Why mandatory reporting of gunshot wounds is necessary: A response from the OMA's Executive of the Section on Emergency Medicine

It has been almost 4 years since I received a call from one of my staff physicians looking for guidance because the police were in our emergency department demanding information. A shooting victim was refusing to tell the police anything. The police wanted us to provide the patient's identifying information and argued that it was not privileged. They were frustrated because they felt they did not have enough information to support obtaining a warrant (or that it would take too long). We stood our ground: no warrant, no information. We later contacted colleagues and found that many of them had faced similar situations and that some of them routinely collaborated with police, in most cases because they thought they were legally required to do so.

In the aftermath of the event in our emergency department, we checked with authorities to assure ourselves that our position was legally and professionally sound. We talked to a wide range of individuals, including experts in pubic health, injury prevention and gun control, and found that many thought gunshot wounds were already reportable. The Executive of the Section on Emergency Medicine of the Ontario Medical Association (OMA) took on the challenge of reviewing the problem and suggesting improvements.

Following a literature search, a survey of our members and much debate, we concluded that mandatory reporting of gunshot wounds was justified. We published our results as a position statement that appeared in November,¹ at a time when gun violence was a hot topic in Toronto. It garnered media attention and many positive responses, but for some we clearly struck a nerve. In this issue of CMAJ, Pauls and Downie speak out against our position (see page 1255).² On behalf of the Executive of the OMA's Section on Emergency Medicine, I would like to address their criticisms.

Pauls and Downie quote the statistics on shootings in Canada, the majority of which are self-inflicted or accidental. They feel that there is little threat to the public from victims in these groups, that no investigation is required and that any further risk is undefinable. We disagree. Specifically, we pointed out in our position statement that guns are lethal and indiscriminate weapons. The suicidal patient needs and deserves our full support and care, but suicide is an impulsive act. The gun used may be a continuing risk to them after hospital discharge should suicidal feelings recur. Guns have also been used by depressed individuals to kill family members or others close to them before attempting to kill themselves. So-called accidental shootings are troubling as well because they strongly indicate that the shooter is using firearms inappropriately and dangerously. Furthermore, one-third of firearm-related accidents involve children 5–19 years old.³ An investigation may reveal whether the gun or shooter poses further risk to anyone and may provide useful data for injury prevention.

Pauls and Downie state that “the logic” of the OMA's Section on Emergency Medicine is that “all serious crime should be reported to police.” They miss the point. We are not advocating for physicians to become crime fighters, we are interested in public safety and injury prevention. We specifically argued against reporting injuries from stabbings and beatings in our paper and provided several reasons, mainly that this type of behaviour is less lethal; a stray punch or knife will never come through the wall of a house and kill a man watching television with his wife and child as a stray bullet did in Toronto recently. Although a motion was passed in the Ontario legislature this December calling for wide reporting of injuries resulting from crime,⁴ we clearly stated and explained our opposition to this in our position statement. We will actively oppose the introduction of any such law.

Also questioned by Pauls and Downie is the involvement of the police. Who, other than trained law enforcement officers, will investigate cases of suspected firearms abuse? Concerns over personal safety might preclude anyone but the police taking on the job of investigating shootings. Nonetheless, we would support any suggestion that meets the goals of protecting public health without endangering the investigating individuals and without automatically involving the police.

The authors speculate that physicians who report gun-related injuries will be seen as an extension of the police and that this might deter not only shooting victims but also others from revealing their drug use or disclosing their sexual practices. Perhaps, but we don't think so. We are advocating that physicians report all injuries involving firearms to the police at the time of the emergency department encounter. The patient is not accused of a crime but instead is being identified as someone who may have information that could lead to his or her own protection and that of other people. The patient's personal health information would remain confidential, as would their right to silence (there is no legal obligation to assist a police investigation) and to seek counsel. Physicians report unfit drivers and child abusers, yet no one has documented concerns over widespread avoidance of care or called for repeal. Pauls and Downie draw great significance from the distinction that it is not the police who are called in these other reporting situations. Given the stakes, is this of much solace to the person reported? It is somewhat reassuring that American jurisdictions with laws for reporting of gunshot wounds have not reported problems with avoidance.^5,6

Patient confidentiality is not an absolute right in Canada. Exceptions have been defined and broadly accepted by the public and the medical profession. The question we raised was whether the discharge of a gun causing personal injury is of sufficient public concern that it, too, should override a patient's right to confidentiality. We believe that it does, and we support legislation that would mandate such reporting. It is curious that the United States, a jurisdiction with an overwhelmingly powerful gun lobby, had laws for mandatory reporting of gunshot wounds in 48 states as of 1995,⁷ whereas Canada, a country that regulates guns much more closely, has no such provision. We felt that this situation called for some attention and debate. We are pleased that our position statement has ignited that debate, and we appreciate the contributions made by colleagues on both sides of the issue.

β See related articles pages 1255 and 1258