As America's gun violence epidemic continues, many people are wondering how so many troubled and dangerous individuals escaped relevant authorities' notice for so long. Surely someone unstable enough to commit such heinous acts would display warning signs, right? Yes, it turns out the people most equipped to pick up on these signs often do. But there's a problem: the professionals who are often able to make note of an individual's tendency towards violence are their doctors — the same doctors who are legally required to keep such information confidential.
The Health Insurance Portability and Accountability Act, or HIPAA, is an important piece of legislation that keeps interactions between doctors and their patients private. It also outlaws employer discrimination based on medical history, which is definitely up there on the list of "super important laws to have in a fair society." But because of doctor/patient confidentiality, physicians are not allowed to report someone as a potential risk unless they pose a threat that is both “serious” and “imminent.”
According to David Rosmarin, Director of Forensic Psychiatry at Harvard Medical School’s McLean Hospital:
Sometimes the only person who is aware that there’s a serious and imminent threat is a physician, and that clinician is barred under HIPAA from disclosing that threat if it’s below serious and imminent.
Doctors' jobs become even harder when they encounter patients who display warning signs of gun violence, but who give no indication of an imminent threat. The below list of gun-related incidents, published by the blog VT Digger, took place in one Vermont emergency room. If doctors had guessed wrong and reported, they would very likely have committed a criminal and ethical offense.
...the abused woman whose husband put a handgun on the kitchen table “for effect” when he beat her; the out-of-control kid who grabbed an unsecured gun and faced down his parents when he was mad; the mentally unstable man who scared the hell out of his neighbors with an impressive array of high-capacity firearms; the woman who tried to shoot herself with a long gun, but jerked the stock when she pulled the trigger, missed and blew a hole through her apartment wall; the heroin addict who dropped a handgun out of his pocket before passing out on the gurney; the kid who could have been a school shooter, but someone got worried and brought him in for treatment; the woman who overdosed on pills after witnessing the shooting death of a loved one.
To complicate matters further, there are instances when reporting gun violence risk has negative effects on the patient and family even when the analysis is legal. There is always the risk, for instance, that a child's parent who's reported to the police by a doctor will simply go elsewhere, or even take his or her child out of the healthcare program.
With all this talk of spotting potential threats, it's easy to forget this isn't what doctors signed up for. They simply want to help their patients.
Many doctors see their patients as their primary responsibility. Or, as Rosmarin said:
We’re there to treat people. Putting us in the position of being the gun snitches is a difficult position to be in.
Doctors need to disabuse themselves of the notion they have no duty to their community. They advocate for additional funds. They advocate for needle exchange.— Felicia Clemens (@clemens_felicia) March 1, 2018
While changing HIPAA to let doctors report certain people at risk of gun violence seems like an easy fix, that isn't always the case. In New York, the NY SAFE Act was passed after the Sandy Hook Elementary School shooting to stop "criminals and the dangerously mentally ill from buying a gun." While the bill had the best intentions, many mental health professionals now believe the law was passed rashly, and has contributed to the misconception that mental health is linked to gun violence. In truth, the mentally ill are far more likely to be victims of gun violence than perpetrators.
Dr. James Knoll IV, Director of Forensic Psychiatry at SUNY Upstate Medical University in Syracuse, said of the NY SAFE Act:
It was passed with some haste, in my opinion, without adequate input by the mental health community and specifically the New York State Office of Mental Health. The vast majority of psychiatric diagnoses and mental illnesses are just completely unassociated with the potential for gun violence.
The idea of doctors taking a more active role in identifying potential shooters raises many ethical questions that have no clear answers. One possible solution: enforce stronger background checks for warning signs so dangerous individuals find it harder to get a gun in the first place.
Just a thought.
It’s time for a change. When people’s safety is a stake, Hippa should allow it.— Lill_DNP (@Blessed_APN) March 1, 2018