Does the oath to "do no harm" conflict with the right to bear arms?
Issues related to gun violence and regulation are among the most divisive in the United States, with Americans split on the question of whether it is generally more important to protect the right to own guns (52%) or to control gun ownership (46%).1 Physicians are no exception.
"Many physicians and hematologists own guns, and not all doctors support gun control," Alan Lichtin, MD, a hematologist at Cleveland Clinic in Ohio, told ASH Clinical News. "Doctors represent a wide spectrum of people, and some feel that any attempt to limit their access to guns or modify the second amendment is a great personal affront."
For this reason, it should come as no surprise that, when the American College of Physicians (ACP) issued a call to action for policies to help mitigate the rate of firearm injuries and deaths,2 the American Society of Hematology's (ASH) decision to endorse the position paper did not come about easily.
The 2015 paper, published in the Annals of Internal Medicine and credited to eight health-care professional organizations and the American Bar Association, designated firearm-related deaths and injuries "a major public health problem that requires diligent and persistent attention." The authors called for a series of measures to help reduce the "health and public health consequences of firearms," including universal background checks of gun buyers, restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths.2 (See SIDEBAR for a list of the actions recommended in the ACP paper.)
Referencing the discussions the ASH Committee on Government Affairs held about endorsing the ACP's paper, Alan G. Rosmarin, MD, chair of the committee, recalled the disagreement between members. "In that small sample of people," he said, "it was clear that not all hematologists were of one mind."
ASH Clinical News spoke with Dr. Rosmarin and other members of the committee about the complexities of treating gun control as a health-care issue, and the role physicians can (and cannot) play in advocating for or counseling patients about firearm safety.
Firearms by the Numbers
Since the publication of the ACP paper, mass shooting incidents in the U.S. now include a nightclub in Orlando, Florida (49 fatalities); a not-for-profit for people with developmental disabilities in San Bernardino, California (14 fatalities); a church in Charleston, South Carolina (9 fatalities); a military recruitment center in Chattanooga, Tennessee (5 fatalities); a music festival in Las Vegas, Nevada (58 fatalities); and a church in Sutherland Springs, Texas (26 fatalities).3
Mass shootings receive national attention, but the number of deaths and injuries resulting from these events is only a small percentage of the total firearm-related deaths and injuries anticipated each year in the U.S. In 2014, the Centers for Disease Control and Prevention (CDC) estimated that there were 33,500 firearm-related deaths in the U.S. (about 10.5 deaths per 100,000 population), accounting for 16.8 percent of all injury-related deaths that year, and making firearms the third-leading cause of injury-related death.4 For comparison, the National Cancer Institute (NCI) estimates that leukemia will result in 24,500 deaths in 2017 (about 6.8 deaths per 100,000 population), and lymphoma will result in 20,140 deaths (about 5.9 deaths per 100,000 population).5,6
The two major causes of firearm death in the U.S. are suicide (63.7%) and homicide (32.8%), and firearms are estimated to injure an additional 67,000 people each year. The direct harm to victims is tragic, and the downstream consequences to the health-care system are grave. A review of emergency department (ED) visits for firearm-related injuries between 2006 and 2014 found that these injuries cost the U.S. health-care system approximately $2.8 billion in ED and $22 billion in inpatient charges annually.7
"There is a huge diversion of health dollars that are not going to logical places and are spent on something that is completely preventable," said Jerald Radich, MD, a medical oncologist with the Fred Hutchinson Cancer Research Center and professor at Washington University School of Medicine in Seattle. "It hurts our patients and their families, who are all victims of this."
“A number of physicians go into work every day to help prevent injury and death, and [firearms] are a big source of that.”
â€”Jonathan G. Hoggatt, PhD
How Does Gun Violence Affect Hematology?
The question remains whether these statistics should be of specific concern to hematologists.
"Gun-related injuries and deaths are roughly equivalent to the CDC estimate of the number of Americans living with sickle cell disease (SCD) – 100,000 – but [the former] are associated with a dramatically worse mortality rate," Jonathan G. Hoggatt, PhD, assistant professor of medicine at Harvard Medical School in Boston, Massachusetts, and a member of ASH's Committee of Government Affairs, told ASH Clinical News.8 "A number of physicians go into work every day to help prevent injury and death, and [firearms] are a big source of that."
Gun violence and injuries are also a drain on blood products – an already scarce resource in the U.S.
Patients with gun injuries require transfusions; when mass shootings occur, that need multiplies. The transfusions required by patients with gun injuries "take away from the national blood supply for people with hematologic disorders, such as SCD," Dr. Hoggatt said. In the two days after the mass shooting at the Route 91 Harvest musical festival in Las Vegas, for example, a nationwide platelet shortage restricted leukemia specialists from giving platelet transfusions to patients unless they were actively bleeding.
"Guns are used to inflict injury on others, and those injuries often lead to a lot of bleeding," said Dr. Lichtin. "So, is gun violence a concern for hematologists? Yes."
Other hematologists make the point, though, that gun-safety law advocacy may not be the best use of time and resources.
"On the Committee on Government Affairs, we have tried to be mindful of the fact that we do not want to dilute the energy or attention from the patients and caregivers whom we advocate with and for," said Dr. Rosmarin, who is also professor of medicine at the University of Massachusetts Medical School in Worcester. "We could list 100 topics we care strongly about, but maybe we should put our energies and dollars behind working on something that we have the ability to make a major impact on, like SCD."
Despite the disagreement among medical professionals about whether gun control or counseling on firearm safety should fall under health care's purview, there is broad agreement on one area: We need more research about the effects of firearm violence.
"Physicians and scientists are a group of people who rely on evidence, but there are few strong studies about guns that can tell physicians what to do to improve patient safety," Dr. Hoggatt added.
According to Dr. Hoggatt, the U.S. has a long history of improving citizens' safety through policy actions. Three obvious examples include enacting food safety laws, reducing motor vehicle deaths by mandating the use of seatbelts and airbags, and restricting the use of tobacco in public spaces.
"Physicians, scientists, and engineers – supported by government-funded agencies – were able to study better methods of food safety and rates of injury or death associated with motor vehicles or tobacco use, but they have been restricted in being able to study firearm injuries and deaths," Dr. Hoggatt said. "The only unique thing about firearms compared with food or cigarettes is that they are protected by the Second Amendment."
Many of the limitations on government-funded firearm research relate to what was dubbed "the Dickey Amendment," a provision inserted as a rider into the 1996 federal government spending bill that mandates that "none of the funds made available for injury prevention and control at the CDC may be used to advocate or promote gun control."9
This provision does not explicitly ban research on firearms, but Dr. Hoggatt explained, "the CDC and other agencies have interpreted this very conservatively and fear for their funding. There is a feeling that if federal agencies start delving into the topic, and even if they believe they are following existing restrictions, their funding could be pulled."
A 2017 study published in JAMA showed that, compared with funding for and publication of research into other leading causes of death, funding and publication of gun violence research were disproportionately low.10 The authors analyzed mortality statistics from the CDC between 2004 and 2014 to determine the top 30 causes of death in the U.S., then performed two linear regression analyses to determine if mortality rate correlated with funding or publication count.
If mortality rate was an accurate predictor of funding and publication, the researchers predicted gun violence research would have received $1.4 billion in funding and 38,897 publications during the 10-year period. However, it received only $22 million in funding and 1,738 publications – or 1.6 percent and 4.5 percent of the predicted figures, respectively. Overall, gun violence was the least-researched cause of death and the second-least funded cause of death after falls.
"We're spending and publishing far less than what we ought to based on the number of people who are dying," said lead author David E. Stark, MD, MS, from Icahn School of Medicine at Mount Sinai in New York, in a news release discussing the study.11 "Research is the first stop on the road to public health improvement, and we're not seeing that with gun violence the way we did with automobile deaths."
In September, the National Institutes of Health (NIH) quietly let lapse a program funding research into firearm violence and its prevention, known as the Research on the Health Determinants and Consequences of Violence and its Prevention, Particularly Firearm Violence program.12 Launched at the urging of President Barack Obama following the mass shooting at Sandy Hook Elementary School, the program ran from January 2014 to January 2017 and cost $18 million to support 22 projects, such as investigating how to implement gun safety counseling by pediatricians to prevent youth suicide.
The action gained new public attention following the shooting at the Heartland Music Festival, when 26 U.S. senators wrote NIH Director Francis Collins, MD, PhD, asking for the program's renewal. According to Science magazine, the decision to let the program's funding lapse came after the election of President Donald Trump, whose campaign received $30.3 million in 2016 from the National Rifle Association.
In response to the report, NIH Principal Deputy Director Lawrence Tabak, DDS, PhD, stressed that "we haven't stopped funding work in this area, and we intend to continue funding work in this area." He identified two multi-year grants issued since the program was shelved, totaling $1.4 million in funding this year alone, that are supporting the development of a web-based tool for firearm suicide prevention and the creation of a database of childhood firearm injuries.12
"The absence of knowledge about this issue is sort of insane," said Dr. Radich. "What other major problems do we have in the U.S. where we lose thousands of lives, but refuse to look into the causes or solutions?"
"ASH supports expanding resources in the NIH, CDC, and other agencies … increasing research support and reducing restrictions on the support [across all areas of investigation," Dr. Hoggatt clarified. "Research is not advocacy; it just provides a service to help everyone make informed decisions."
"I have begun asking my patients questions about firearms, at times, For example, whether there is a firearm in the house and who has control over it."
â€”Alan Lichtin, MD
Physicians who want to promote firearm safety have many avenues within and outside of ASH or any medical association. ASH has an advocacy arm to support issues important to its membership. "If gun safety is an issue important to you as an ASH member, reach out and contact ASH leadership or its government affairs committee," Dr. Hoggatt said.
Like any other citizen, physicians should call or email their local congressional office to voice their opinions about gun safety. This can be done at a national level, but just as importantly, at a local level in town hall meetings.
Physicians also can l donate to political candidates who support policies in line with their own beliefs or, Dr. Radich added, to charitable organizations like Americans for Responsible Solutions – a non-profit founded by former U.S. Representative Gabrielle Giffords (a gun owner and victim of gun violence) that advocates for safer gun laws.
"These organizations are [run by activists] who have boots on the ground and are 100 percent devoted to this issue," Dr. Radich said. "This is their job. We're busy with our own jobs as hematologists and can't do what they can."
Finally, physicians can take the initiative to talk with their patients about gun safety.
The Affordable Care Act includes language discussing gun rights in Section 2716(c) "Protection of Second Amendment Gun Rights."13 Within that section, the law states that wellness and prevention programs cannot require the disclosure or collection of information related to "the presence or storage of a lawfully-possessed firearm or ammunition [in a residence]" or "the lawful use, possession, or storage of a firearm or ammunition by an individual." Additionally, the law does not authorize maintaining records of individual ownership or possession or a firearm.
However, this law does not prohibit physicians from asking about gun ownership and storage. In fact, in February 2017 a federal appeals court struck down a Florida law known as the Privacy Firearm Owners Act, which attempted to restrict physicians from speaking to patients about firearm ownership, as a violation of doctors' First Amendment rights.14
The ACP paper supported the eradication of so-called "physician gag laws," arguing that, "confidential conversations [about firearm ownership and safety] occur during regular examinations and are a natural part of the patient-physician relationship. … Physicians must be allowed to speak freely to their patients in a non-judgmental manner about firearms, provide patients with factual information about firearms relevant to their health and the health of those around them, fully answer their patients' questions, and advise them on the course of behaviors that promote health and safety without fear of liability or penalty."2
"I have begun asking my patients questions about firearms, at times," said Dr. Lichtin. "For example, whether there is a firearm in the house and who has control over it."
In an editorial published in the Annals of Internal Medicine, Garen J. Wintemute, MD, MPH, from the Violence Prevention Research Program at the University of California Davis Medical Center in Stockton, outlined the specific situations in which physicians can and cannot ask and counsel.15 The authors suggest that physicians have a responsibility to ask about firearms when it could be directly relevant to the health of a patient, especially in three situations: when a patient provides information or exhibits behavior suggesting increased risk for violence, when a patient possesses individual-level risk factors for future violence, or when a patient is in a demographic group at increased risk for firearm-related injury, including suicide.
No Quick Fix
Though many physicians advocate for gun violence to be treated as a public safety concern, solving the problem of gun safety is not something doctors can do alone.
"These are much bigger issues than ASH and hematologists can tackle, but that does not mean we should do nothing," Dr. Rosmarin said. "The impact of a physician speaking with a patient about this, or talking to spouses with uncontrolled guns in the house, can be very powerful."
Hematologists can develop close relationships with their patients as they manage chronic diseases together over long periods of time. When gun violence disrupts their lives, it can be shattering, Dr. Lichtin said.
"I have personally had patients who went through multiple rounds of chemotherapy and multiple battles with cancer, with a lot of family support, who then have committed suicide using a gun," he said. "Everybody is left looking at each other – the family, physicians, [and] nurses. We spent a lot of time monitoring every detail of care, but when gun violence happens and takes the life of a patient, it is devastating."
"How many lives could be saved or injuries prevented by speaking with patients about these issues? Who knows?" Dr. Rosmarin said, "But we have a responsibility to do it in the care of our patients."â€”By Leah Lawrence
- Pew Research Center. U.S. Politics & Policy: Opinions on Gun Policy and the 2016 Campaign. Accessed October 25, 2017, from http://www.people-press.org/2016/08/26/opinions-on-gun-policy-and-the-2016-campaign/.
- Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6.
- Mother Jones. "US Mass Shootings, 1982-2017: Data From Mother Jones' Investigation." Accessed November 5, 2017, from http://www.motherjones.com/politics/2012/12/mass-shootings-mother-jones-full-data/.
- Centers for Disease Control and Prevention. National Center for Health Statistics. All Injuries. Accessed October 25, 2017, from https://www.cdc.gov/nchs/fastats/injury.htm.
- National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Cancer Stat Facts: Leukemia. Accessed October 25, 2017, from https://seer.cancer.gov/statfacts/html/leuks.html.
- National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Cancer Stat Facts: Non-Hodgkin Lymphoma. Accessed October 25, 2017, from https://seer.cancer.gov/statfacts/html/nhl.html.
- Gani F, Sakran, JV, Canner JK. Emergency department visits for firearm-related injuries in the United States, 2006-14. Health Aff. 2017;36:1729-38.
- Centers for Disease Control and Prevention. SCD: Data & Statistics. Accessed November 5, 2017, from https://www.cdc.gov/ncbddd/sicklecell/data.html.
- 104th Congress. Public Law 104-208. Accessed October 25, 2017, from https://www.gpo.gov/fdsys/pkg/PLAW-104publ208/pdf/PLAW-104publ208.pdf.
- Stark DE, Shah NH. Funding and publication of research on gun violence and other leading causes of death. JAMA. 2017;317:85-6.
- Mount Sinai Health System. "Gun violence research dramatically underfunded, understudied compared to other leading causes of death." Accessed October 25, 2017, from https://www.sciencedaily.com/releases/2017/01/170103151717.htm.
- Wadman M. NIH emails reveal divisions over renewal of gun research program. Science. Accessed October 25, 2017, from http://www.sciencemag.org/news/2017/09/nih-quietly-shelves-gun-research-program.
- 42. U.S.C. United States Code, 2011 Edition. Title 42 – The public Health and Welfare. Chapter 6A – Public Health Service. Subchapter XXV – Requirements relating to health insurance coverage. Accessed October 25, 2017, from https://www.gpo.gov/fdsys/pkg/USCODE-2011-title42/html/USCODE-2011-title42-chap6A-subchapXXV-partA-subpartii-sec300gg-17.htm.
- Hersher R. Court strikes down Florida law barring doctors from discussing guns with patients. NPR. Accessed October 25, 2017, from http://www.npr.org/sections/thetwo-way/2017/02/17/515764335/court-strikes-down-florida-law-barring-doctors-from-discussing-guns-with-patient.
- Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016;165:205-13.
The following measures aim to reduce the health and public health consequences of firearms, according to the American College of Physicians:
- institution of universal background checks of gun purchasers
- elimination of physician "gag laws"
- restrictions on the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use
- research to support strategies for reducing firearm-related injuries and deaths
Source: Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6.