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[at-l] Dangerous Doctors?



You asked for this one and here it is:




Boundary Violation:
Gun Politics in the Doctor's Office

By Timothy Wheeler, MD
{Appeared originally in the Medical Sentinel of the Association of American
Physicians and Surgeons, March/April 1999, pp. 60-61}


Imagine this scenario: you visit your doctor for back pain. Your doctor asks
if you have firearms in your home. Then he announces that your family would
be better off (especially your children) if you had no guns at all in your
house. You leave the doctor's office feeling uneasy, wondering what guns
have to do with your backache. Does your doctor care about your family's
safety? Or instead, did he use your trust and his authority to advance a
political agenda?

American families may soon find themselves in this scenario. Social
activists are taking their war on gun ownership to a new battleground: the
doctor's office. (1) The American Medical Association (AMA) (2), American
Academy of Pediatrics (AAP) (3), and American College of Physicians (ACP)
(4) 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
nonsexual violations. (5) 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. (6)

Boundaries in the doctor-patient relationship derive naturally from the
relationship's fiduciary nature. In general, "treatment boundaries can be
defined as the set of rules that establishes the professional relationship
as separate from other relationships and protects the patient from harm. A
patient who seeks medical or psychiatric treatment is often in a uniquely
dependent, anxious, vulnerable, and exploitable state. In seeking help,
patients assume positions of relative powerlessness in which they expose
their weaknesses, compromise their dignity, and reveal intimacies of body or
mind, or both." (7)

Thus compromised, the patient relies heavily on the physician to act only in
the patient's interest and not the physician's. A doctor must put the
patient's needs before his own. But a physician reverses the priorities when
because of passionate political beliefs he tries to influence his patient
against guns. This physician puts his own need to "do something" about the
perceived evil of guns before the needs of his patient. He crosses the line
from healer to political activist. Such doctor-on-patient political activism
is recognized in Epstein and Simon's Exploitation Index (8) as a boundary
violation.

Just as some physician sexual transgressors may insist their sex relations
with a patient are therapeutic, the activist doctor may protest that he only
seeks to prevent "gun violence." However, the conduct of the medical
activists strongly indicates that their interest in patients' guns is
political, not therapeutic.

The AAP, ACP, and AMA are members of the Handgun Epidemic Lowering Plan
(HELP) Network, based in Chicago. HELP is an exclusive advocacy group
dedicated to banning guns. Physicians who disagree with HELP's anti-gun
agenda are barred from attending HELP's conferences, a policy unthinkable in
any scientific organization. HELP's founder and leader Dr. Katherine
Christoffel has compared guns to viruses that must be eradicated. (9) The
group's militant advocacy has no place for differing viewpoints on firearms,
and apparently neither do the medical organizations which have signed on as
HELP members.

In fact, the AAP has adopted its "gun safety instruction" patient materials
from the gun-ban lobby Handgun Control, Inc. (HCI). The AAP and Handgun
Control, Inc.'s informational wing the Center to Prevent Handgun Violence
advise families in their STOP pamphlet, "The safest thing is to not have a
gun in your home, especially not a handgun." (10) And a survey of
pediatricians showed 76% supported a ban on handguns. (11) Patients who seek
objective advice on firearm safety should not look to pediatricians as a
group. And any doctor should know that patient counseling based on these
materials is politics, not medicine.

Perhaps the most revealing aspect of organized medicine's anti-gun bias is
its persistent refusal to address the criminology literature on guns. For
over twenty years, criminologists have studied firearms, their use and
misuse, their risks and benefits. Especially in the last two years prominent
researchers have found that firearm ownership is not the scourge that
medical activists have claimed it to be. The best and latest research finds
that private gun ownership by responsible citizens not only is safe, but
protects the individual as well as his community from violent crime. (12)

One would think that medical firearm researchers would be intensely
interested in this scholarship. But so far the editorial boards of the
journals of the AAP, AMA, and ACP have neither responded to nor acknowledged
it. With their silence these editors have effectively ended whatever
credibility they had in firearm research. That field of study is apparently
useful to them only as a vehicle for the advancement of their political goal
of gun prohibition. When the scientific process yields knowledge contrary to
that goal, activists either attack its author (13) or ignore it altogether.
Such conduct is inexcusable in any area of scientific endeavor. Honest
scientists face conflicting data objectively. And honest doctors do not use
biased research to give false authority to their negative feelings about
guns.

So how can a patient tell if his doctor's advice about guns is good
preventive medicine or political activism? Patients can assess a doctor's
advice by keeping the following questions in mind:

Does the doctor respect your right to keep guns? Or does he subtly send a
message that guns are somehow bad? Moral judgments about the right to self
defense, hunting, or other legitimate uses of guns are not acceptable
subjects for a doctor talking to a patient.
Does the doctor quote statistics from the American Academy of Pediatrics or
the American Medical Association about the supposed risks of guns in the
home? Do you see anti-gun posters or pamphlets from these organizations in
her office? These materials are based on the "advocacy science" of anti-gun
activists like Dr. Arthur Kellermann, much of which was funded by the
federal Centers for Disease Control and Prevention (CDC). Congress cut off
all the CDC's 1997 funding for gun research because of the CDC's anti-gun
bias. (14) No doctor who knows firearms would base her advice on this
frankly political literature.
Is the doctor familiar with the National Rifle Association's (NRA) Eddie
Eagle gun safety program for children, or other established gun safety
education programs? If not, is she interested in learning about them? Unlike
the AAP's Stop program, Eddie Eagle educational materials for children
contain no political or moral judgment about guns. This NRA program has been
honored by the National Safety Council, the American Legion, and the
governments of 19 states. The Eddie Eagle slogan "If you see a gun, Stop,
Don't touch, Leave the area, Tell an adult" was even endorsed by the
generally anti-gun California Medical Association (CMA). (15)
Despite intense publicity for the AAP's Stop program and similar
initiatives, most doctors shy away from scrutinizing their patients' gun
ownership. In a recent study 91% of surveyed doctors felt that firearm
violence is a public health issue. But only 3% said they frequently talk to
patients about firearms in the home. Two thirds of the surveyed doctors said
they never talk to patients about the subject. (16) This may indicate that
although they are generally concerned about firearm injuries, doctors do not
see politically motivated patient counseling as appropriate professional
conduct.

In a revealing section, the AAP's Stop speaker's kit warns would-be
lecturers of "resistant audiences" who may disagree with them on scientific
or ideological grounds. One section offers talking points for dealing with
these "challenging individuals." (17) The kit's authors seem to anticipate
their audiences may recognize its political nature.

Patients do have remedies for the boundary-crossing doctor. In today's
competitive health care market most patients can choose from many doctors.
Changing doctors is the simplest solution. A written complaint to the health
plan's membership services department can send a powerful message that
boundary violations by doctors will not be tolerated. If the problem
persists, patients can file a complaint with the doctor's state licensing
board. Medical licensing boards are increasingly aware of the problem of
boundary violations. Although state boards have addressed primarily sexual
and financial misconduct, the broad principles they have developed to guide
doctors in these areas apply to the entire doctor-patient relationship. (18,
19)

The author cannot advise the reader to take a particular course of action. A
patient confronted with physician misconduct must decide for himself which
action, if any, to take. But patients should realize they do have choices in
dealing with physician boundary violations involving political activism,
especially in such personal matters as firearm ownership. And physicians
should be aware of the personal risks they take when they bring political
activism into the exam room.


Endnotes

HELP Network News, Winter / Spring 1998, p. 1. This quarterly newsletter is
published by the Handgun Epidemic Lowering Plan (HELP) Network.
Ibid. p. 2.
American Academy of Pediatrics Policy Statement, vol. 89, no. 4, April, Part
2, 1992, pp. 788-790.
American College of Physicians Position Paper, "Firearm Injury Prevention,"
Annals of Internal Medicine, 1998, vol. 128, no. 3, p. 238.
Frick, D., "Nonsexual Boundary Violations in Psychiatric Treatment," Review
of Psychiatry, vol. 13, (Washington, D.C.: American Psychiatric Press,
Inc.), 1994, pp. 415-432.
Hundert, E., and Appelbaum, P., "Boundaries in Psychotherapy: Model
Guidelines," Psychiatry, vol. 58, November 1995, pp. 346-347.
See reference 5, p. 416.
See reference 5, pp. 418-419 reprinted with permission from the Bulletin of
the Menninger Clinic, vol. 56, no. 2, pp. 165-166, The Menninger Foundation,
1992.
Somerville, J., "Gun Control as Immunization," American Medical News, Jan.
3, 1994, p. 9.
"Keep Your Family Safe From Firearm Injury," American Academy of Pediatrics
and Center to Prevent Handgun Violence, 1996.
Olson, L., and Christoffel, K., "Pediatricians' Experience With and
Attitudes Toward Firearms," Archives of Pediatric and Adolescent Medicine,
vol. 151, April 1997.
Lott, J., More Guns, Less Crime: Understanding Crime and Gun Control Laws,
(Chicago: University of Chicago Press), 1998.
Ibid. pp. 122-157.
Report from the Committee on Appropriations, U.S. House of Representatives:
Departments of Labor, Health and Human Services, and Education, and Related
Agencies Appropriations Bill, 1997, p. 49.
California Medical Association, Actions of the House of Delegates 1995, San
Francisco 1995, Resolution 109-95, p. 9. The Eddie Eagle slogan was
originally introduced in a resolution crediting its creator, the National
Rifle Association (NRA). But the CMA Delegates refused to mention the NRA in
the final version of Resolution 109-95, preferring instead to credit the
California Department of Justice. This agency had adopted the Eddie Eagle
slogan in its own gun safety program.
Cassel, C.K., and Nelson, B., "Internists' and Surgeons' Attitudes Toward
Guns and Firearm Injury Prevention," Annals of Internal Medicine, 1998; vol.
128, pp. 224-30.
American Academy of Pediatrics, "Preventing Firearm Injury: Protecting Our
Children Speaker's Kit," tab 1, section 5, Elk Grove Village (Illinois),
1998.
Medical Board of California Action Report, April 1996, p. 3, California
Department of Consumer Affairs, Sacramento, California.
Massachusetts Board of Registration in Medicine, "General Guidelines Related
to the Maintenance of Boundaries in the Practice of Psychotherapy by
Physicians (Adult Patients)," Boston.

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Timothy Wheeler, MD is Director of Doctors for Responsible Gun Ownership, a
project of The Claremont Institute.