The doctor is out of bounds
Boundary Violation:
Gun Politics in the Doctor’s Office
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
1. HELP Network News
2. , Winter / Spring 1998, p. 1. This quarterly newsletter is published by the Handgun Epidemic Lowering Plan (HELP) Network. Ibid. p. 2.
3. American Academy of Pediatrics Policy Statement, vol. 89, no. 4, April, Part 2, 1992, pp. 788-790.
4. American College of Physicians Position Paper, "Firearm Injury Prevention," Annals of Internal Medicine, 1998, vol. 128, no. 3, p. 238.
5. Frick, D., "Nonsexual Boundary Violations in Psychiatric Treatment," Review of Psychiatry, vol. 13, (Washington, D.C.: American Psychiatric Press, Inc.), 1994, pp. 415-432.
6. Hundert, E., and Appelbaum, P., "Boundaries in Psychotherapy: Model Guidelines," Psychiatry, vol. 58, November 1995, pp. 346-347.
7. See reference 5, p. 416.
8. 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.
9. Somerville, J., "Gun Control as Immunization," American Medical News, Jan. 3, 1994, p. 9.
10. "Keep Your Family Safe From Firearm Injury," American Academy of Pediatrics and Center to Prevent Handgun Violence, 1996.
11. Olson, L., and Christoffel, K., "Pediatricians’ Experience With and Attitudes Toward Firearms," Archives of Pediatric and Adolescent Medicine, vol. 151, April 1997.
12. Lott, J., More Guns, Less Crime: Understanding Crime and Gun Control Laws, (Chicago: University of Chicago Press), 1998.
13. Ibid. pp. 122-157.
14. 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.
15. 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.
16. 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.
17. American Academy of Pediatrics, "Preventing Firearm Injury: Protecting Our Children Speaker’s Kit," tab 1, section 5, Elk Grove Village (Illinois), 1998.
18. Medical Board of California Action Report, April 1996, p. 3, California Department of Consumer Affairs, Sacramento, California.
19. 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.
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copyright © 1999 The Claremont Institute
BACK2nd Amendment
4 August 1999