By MATTHEW S. ELLMAN, MD and JULIE R. ROSENBAUM, MD
What if firearm deaths could be reduced by visits to the doctor? More than 35,000 Americans are killed annually by gunfire, about 60% of which are from suicide. The remaining deaths are mostly from accidental injury or homicide. Mass shootings represent only a tiny fraction of that number.
There’s a lot physicians can do to reduce these numbers. Typically, medical organizations such as the AMA recommend counseling patients on firearm safety. But there is another way to use medical expertise to help reduce harm from firearms: physicians should evaluate patients interested in purchasing firearms. The idea would be to reduce the number of guns that get into the hands of people who might be a danger to themselves or others due to medical or psychiatric conditions. This proposal has precedents: physicians currently perform comparable standardized evaluations for licensing when personal or public safety may be at risk, for example, for commercial truck drivers, airplane pilots, and adults planning to adopt a child. Similar to these models, a subset of physicians would be certified to conduct standardized evaluations as a prerequisite for gun ownership.
As a primary care physicians with decades of practice experience, we have seen the ravages of gun violence in our patients too many times. A 50-year-old man shot in the spinal cord 30 years ago who is paraplegic and wheelchair-dependent. A 42-year-old woman who sends her teenage son to school every day by Uber because another son was shot to death walking in their neighborhood. A teacher from Sandy Hook who struggles to cope with post-traumatic stress disorder.
Physicians can contribute their expertise toward determining objective medical impairments impacting safe gun ownership. These include undiagnosed or unstable psychiatric conditions such as suicidal or homicidal states, memory or cognitive impairments, or problems such as very poor vision, all of which may render an individual incapable of safely storing and firing a gun. In this model, the clinical role would be limited in scope. The physician would complete a standardized evaluation and offer recommendations to an appropriate regulatory body; the physician would not be the final decisionmaker regarding licensing. An appeal process would be assured for those individuals who disagree with the assessment.
While the relationship between gun violence and mental illness is complex, evidence shows that certain untreated psychiatric conditions are associated with violent acts, including active suicidal or homicidal ideation. Objective tools already exist to predict predisposition towards violent behavior such as the “SaFETY Score” that could be readily adapted to firearm safety assessment. Many countries, including Japan, Germany, India, and Israel, currently require an evaluation by a clinician as part of process of licensing to purchase a firearm.
To be sure, some say that doctors should “stay in their lane” when it comes to 2nd Amendment rights. However, advocates on both sides of the debate agree that firearms should be kept out of hands of those who might be a danger to themselves or others. With an objective and standardized examination, physicians could help accomplish this. While the 2nd amendment protects the right to bear arms, numerous laws already exist regulating features of firearms (such as silencers, shotgun barrel-length), and current laws permit seizure of firearms from certain dangerous persons, including those with substance use disorder or persons “adjudicated as mental defective or have been committed to any mental institution”.
New approaches are needed to bridge the chasm in this debate. The creation of a system of physician evaluation as a requirement for a license to own a firearm could take several forms but must include a process that includes all stakeholders. Physicians perform safety assessments already as part of our job. By developing a way to assess patients for safe firearm ownership, we can help address this alarming public health challenge.
Matthew Ellman is Professor of Medicine and Director of the Yale Internal Medicine Associates where he practices internal medicine at Yale School of Medicine.
Julie R. Rosenbaum is Chief of Medicine and Acute Care at Yale Health where she practices internal medicine.