No ethical lapses in physician efforts to protect public and patients by Dr. Richard L. Elliott (And reply by Dr. Miguel Faria)

In his reply to my article, Dr. Miguel Faria, a very fine neurosurgeon and writer, states that it is unethical for physicians “to intrusively ask patients about the presence of guns in the home” and that by so doing, physicians become “snitches” against their own patients.

I agree that if the purpose of asking about guns is solely to report the possession of guns, and that if the physician asks “intrusively” and reports without the patient’s permission and in the absence of an imminent threat, it would be wrong.

But Florida law, which has been blocked in federal court, makes it illegal to ask about the presence of guns in the home in the absence of an emergency. The AMA supported the suit blocking the Florida law, as have a number of other physician groups. The basis for the objection is that encouraging patients to consider such safety measures as wearing seat belts and locking up guns goes a long ways towards preventing injuries and deaths. Nothing unethical about this at all.

Faria also suggests that I wrote “it is not OK for a psychiatrist to report a potential threat by a mentally disturbed patient.” I wrote nothing of the sort. What I did say is that mandatory reporting can create problems. Most, (but not all) states that have looked at this follow a Tarasoff-like policy that when a psychiatrist determines a patient presents an imminent risk to another person, the psychiatrist incurs a duty to protect that individual. This may involve reporting the threat, but a variety of other, potentially more protective means may be used to protect the person, e.g., involuntary hospitalization, notifying that individual, or perhaps reporting to authorities.

I agree with Faria that thoughtful consideration is needed in light of recent events and in the face of potential present danger. Knee-jerk reporting without considering measures which may be more effective protects neither the public nor personal rights.

Written by Dr. Richard Elliott

Richard L. Elliott, M.D., Ph.D., is a professor of Medical Ethics at Mercer University School of Medicine. This editorial was originally published as a Special to the Macon Telegraph on January 29, 2013.

Dr Faria Replies:

I think our divergent positions as well as areas of agreement are clear now. I do believe that physicians asking their patients about guns is a ethical boundary violation for reasons stated by Dr Timothy Wheeler and myself in different articles. He wrote in 1999:

"The American Medical Association (AMA), American Academy of Pediatrics (AAP), and American College of Physicians (ACP) are urging doctors to probe their patients about guns in their homes. They profess concern for patient safety. But their ulterior motive is a political prejudice against guns and gun owners. And that places their interventions into the area of unethical physician conduct called boundary violations.

"Doctor-patient sex is the most well-known and sensational example of a boundary violation. More recent literature recognizes a wide variety of non-sexual violations. These cover such issues as finances, confidentiality, and gratification of the doctor's needs. Although boundary violations were first addressed in the psychiatry literature, it has become clear that they also occur in general medical practice."

As far as the AMA, it ceased being a respected organization long ago because "of playing politics for a seat at the table" and because of inconsistent "flexible ethics" that swing with blowing political winds. It is an organization only interested in pocket book issues and everything else including ethics is sacrificed for a seat at the same table! (See my article, "Transformation of Medical Ethics Through Time.")

As Dr. Leo Alexander, the Chief U.S. Medical Consultant at the Nuremberg War Crimes Trials, wrote in his momentous article, "Medical Science Under Dictatorship" in the 1949 issue of The New England Journal of Medicine:

"It is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions."

This was substantiated not only by the behavior of Nazi doctors but also Soviet and Cuban psychiatrists. (See my article "Cuban psychiatry — the perversion of medicine.")

You may be interested in my article that was just published this morning in Surgical Neurology International: "Faria MA. Shooting rampages, mental health, and the sensationalization of violence. Surg Neurol Int 2013;4:16."

As we continue to debate these issues in the Macon Telegragh pages, I have proposed that you and Professor David Oedel, also currently at Mercer, should set up an oral debate with myself and Eric Erickson (also a lawyer). Mercer would be a good place: 2 lawyers and 2 physicians. Subjects:

1) Doctors asking patients about guns in the home.

2) Original intent and purpose of the Second Amendment.

Our disagreement does not detract from the fact that I also consider you an excellent  psychiatrist and remember fondly when we collaborated in some writing projects years ago. We must be careful that science and medicine do not become subordinated to the state. As I have written elsewhere:

"The lessons of history sagaciously reveal that whenever and wherever science and medicine have been subordinated to politics, the results have been as perverse as they have been disastrous, as totalitarian examples of the 20th Century so aptly testify."  — MAF

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