Medical school taught me a lot about treating disease, but guns were never on the curriculum. I am a family doctor who cares for patients with addictions, and I am faced daily with the challenge of balancing patient confidentiality and public safety. My patients are largely law-abiding citizens with an illness that requires treatment.
Doctors have a duty to report their patients’ medical conditions to the Ministry of Transportation when a doctor believes a patients’ illness could pose a threat to public safety. We are required to report any medical condition that may impair a patient’s ability to drive safety, such as uncontrolled diabetes, seizure disorders, dementia, and addictions. Doctors are expected to report these patients for their own safety and the safety of others. We have a duty to break confidentiality in order to tell the Ministry of Transportation our concerns. When I personally struggle with the act of breaking the sacred bond of confidentiality, I have to remind myself that I’m preventing a vehicle from becoming a weapon.
The same is true of patients who are primary caregivers of small children, but whose addictions have consumed their lives to the point where I am concerned that the children are not receiving care or are in danger. The law says that I must over-ride the sacred doctrine of doctor-patient confidentiality in order to protect the public, the patient and the child.
But what about guns? Some of my patients own guns. As I said before, most of my patients are law abiding citizens. Their guns are not acquired on the street. They have licenses and permits for their guns. They have taken courses in gun safety and have acquired guns through legal processes. Since there is such a clear link between violence and intoxication, you might think I would have a duty to report their addiction to the Chief Firearms Officer, just like I must report it to the Ministry of Transportation and the Children’s Aid Society. But my legal duty to report an addiction in the case of a patient who owns a gun is much less clear than in the case of cars or children.
So what do I do if my patient – the same one I have reported to the Ministry of Transportation and the Children’s Aid Society – has a gun? According to my professional regulator, this is a case of permissive, rather than mandatory, reporting. I can call and make a report to the Chief Firearms Officer in my province if I am concerned that the patient is a threat to self or others, but I don’t have a legal duty and I have to make a careful case in order to break confidentiality.
If the patient makes a clear threat to another person, then I have a duty to report this to the police and I can hold the patient for psychiatric assessment, but what of the more common case where the patient is non-violent and simply has a gun at home? Is this enough for me to report?
This might seem obvious. You may be thinking “there’s a clear danger – of course she has a duty to report!” But it’s not that simple. For doctors, patient confidentiality is sacred – it is the pillar of the doctor/patient relationship. If I break confidentiality without very good reason, I have done my patient a terrible wrong, and they can rightfully complain about my behavior to the College of Physicians and Surgeons, or sue me. But, more importantly, I will have stigmatized this patient. They may never trust a physician again and may delay or avoid seeking treatment in the future.
In the cases of the mandatory reporting for the Ministry of Transportation and the Children’s Aid Society, my duty is clear: there are laws that spell out to the patient and the physician when and how addictions must be reported. But, in the case of firearms, doctors are left to make a judgment call. I must determine whether there is a significant risk. Is the patient going hunting with his/her gun while intoxicated? Is his/her judgment so clouded that the gun may not be appropriately stored in a home with small children? Could the patient become angry while intoxicated, and use his/her gun in an act of domestic violence?
When I am faced with this situation in clinical practice, I turn to the resources I have. My hospital lawyers provide one point of view, the College of Physicians and Surgeons of Ontario provide another and malpractice insurance providers a third. Often the recommendations from all three are in conflict. What is a doctor to do? The short answer is: you do what you think is right and hope that it is good enough to protect both your patient’s rights and the public safety. But, as we think about gun control in the wake of another massacre, I wonder – given mandatory reporting for patients with addictions who have a driver’s license – should we have the same guidelines and mandatory reporting for gun licenses?

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Although there is some empirical evidence to link intoxication and violence, there is not currently evidence (to my knowledge) that demonstrates a causal relationship between people suffering from addiction and increased rates of violence, and more specifically, gun-violence. Many people can take substances because of an addiction but never appear or act “intoxicated”, especially if their addiction is so severe they are using to maintain a sense of normalcy and prevent withdrawal.
So, of course there shouldn’t be mandatory reporting. As with any patient care decision, there are too many grey areas and we should all use our own training, judgement, and common sense.
Thanks for your comment, Clare. In my view there is quite a lot of evidence for a link between intoxication (especially alcohol) and violence (especially Intimate Partner Violence and Femicide). For example, one study in a prominant journal of addictions medicine found "Perpetrator problem drinking was associated with an eight fold increase in partner abuse (e beta = 8.24, p < .0001) and a two fold increased risk of femicide/attempted femicide (e beta = 2.39, p = .001), controlling for demographic differences." I think this raises the question of where the bar for evidence should be set. Are we only willing to consider someone "addicted" if they have received a diagnosis from an addictions specialist? This introduces a fair bit of bias into the sample. Does causation need to be established or are extremely strong correlations (like the one described above) sufficient? Causation is a tricky thing to establish in any social science research. This is not exactly the kind of problem we can study with an RCT. And of course, as the author mentions, many of her concerns aren't even related to intentional violence – they're analogous to concerns about impaired driving – safe storage of guns and hunting while impaired, for example. All in all, I don't think this is quite as easy as it might seem.