Friday, January 4, 2013

Guns, Pediatricians, and Framing Violence Risks

Joey, 11, killed his first deer when he was 7. He lives with
his family in Kentucky.
Image from New York Times "Where Children Sleep"
photo essay.
Is it within a pediatrician's authority to warn parents about unlocked guns in the homes of child patients?

That question came up in Florida last year, and the recent tragic events in Newtown have brought it back to the forefront. This fascinating article, by Schaechter et al., provides a good overview of the question in the context of a Florida law that was supposed to block pediatricians from asking about gun ownership, pointing out the risks to patients' families, and recommending that they don't keep a gun in the home, or at least that the gun is kept locked.

Now, the legal controversy was about whether the law protected people from the pediatricians' supposed infringement upon their Second Amendment rights. A Florida court found that it did not:

“Despite the State’s insistence that the right to ‘keep arms’ is the primary constitutional right at issue in this litigation, a plain reading of the statute reveals that this law in no way affects such rights,” wrote U.S. District Judge Marcia Cooke. “A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient’s right to continue to own, possess, or use firearms.”

Subsequently, the law was permanently blocked, as violating the physicians' First Amendment rights:

“What is curious about this law — and what makes it different from so many other laws involving practitioners’ speech — is that it aims to restrict a practitioner’s ability to provide truthful, non-misleading information to a patient, whether relevant or not at the time of the consult with the patient,” Cooke wrote, citing the benefit of such “preventive medicine.”

 But rather than a doctrinal debate about the First or Second Amendments, let's focus on something that I find more interesting: The question of how one defines what is the legitimate business of a pediatrician and what isn't. This Time article provides some interesting quotes from the sparring parties about what's really at stake: Whether warning parents about gun ownership risks is within the provenance of the medical profession or an unwarranted moral intervention.

”We take our children to pediatricians for medical care — not moral judgment, not privacy intrusions,” NRA lobbyist Marion Hammer told NPR in May.

“The law was crazy,” says Louis St. Petery, a pediatric cardiologist in Tallahassee and executive vice president of the Florida Pediatric Society. “The NRA [National Rifle Association] argued that we were out to rid the state of firearms, but that’s a distortion. Our issues as pediatricians are all about safety.”

Now, there is no doubt that bringing in someone who has been shot by a gun is a medical issue. But does that extend to pointing out the risk that that might happen with a gun kept in the house? On one hand, there are studies linking carrying guns to the risk of being shot, and studies linking keeping guns at home to similar risks. It is these studies that prompted the American Academy of Pediatrics to adopt a policy stance against gun ownership. On the other hand, I suppose studies of causal inference in this regard do not require medical education to understand.

But this raises the question of how much of violence prevention (with injury or death being possible result of said violence) is within the provenance of the medical profession. Interestingly, medicalization is often offered as a counterbalance to criminalization. In the context of drugs, making them a medical, rather than a criminal, issue is sometimes considered a benign approach. And, in Governing Through Crime, Jonathan Simon suggests supplanting the war on crime with war on something else, such as on cancer.

Whenever I've heard Jonathan speak about this, I've thought (and sometimes commented) that the problem is not with the subject of the war; it is war itself as a model to tackle problems. But I also think that Conrad and Schneider were right in pointing out that medicalization can be just as pervasive and intrusive as criminalization, and sometimes more. A case in point is our locking up of sexual violent predators in civil commitment long after their sentences have been served. I also think that the expansion of the field of medicine is perhaps easier to do now that we tend to see disease in holistic, environmental terms. Studies increasingly link disease to factors that involve people's overall lifestyle: Stress, smoking, overworking, sexual habits. Doctors are bound to touch upon these topics when discussing their health risks, and all of these are, to some extent, statements that go beyond treating the person's immediate problem.

Seems to me that one's acceptance of, or outrage at, a doctor's mention of the connection between a given lifestyle is a good litmus test as to one's political beliefs. Remember the fear in the early days of AIDS discoveries that it was a form of "gay cancer?" And the battles in San Francisco and in New York over shutting down bathhouses? Gay activists at the time protested that the medical profession was using AIDS as a tool to oppress them and morally sanction their sexual behavior. We now know that the HIV virus is transmitted through unprotected sex, and that refraining from unprotected sex was sound medical advice. But the community's sentiment that there were political repercussions to these medical policies can be understood. They are not much different than the sentiments expressed by NRA activists.

While I understand the concerns about medicalization as a way to legitimize political interference in private choices, I tend to err on the side of allowing the doctors to rely on studies of risk to educate and warn us about our choices. The bottom line is that providing advice and warning is nothing more than medical advice, which we might heed or discard depending on our priorities in life, risk averseness, and values. And if we get bent out of shape because a doctor tells us that keeping a gun in the house increases the odds that our child will be injured, maybe it's because we are feeling a bit insecure about the choice we made in the first place.

Props to Viet Bui for bringing the article to my attention, and to Aatish Salvi for the conversation that helped me clarify my ideas on the topic.

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