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Last spring a group of physicians and medical societies filed suit in federal court to overturn a state law that bans healthcare professionals from asking patients about whether they own a gun. On first blush, it seems like the reasonable and responsible thing to do. The government has no place in telling doctors what they may or may not ask a patient, right? Maybe. But a closer look reveals a deeper issue and underscores the delicate balance physicians face between their political and professional lives.

The story in Florida began in the town of Ocala with a case in which a pediatrician asked the mother of a young child whether there were firearms in the household. She refused to answer because, as she put it, “whether I have a gun has nothing to do with the health of my child.” The pediatrician told her to answer the question or find another doctor.
This incident led to the passage in early June of The Privacy of Firearms Owners Statute, which prohibits both written and oral inquiries regarding firearms ownership, entering such information into a medical record, “unnecessarily harassing” gun owners, or turning away patients who refuse to answer gun questions. Violation of the law can result in a fine of up to $10,000. In other words, as the NRA put it, the law is designed to “keep politics out of the examination room.”

In fact, to hear the NRA put it, doctors have already become the bad guys in this scenario. On their web site, the NRA states that “Pediatricians and other physicians, in growing numbers, are prying into our personal lives, invading our privacy and straying from issues relating to disease and medicine by questioning children or their parents about gun ownership. We take our children to physicians for medical care, not moral judgment . . . This bill comes in answer to families who are complaining about the growing political agenda being carried out in examination rooms by doctors and medical staffs - and the arrogant berating if a patient refuses to answer questions that violate privacy rights and offend common decency.”

Other proponents of the law, such as the law’s sponsor, Rep. Jason Brodeur, claim such questions are an effort to harass patients into relinquishing their right to own a gun or subject them to increased insurance premiums for gun ownership. Opponents of the law call it a “gag rule” that impinges upon the physicians ability to practice preventative medicine, suggesting that providing a patient with a gun safety pamphlet could be construed by the patient as “harassment” under the law and could be used to prosecute a physician.

Accidental shootings kill children every day, so it is easy to see how a pediatrician could feel strongly about, and want to discourage, the careless handling of firearms. But the larger question remains: when does a physician’s concern cross over from patient care to political activism? To what degree can a physician act in a political manner?

The AMA Code of Ethics underscores the push and pull of this issue. On one hand it states that, “the responsibilities of the physician extend not only to the individual, but also to society where these responsibilities deserve his interest and participation in activities which have the purpose of improving both the health and the well-being of the individual and the community.” At the same time, the AMA’s guidelines are clear that “under no circumstances should physicians allow their differences with patients or their families about political matters to interfere with the delivery of high-quality professional care.”

This might all seem elementary – of course you’re not going to “harass” a patient, haranguing them with political sound bites. That would make you a terrible doctor and you would probably get fired. But things quickly become less black and white when we dig deeper, and examine our own biases. I, for instance, happen to be a social conservative. I’ve rallied with Pro-Life causes, lobbied on behalf of the repeal of Roe V. Wade, and testified before the state legislature in support of parental notification in cases of abortion. I believe that my actions are in the best interest of my patients as a group. However, when confronted by a patient who wishes to abort her pregnancy, I will refer her to someone who will do the procedure, something that I feel in my heart is immoral. And I will try to do it without betraying my inner feelings. Am I being a hypocrite or a good doctor?

Abortion proves an interesting example in this discussion as political opponents on both sides of the issue have succeeded at various times and places in enforcing their views in the law. Abortion proponents have succeeded in many states in placing on the books laws allowing minors to have surgical abortions without parental notification, let alone consent. School counselors may take minor females to obtain an abortion where they could never provide even moderate pain relief without written consent. On the other end of the spectrum, some states now require, as a part of informed consent before an abortion, that the mother view an ultrasound of her unborn child.

To return to the example of the gun law case, maybe the conflict is whether our care is aimed at the patient in front of us or at patients at large. For instance, if a patient has a history of suicidal thoughts, but is felt to be currently stable enough to be released to home, the question of “Do you have any firearms in the house?” is relevant to that patient’s immediate health and well being. Refusing to answer that question might require the prudent practitioner to rethink discharge or even demand further hospitalization. Few would see that as harassment. But what about asking a parent of a child with a sore throat if there are firearms in the home? And if this is within bounds, what about questions related to the presence of a non-biological male in the home, aka boyfriend, something that subjects children in the home to an increase risk of abuse? Should we refrain from asking such questions for fear of being perceived as taking a moral position on the relationship?

It should be noted here that emergency medicine is unique among the medical specialties in its ability – or inability – to act politically. Technically speaking, most specialties currently have the right to turn away patients based on political discrimination. Last year, Slate magazine reported on Florida physician Jack Cassell who, angered by the passage of healthcare reform bill, taped a sign to his office door advising Obama supporters to “seek urologic care elsewhere.” The article went on to explain that while the law bars physicians from excluding patients on the basis of traditionally protected classes like race, religion, national origin, and disability, most jurisdictions do in fact permit political discrimination. That makes the emergency department, with its EMTALA mandate and safety net mantra, the closest thing medicine has to a political safe zone. You cannot, by law, refuse to treat an emergency patient for a political reason. This might seem obvious, but, in light of recent world events, it’s not something that we should take for granted. We should specifically consider what took place in Bahrain last March.

On March 16th of this year, wide spread protests against the Sunni monarchy in Bahrain clashed with police forces, who used tear gas and rubber bullets to control the crowds. What happened next, as injured parties began to seek emergency treatment, was either political theater by medical professionals or government abuse, depending on your political persuasion. It was reported by several news outlets that many patients had been treated at Salmaniya Hospital, in the capital city of Manama, a facility that had been taken over by the military the day before, following a declaration of martial law. However, subsequent to that day, dozens of physicians and nurses at the hospital who had treated the protesters were arrested, and jailed. The government charged 47 doctors and nurses with using the hospital complex to stage protests. The doctors claimed that soldiers and police had conducted interrogations and detentions inside the hospital complex. Further, they claimed that the government intimidation had been so severe that many injured protesters had not sought care for fear of being harassed or arrested.

International rights groups claimed that the Bahraini government had targeted medical professionals. They claimed to have credible evidence that military and police detained and tortured physicians and nurses who treated the protesters. But the emergency physician in charge of the ED at Salmaniya at the time of the protests had a different view on what happened. In an interview with Voice of America, Nabeel al Ansari claimed that the ED was functioning normally when it was taken over by the protesters who had their own physicians–“orthopedic surgeons, dentists, neonatologists, with totally no background in emergency medicine.” Stating that they routinely handled 250-300 urgent and emergent patients, he denied that a disaster was called by the staff that would have brought in other providers.    

“Our people were put aside,” he said. “If they were needed to handle any real emergencies, then they were brought in to help. Otherwise, the other doctors were taking over the place. We were occupied by physicians who were not trained in the speciality to handle all these things.” He went on to claim that the protesters commandeered ambulances to come to the ED and to protest there. He pointed to YouTube videos showing protesters in front of the ED with banners. Further, he claimed that truly sick people were being ignored or worse by the protesting physicians occupying the ED. “I have testimonials from some nurses – six of them, actually, from the ICU (intensive care unit) – stating that one of these doctors switched off the oxygen of an ICU patient, because he was an expatriate and she wanted him to be dead.”

Extreme? Certainly. Could it happen in America? Probably not. But it is a cautionary tale that physicians everywhere should be aware of. These stories should cause us to think, to ask what the intersection of medicine and politics should look like. When am I acting on the behalf of my patient, when am I acting on the behalf of patients as a whole, and when am I acting on my own moral or political agenda?

Obviously physicians are moral individuals with political and personal rights. But when have we stepped over the line to use our moral authority as physicians to advocate a political position? This is one time that I think the military gets it right. As an officer I can make any political statements or take any political position that I want, but I can never do it in uniform. I’m just as free as any other citizen to participate in the political process, but I can’t use the moral authority of the military to bolster my position. Maybe medicine should take a lesson.   

 

Comments   

# john dale dunn md jd 2011-08-10 10:44
Editor in chief,

You revealed a significant gap in knowledge early in the essay about guns--"children die of gun violence every day" is not true, but why should you know the truth when our specialty was the home of the research by those who succeeded in planting some myths about guns in political efforts to support gun control.

Myths, like children are killed every day by guns, are assumptions that should be assessed.

The research had an agenda and the claims from the research got a lot of general news coverage from the gun control media, claimed two major things that have been used to justify gun control projects. Claims that subsequently have been criticized and proven to be exaggerations by people like economist John Lott PhD.

1. Children were said to be frequent victims of gun violence. That's the source of your myth. Now let's dissect that. Any accidental killing of kid gets plenty of coverage. How many cases have you read about in the last 10 years? You should have read about 3,600 deaths. You didn't.

Here's what research did, the authors just expanded the age for kids to include gang banger age thugs who are more inclined to gun violence than even their older criminal counterparts. So the gang bangers became kids and the anxious said--we must confiscate guns and limit gun ownership.

2. Researchers also claimed research that showed a high percentage of gun deaths that were acquaintance deaths and having a gun in the household increased the risk for gun violence deaths. The researchers skipped telling the part about the confounders--pe ople who live in more violent neighborhoods have a higher rate of home owner gun ownership, and the "acquaintances" included causal business contacts, like passenger/cab driver, hooker/john, and even enemies who knew one another,gang members who might know the name and identity of an opposing gang member they killed.

So the argument was that home guns are the problem and people are killing their friends and family. another myth.

I know it seems that the researchers could have avoided such deceptions, but in the pursuit of a political agenda they put out research that helped to make the gun control arguments stronger. The myths still prevail because some have political agendas that are still energizes by the myths and the meddlesome nature of statists, who hate personal gun ownership that might make the citizen less easily controlled by the state.

I won't go into other gun control deceptions like the comparative studies of gun ownership countries that shows that gun ownership does not increase gun violence, gun violence is a cultural and societal thing.

However no one who's conscious is unaware that gun control is a liberal/leftist issue, and the majority of educated people, including physicians, are prone to be liberal because of their leftist university educations.

So where to start, Mark? Socialism is immoral and cruel and diminishes the value of human life in favor of the needs of or the usefulness to the "collective" and the state's interest in the society--would that then put physicians against socialism? Should it?

Is rationing and other medical resource manipulation in the interest of society and the collective at the expense of any individual person on the basis of their quality of life, age, functionality or accomplishments unethical in the new world of socialism. Where do physicians come down on socialist resource management to the detriment of an individual and the advantage of the "collective" or to the advantage of the Hegelian "useful" person as compared to the disabled, deformed, impaired, aged or dysfunctional "useless eater."

Before we answer those questions about state controlled and socialist medicine, we might benefit from reading the Leo Alexander MD, investigator for the Nuremberg War Crimes Court, who wrote about the conduct of physicians under Nazi rule and how physicians were compromised of their ethics and became the killers,the instruments of pogroms and torture/experim entation and "terminal experiments, like live donor limb transplants or heat and cold stress adn injury experiments where the subject or donor was a prisoner and sacrificed after the amputation, injury or exposure.

Researchers in the medical and social sciences sometimes have political agendas. Physicians who agree to certain medical care system changes that interfere with the physician obligation to the patient are making political decisions. Nothing is simple.

But, as Michel de Montaigne said--What do I know?
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