is very dangerous for physicians to get involved in it," says Faria. "In the Soviet Union, you saw the perversion of psychology so that it could be used against dissidents. It's the same thing with the gun control issue today — doctors have too much moral authority to influence their patients."
Gun violence, like any other type of violence, is a grave public health concern, Faria says.
"I was a neurosurgeon before I retired, and I was often called in the middle of the night to operate on someone who had been shot, so I know it is a problem," he says. "But the problem is the violence. Not the guns. Gun control is a political issue, not a medical or ethics issue."
Physicians should stick to health care, he insists. To do otherwise "can become a boundary violation — a physician using his influence with his patients to sell a political idea," he says.
"The American Medical Association has imposed its anti-gun bias on doctors, and for doctors to impose their bias on patients is unethical," he asserts. "Are physicians going to also inquire about the storage of household cleaning agents, or matches, and about swimming pools? More youngsters die annually of poisoning, fires, and drowning than of firearm injuries."
What's the role of physicians?
Physicians for Social Responsibility advocates against violence prevention and was involved in gun control for some time, McCally says, in an effort to have gun violence seen as a public health issue.
"Medicine deals with treating gunshot injuries, but what's the role of physicians who also have public health responsibilities and work in the public health paradigm?" he asks. "Even though we are clinicians, that argument became the argument for dealing with gun violence as a public health issue."
McCally says Physicians for Social Responsibility found its efforts in the gun control arena pitted it against the juggernaut of the National Rifle Association (NRA).
"When you get into the politics of gun control, you end up engaged with the NRA, and we've never won that," McCally says. "Now, if you could somehow position that the NRA stance is unethical, that would be a useful contribution."
In recent years, two organizations of physicians interested in the gun control issue were organized — Doctors for Sensible Gun Laws, a collaboration stemming from KeepAndBearArms.com, and Doctors Against Handgun Injury, a division of the New York Academy of Medicine.
Both organizations are currently inactive.
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