My daughter, Casey, has just begun her second year of physician residency in Pediatrics at UCLA Hospital. Her job features an 80-hour workweek and relatively low pay. The work can be challenging and rewarding, but occasionally depressing: some of her patients are deathly ill or wounded. And all too often, nothing she can do will change the inexorable outcome.
Before long, she may well incur a different kind of problem, one where she could save a life. But to do so she would have to confront an unwieldy moral and professional dilemma that often vexes pediatricians.
What if, during an office visit, she learns or comes to reasonably suspect that one or more adults in her patient’s household keep firearms in the residence. What should she say? What can she say? Our new physician is thereby put to a decision, one that thrusts her into the maelstrom of a volatile, intense and enduring national debate.
The debate antagonists are the gun lobby and physicians, two of the most powerful interests in the country. At stake are fundamental issues: gun owner privacy versus physician responsibility; constitutional rights versus public safety.
Grim data: Children in jeopardy
David Hemenway, Director of the Harvard Injury Control Research Center, writes, “A nation may be judged by how well it protects its children.” If so, any objective judgment of the U.S. would be harsh. Indeed the data suggest a collective deafness to the cacophony of child-victim gun violence endemic to the U.S.
According to the Centers for Disease Control and Prevention (CDC):
- The U.S. firearms fatality rate among children under 15 years old is nearly 12 times higher than in 25 other industrialized countries combined, a stunning lapse of core government responsibility.
- About 3,000 children and teens die from gun injuries every year. (That exceeds one Sandy Hook Massacre every three days.)
- A child or teen dies or is injured every 30 minutes from guns.
According to The New England Journal of Medicine, among children and young people (1 to 24 years old), gun-related injuries caused 6759 deaths nationally. For perspective, that’s twice as many deaths as caused by cancer, five times as many as heart disease, and 15 times as many as infections.
To those fatality numbers, add the 20,000 children rushed to emergency rooms with gun injuries every year.
Home may be where the heart is, but is also where the guns are. One-third of all U.S. households with children younger than 18 have a gun, and over two-fifths (43 percent) of those households had at least one unlocked firearm. Studies published in the Journal of the American Medical Association concluded that this substantially increases the risk of suicide and unintentional injury among youths.
This potentially disastrous threat to children goes largely unaddressed by those who could remedy it: the parents. Studies of parents with guns in the homes show their failure to appreciate the lethal danger to their children. About four in ten (39 percent) parents with guns in their homes are ignorant of, or indifferent to, the related dangers to their kids.
Another study finding may be even more troubling, finding that households with adolescents only were more likely to store a firearm unlocked. Given that most youth firearm injuries happen to adolescents, this is akin to keeping your most inflammable household items next to the stove.
The National Rifle Association (NRA) has nonetheless opposed “safe-storage” bills — those requiring locked up guns in homes with children. Why? According to the NRA’s Institute for Legislative Action, storage locks “would have rendered homeowners defenseless and given criminals a clear advantage in home invasions.” Yet no study data support that contention.
Then there's suicide. Young people get depressed; often unavoidably. Many of those who do attempt suicide: for youth between the ages of 10 and 24, suicide is the third leading cause of death in the U.S. It results in approximately 4,600 lives lost each year. The most common means? A firearm.
Given the inevitability of depressed youths, the means available in the home to carry out their suicidal urges become important. Vitally important. Less than 5 percent of such attempts using drugs are lethal; but 90 percent of those involving guns are.
Reformers bearing stethoscopes
So, what are the prospects of meaningful gun control reform for the specific benefit of American children? Few if any groups have been more influential in the campaign against child gun violence than pediatricians.
Here was the core message from the American Academy of Pediatricians (AAP) in 2009:
Where We Stand: Gun Safety
Pediatricians play a key role in injury prevention by providing anticipatory guidance to parents... In controlled studies, individuals who received physician counseling were more likely to report the adoption of 1 or more safe gun-storage practices.
At the heart of this counseling process is the pediatrician’s meeting with his or her patients’ families to discuss the issue of guns in the home. In surveys reported in Pediatrics, the AAP’s official publication, approximately 70% of physicians asked if there were guns in the home. If so, they recommended unloading and locking guns.
But many went further. About half of the doctors surveyed reported “always or sometimes recommending the removal of the guns from the house.” (In a nod to political reality, pediatricians in states with high levels of gun ownership tended to counsel safe gun storage rather than removal.)
Three years later, the AAP sharpened its message — from asking to telling. What had been a gentle suggestion became a grab-your-shirt-and-look-you-in-the-eye admonition. In the October 18, 2012 issue of Pediatrics, the AAP prescribed first, that pediatricians incorporate questions about the presence and availability of firearms into their patient history taking, and then urge parents who possess guns to prevent access to these guns by children. “Safer storage of guns reduces injuries… Nevertheless, the safest home for a child or adolescent is one without firearms.” (Emphasis supplied.)
The AAP focused on reaching parents. Its guidelines urge pediatricians to counsel parents during checkups about the dangers of allowing kids to have access to guns. About half of all AAP pediatricians say they recommend the removal of handguns from the home, according to a national survey.
In sum, the AAP has advised parents to rid their houses of guns. But if not, the next best thing is to have the family talk to the children’s doctor, and lock up their guns. In all, an unmitigated finger-in-the-eye rebuff to the most powerful lobby in the country.
Gauntlet laid.
NRA strikes back
Such a public admonition by a well-respected group deeply rankled the NRA. Its shrill retort reeked of indignation. This from Kaiser Health News: “'We take our children to the doctor because they're sick or need health care,' fumed Marion Hammer, a former NRA president who is the executive director of United Sportsmen of Florida, the NRA's legislative affiliate for the state. 'We don’t take them there for political dialogue or for pediatricians to ask us not to exercise a constitutional right.'”
Public policy is often (some would say inevitably), the product of political power. Historically, few lobbies have exercised more power than the NRA. Here are three prominent illustrations:
- Guns cannot be regulated by the Consumer Product Safety Commission. A 1976 amendment to the law forbade any regulation of guns or gun ammunition. Consequently, the Commission can regulate toy guns (along with teddy bears), but not real guns. Yet what unregulated consumer product is more of a threat to public safety?
- Under pressure from the NRA, funding for gun-violence research by the CDC recently dropped from $2.5 million per year in the early 1990s to a laughingly insignificant $100,000 per year today — a 96 percent cut and a virtual freeze.
- “Physician Gag Laws” suppress physician questions to patients regarding guns.
A prominent display of the NRA’s daunting influence over Congress was in getting the “Protection of Second Amendment Gun Rights” provision inserted into President Obama’s signature legislation, The Affordable Care Act (ACA). The provision bans doctors, health care programs and insurers from “collection of any information relating to the presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property of an individual.”
This language (“any information relating to”) is so vague that it has been widely interpreted to prohibit doctors from asking patients about guns in their homes. In essence, an old-fashioned gag rule. Shakespeare, meet the NRA: a gag rule by any other name would smell as rank.
President Obama clearly sensed the threat that this language presents to pediatricians and their patients. He replied with multiple executive orders expressly authorizing the agencies to conduct gun violence research. But none explicitly reverse the ACA’s moratorium on data collection of gun ownership, nor could they. A president cannot unilaterally repeal parts of enacted law.
Yet the NRA wasn’t done. Perceiving the AAP as a continuing threat, NRA lobbyists sponsored legislation in thirteen states barring doctors from “making written inquiry or asking questions concerning the ownership of a firearm or ammunition by the patient or by a family member of the patient.” This proposed legislation is the so-called Firearm Owners Protection Act, also known as the “Docs vs. Glocks” law or “physician gun gag” law.
In June of 2011, Florida became the first state to statutorily bar doctors from merely asking patients if they own guns. For asking a question that could save a child’s life, a doctor in Florida can lose her license or be fined $10,000. The AAP fought back. It challenged the law in federal court as a violation of the First Amendment freedom of speech. U.S. District Judge Marcia Cooke issued an injunction against implementation of the law. In her orders, she wrote:
The State has attempted to inveigle this Court to cast this matter as a Second Amendment case. 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. … [T]his law … aims to restrict a practitioner’s ability to provide truthful, non-misleading information to a patient.
But on appeal, a three-judge panel of the U.S. Court of Appeals for the 11th Circuit reinstated the law, two-to-one. The doctors challenging the ruling are seeking review before the full Circuit.
In his lengthy dissent, Judge Charles Wilson cut to the heart of the matter. He suggested that “the poor fit between what the Act actually does and the interests it purportedly serves belies Florida’s true purpose in passing this Act: silencing doctors’ disfavored message about firearm safety.” He argued that the law amounts to a content-based restriction and is a clear violation of doctors’ free speech rights.
Florida’s gag rule significantly limits doctors’ ability to speak to their patients in ways that could protect public health and save children’s lives. And the sentiment impelling that law is spreading. Twelve other states have introduced similar “gun gag” laws.
Docs on the march: AAP (and its allies) respond
In May, 2013, the AAP, representing 60,000 doctors, voted overwhelmingly to support stronger gun control measures. Over 100 pediatricians marched on Capitol Hill with demands for greater child safety from gun violence.
They were responding to the Congressional budget freeze on firearms violence research. The freeze had two impacts: inhibiting pediatricians from discussing guns with their patients; and eliminating research that unequivocally implicated the tie between guns and violence to children, including a greater incidence of child suicide with a gun.
The AAP endorsed President Obama’s calls for an assault weapons ban and mandatory background checks. But they wanted more: handgun regulations, a ban on high-capacity magazines and requirements for safe firearm storage. Speaking at a meeting of the Pediatric Academic Societies, Dr. Danielle Laraque, chair of the Pediatrics Department at Maimonides Infants and Children's Hospital in Brooklyn, New York said: “What we need is a call to action, to really look at how we can change public policy that is not often affected by [negative] data.”
Dr. Daniel Webster of Johns Hopkins University is one of the few experts whose research on gun violence has continued despite efforts to divert funding. “If you think that Congress has sort of been asleep … you are wrong,” he said. “They have been doing a very good job of weakening the laws to make it easier for gun dealers to have the least amount of responsibility. They have made it harder to sue dealers and made it harder to access data on … which dealers are pumping out guns to criminals. They’ve made it almost impossible to prosecute a gun dealer.”
As part of its campaign against gun violence, the AAP released several videos featuring pediatricians across the country discussing the profound effects that gun violence has on children, families and communities. In one of them, former AAP president Thomas McInerny states: "Every child who dies due to gun violence is someone's son or daughter, brother or sister, and it's a tragedy that is repeated over and over again." Chagrined but unbowed, McInerny adds, "Sixty years ago, children died from things like polio and meningitis and diphtheria, and then we discovered that we could prevent these diseases. Gun violence is the same. We can prevent this."
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