Bioethics Discussion Blog: Legislation in Virginia to Prevent Physicians Asking About Household Guns

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Saturday, February 25, 2006

Legislation in Virginia to Prevent Physicians Asking About Household Guns

From The Virginian-Pilot on February 23,2006,

A pediatrician who asks a child's parent about firearms in their home could lose his or her license or be disciplined under legislation being considered by a [Virginia ]Senate committee today.
The bill would prohibit health care professionals from asking a patient about gun possession, ownership or storage unless the patient is being treated for an injury related to guns or asks for safety counseling about them.


The bill was passed in the Virginia state lower legislative chamber last week 88 to 11. The article continues:

The legislation is opposed by The Virginia Chapter of the American Academy of Pediatrics because it blocks a common practice by medical professionals to inquire about gun ownership and safety when they go over a safety checklist with parents during a child's regular checkups from birth to puberty. ?
The National Rifle Association supports the bill because it will protect gun owners "from intrusive, unnecessary questions from medical professionals," according to the NRA Institute for Legislative Action Web site.


Here is my response to this likely unconstitutional (denial of free speech) but also irrational political action:

I think that the Virginia bill represents either meddling into the practice of medicine for the legislator's
own personal political benefit or that they are totally unaware about the process or value of medical history taking as practiced by physicians and as responded to by patients. Physicians take a medical history, both a present illness and past history to attempt to get facts that may or may not be immediately useful in making a diagnosis or in teaching the patient about health matters. The past history may include a variety of psycho-social questions and other questions including questions about understanding about risks for physical injury including controlling those risks. These may include not wearing helmets, not using seat belts, using ilicit drugs, sexual behavior, unlocked medicine cabinets accessible to children and risky management of guns in the household. These are only what the physician believes are pertinent questions for the patient to answer if the patient wishes to. Note that the responses are not made under oath. Patients may refuse to answer or may provide an answer to the physician that is inaccurate or intentionally a lie. But for the physician to be punished simply for asking a question that could in the individual case have profound significance ("oh, I keep my loaded gun under my bed so I will be ready for an intruder at night!") is beyond rational belief regardless of what the general risk statistics show and represents irrational lawmaking. Do the legislators know that at my medical school we actually teach our students to ask the patient about the number of individuals the patient has had sex with over their lifetime, whether with men, women or both, about sexual practices and more sensitive questions? Some argue that physicians should not lecture to patients about issues in medicine that have not been proven by research study. However, physicians often deal with issues that have not been statistically studied with regard to pertinence to a specific outcome but possibly may be of great physical/psychologic and social importance to the life of the individual patient. I think we should all face the fact that what physician advise or carry out is not all evidence-based medicine and often we may end up saying and doing what we think is the best for the patient in our own judgment based on our knowledge and experience. Now I will get off my soap box and will be eager to read what my visitors think. ..Maurice.

FOLLOWUP: In yesterday’s news comes the word that the Virginia Senate Education and Health committee voted down legislation that would have made it unlawful to routinely ask patients about firearms.

9 Comments:

At Sunday, February 26, 2006 6:20:00 PM, Anonymous Moof said...

Dr. Bernstein, thank you for your interesting post.

I can see this particular problem from different angles ...

First and foremost - I don't believe that the government should ever take it upon itself to abbreviate anyone's right to free speech. A physician has the right to ask whatever he'd like, whether in the course of dealing with patients or otherwise.

Outside of the realm of rights, however, I think that certain questions don't belong in the physician/patient venue.

I would not be upset with a physician who asked me about my sexual habits, since that really is a medical question. I would not be upset about anything I was asked which could be seen as medical.

However, questions about my ownership of firearms - no. I don't believe that's a valid part of my medical "history," unless there's been some sort of a mishap which relates to guns.

Will physicians who ask about guns also ask if I keep cleaning products, or use a bath tub, or drive a car, or use a French knife? A few of those I've just named cause more accidents yearly than guns do. So do mishaps with prescription medications.

Beyond the medical aspect, there's also the social aspect ...

Guns are a rather sensitive subject. A great number of people who have guns are knowledgeable regarding their use, storage and care. It's arrogance to automatically assume that having a firearm qualifies me as a dangerous person who has no clue of how it should be handled ... especially if the "advice" is coming from someone who isn't personally familiar with guns.

For that matter, even if the question is coming from someone who uses guns, it's still like grilling a person who drives about the dangers of reckless driving when you've never witnessed them operating a vehicle, and have no idea whether they're careful drivers or not.

Thank you for the opportunity to have my say! I would love to hear more about your own thougths on this. On more than one occasion, you've given me reason to expand my views.

 
At Sunday, February 26, 2006 7:03:00 PM, Blogger Maurice Bernstein, M.D. said...

Moof, you wrote: "I would not be upset with a physician who asked me about my sexual habits, since that really is a medical question. I would not be upset about anything I was asked which could be seen as medical.

However, questions about my ownership of firearms - no. I don't believe that's a valid part of my medical "history," unless there's been some sort of a mishap which relates to guns."

But what if the parent of a small child is in the office with the child for to maintain the child in good health? Shouldn't the pediatrician ask those questions which comes to his/her mind and is supported by consensus pediatric guidelines of practice when the physician's interest is in preserving the health of the child and preventing injury? After all, the basis for the question is logical since children accidentally shot do periodically appear in hospital emergency rooms. Maybe the problem to some families is the way the physician asks the question. If it is in a paternalistic- authoritative or threatening manner, then I can see how this would upset most any family. But if the physician first explains why such questions are asked and asks in a non-threatening manner, such questions should be acceptable. ..Maurice.

 
At Sunday, February 26, 2006 8:42:00 PM, Anonymous Moof said...

Dr. Bernstein, I respectfully beg to differ with you on that score.

Is the same pediatrician also going to ask if the child ever rides in a car, or is ever allowed in the same room as where there are cleaning products? Children also periodically appear in emergency rooms due to accidents with either of those, and far more often than children who've been shot.

We need to hope that parents are capable of taking care of their children - be it by keeping them from harming themselves or others with guns, or with knives, or with Draino! Why specifically single out something as politically sensitive as firearms?

The day before yesterday, I copied the following comment from the excellent Kevin, MD blog. It sounds as if the anonymous commentor is a physician in Massachusetts. This particular fellow would ask his patients about their gun ownership, and then report them to the state ... calling down upon them untold, and more than likely, unjust grief, which could last for years.

----------------------------

"A pediatrician who asks a child's parent about firearms in their home could lose his or her license or be disciplined"

In Massachusetts, we are required by law to report any case in which we think a child is endamgered. I would consider an unlocked gun in a household a child at risk. If we don't report such things to child protective services we can lose our medical license. I would much rather lose my job for reporting gun ownership then pronounce a 2 year old dead of a gunshot wound, which I have done.
# posted by Anonymous : 4:57 PM

Click to read all of the comments to that post.

---------------------------------

Dr. Bernstein, I feel that it may be a good idea for a physician to trust his patients to take care of safety issues in the privacy and sanctity of their own homes, as long as they haven't already proven themselves to be guilty of negligence. Innocent until proven guilty ... responsible until proven otherwise.

Do physicians really believe that asking a patient invasive questions which have nothing to do with medicine is going to somehow influence the patient to change some pattern of behavior?

Think about it - the only patients who would be likely to reform their behavior are those who are conscientious, and probably would not need to do so to begin with - while those who really could be a danger would more than likely feel threatened by the line of questioning, and simply stop being candid.

In either case - it's often a futile line of questioning, and also tends to alienate the patient.

One final point - the physician doing the questioning often knows far less about guns than the person he's querying ... there's no way for him to pull that off without seeming "paternalistic" or arrogant.

I hope that I haven't said anything offensive, because I sincerely respect you and your opinion. I'm afraid, my dear Doctor, that this is one area in which we may need to "agree to disagree."

Have you ever hunted?

 
At Sunday, February 26, 2006 10:29:00 PM, Blogger Maurice Bernstein, M.D. said...

Moof, of course you haven't said anything offensive. I am aware that there are other and opposite opinions to my own. I welcome rational arguments which are used to defend those views. To give you and my other visitors those other views, I found a pro-NRA stance with regard to the legislation on the Alphecca blog. One of the visitors to that blog wrote in response:
" I had the same thing with a doc my kids were seeing a few years back. I was halfway home when my son, then about 12, told me what the doctor had asked about guns in our home. I turned around and went back. I burst into his exam room and told him in very loud, very foul language what I thought of his "medical care" I demanded to see my son and daughter's medical records. As I was a foot taller 20 lb heavier and mad enough to wring his scrawny neck, he handed 'em over. Next morning I went to see the head of the HMO to find out exactly what was going on.
He hadn't heard about it yet, and was appalled. I demanded they fire the twit. It took 'em about two weeks, but they got rid of him. They wanted the records back, but I told 'em to pound sand on that one. My wife and I went through both folders and removed about half of the stuff in there. We made copies of all the rest and let the hospital have that, we kept the originals. They about had an apoplectic fit, but let it go. I suppose they didn't want any flak over the crap they had in my kids' alleged "medical" records. All kinds of notes about My wife's and my attitudes and political proclivities, whether we went to church, what clubs and organizations we belonged to, what hobbies, you name it, along with guesses by the doctor as to what it all meant in our dealings with our children. In retrospect I really should have sued the socks off the bastiges, I suppose, but I thought getting him canned was enough at the time. If it were to happen now, I'd very likely do him severe physical harm. "

Go to the link to read more comments which oppose my view.

No, Moof, I don't hunt.. except for good topics for my blog! ..Maurice.

 
At Monday, February 27, 2006 8:42:00 AM, Anonymous Moof said...

"To give you and my other visitors those other views [...]"

*Ouch!* Dr. Bernstein, I sincerely hope that you're not lumping all of us who own guns under "those other views." I know quite a few people who belong to the NRA, and none of them are like that.

However, I understand that there are some loose canons on this side of the issue ... and what you've posted makes for a very worrisome read.

There will always be people who are lacking balance, lacking good judgment - and those individuals sit on either side of any sensitive issue - including the gun issue. Perhaps it's a lack of education, or even something far more basic - a paranoid egocentric focus that prevents a person from seeing anything but their own perspectives on any issues.

Let me try to balance that a bit, if you don't mind.

In this area, a rural part of SW Maine, our view concerning guns is not quite the same as it might be in many other places.

Children who grew up in this neighborhood 50 or more years ago, still live here today - and their kids and grandkids are often just down the road. I live in a house which was built before the US became a nation ... and none of my doors or windows lock. My husband's father was born in my bedroom over 90 years ago.

When my husband was a boy, it was common for those who hunted to take their firearms to school and work on them in "shop class" - since gunsmithing is considered an "industrial art." As kids, they all learned how to be careful and responsible with their weapons. Saturday afternoons, the local youth were often found out in a hay field sighting in their guns, target practicing, or during the proper seasons, hunting.

Having a firearm was, and still is, a natural part of life here. My husband now works nights, and I still sleep soundly - although my doors don't lock.

Not all of us who own guns, or even who are members of the NRA, are loose canons looking for someone to intimidate. There are extremists on both sides of this issue: from the paranoid gun owner you mentioned, to those who would brand guns as "weapons of mass destruction," or physicians who would report gun owners as abusive or negligent parents simply because they own a gun, or those who believe that everyone who has a gun should be locked up.

I think what we need regarding guns is better education - on both side of the issue.

And thank you again ... I'm awfully glad that you're such a good "hunter" when it comes to "good topics" for your blog! This is extremely engaging.

 
At Tuesday, February 28, 2006 4:44:00 PM, Blogger mary said...

Pediatricians are incorporating questions about guns in the home because the American Academy of Pediatrics' policy statement recommends this. This recommendation is based on solid evidence that the mere presence of guns in the home with a child is related to a significant portion of childhood injuries and death. This is not the same thing as saying that every citizen who has a gun in the home is some kind of derelict parent. It is simply statistically true. For example:

In 1997, 306 (7.2%) children and adolescents younger than 20 years killed by firearms died as a result of unintentional firearm-related injuries. Only 6.5% (20/306) of these deaths involved children younger than 5 years of age. However, deaths from unintentional firearm-related injuries account for a large proportion of firearm-related deaths of younger children. Twenty-four percent of firearm-related deaths in children younger than 5 years of age are attributable to unintentional shootings; 26% for children 5 through 9 years of age; 21% for children 10 through 14 years of age; and 5% for adolescents 15 through 19 years of age. The rates for males are higher than those for females, and the rates for blacks are higher than those for whites. Most unintentional shootings occur among children left unsupervised at home.

Pediatricians are not under OBLIGATION to ask about gun use, but they are following the professional guidelines issued by their own professional organization; guidelines which are based on statistical linkage of gun presence in the home and childhood injury and death.

To have something pointed out to you by your professional association-and to understand the significance of the findings-and NOT to act upon it, could be thought of as "bad medicine", couldn't it?

I think it is entirely ethical for physicians to query parents on a practice that is highly likely to cause harm to the child who is, after all, the pediatrician's client. Health teaching comes under the scope of practice for doctors, and this includes safety for minor and/or incapacitated clients.

In fact, now that pediatricians are aware of the statistics and the AAP policy, it would seem a little substandard to not incorporate questions about guns in the home when talking to parents. That's what we might say about other AAP policies...why is this one so much different? It is not against the law to keep poisons in the home, either, but doctors have asked for years about storage of poisonous materials. It is not against the law to smoke, but doctors ask us all the time if we smoke around our children.

What's the special case about guns?

see: this page from AAP

 
At Tuesday, February 28, 2006 9:36:00 PM, Blogger Maurice Bernstein, M.D. said...

Mary, to answer your last question: politics and NRA. ..Maurice.

 
At Monday, July 23, 2007 10:41:00 AM, Anonymous Anonymous said...

I just left my pediatricians office where I took my 16 year old son and 13 year old daughter for their yearly check-ups/shots. I am more than offended. I've been going to this pediatrician's office for over 30 years but our pediatrician, whom I love with all my heart, has retired. We saw another individual today. He came in and asked me if we had any questions, comments, problems, complaints, issues, etc. I told him no. Just a check-up. He chatted a little while about sports, etc. Next comes some type of "survey/questionaire" that absolutely positively OFFENDED ME. Directly to my children, in front of me: "Do you eat dinner with the family...at the table every night?" "Does anyone in your household smoke?" "Do you eat fruit? How much? Do you eat vegetables?" By this time I had had it and interrupted. I'm sorry: What?~! If needing to know the amount of vegetable servings my children have daily is necessary to his practicing then he's not going to practice on my children anymore. Our pediatrician got by years without asking those questions. This guy has our records for all the years of my children's lives and I see no need in for his questions now.

Checking in to this so I can protest!

 
At Monday, July 23, 2007 2:37:00 PM, Blogger Maurice Bernstein, M.D. said...

There is a rationale for the physician asking questions such as the ones Anonymous from today noted. It all has to do with physicians being proactive regarding health issues rather than ignoring asking these questions and simply awaiting for and treating the medical consequences of poor family practices. However, it is very important that the parents be educated by the doctor the reasons why these questions are being asked and not simply just asking them with no explanation. As with any medical history, no patient or parent is compelled to answer any questions as long as they have been informed about their medical value. Doctors in the past have not been thinking in proactive terms as they do now. This is because of more statistical studies available about the various health issues and because of pressure to be proactive by specialty groups and insurance companies. ..Maurice.

 

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