By Rose Hoban

What are the responsibilities of doctors who are asked to sign off on a permit for a concealed weapon?

In the wake of high-profile shootings, that’s a question that several local physicians began bandying about among themselves.

The result of their musings ended up last week in the New England Journal of Medicine.

UNC-Chapel Hill family doctor Adam Goldstein said that in the wake of the December shootings that killed 26 children and their teachers in Newtown, Conn., he started getting requests from his local sheriff to sign off on concealed carry weapons permits.

“In certain various jurisdictions in various states, to get a concealed carry license you have to exclude those with mental or physical conditions that could impair that person’s use of a concealed handgun,” Goldstein said during an interview.

He explained that in many places, the applicant only needs to self-disclose any problems and go through a criminal background check.

In North Carolina, at least 240,000 people are permitted to carry a concealed weapon. Between 30,000 and 40,000 people apply for new applications annually.

Goldstein said checking on a criminal background is pretty straightforward for law-enforcement agencies that grant the permits, but the mental and physical health part is trickier.

According to Goldstein, for medical clearance, an applicant puts down his or her physician’s name and contact information. Sheriffs can send off the application to the doctor for approval.

“After December, a number of my colleagues and I started getting these requests from sheriffs to sign off on these applicants. So we didn’t know what to do with it,” he said.

That got him thinking, and talking. Goldstein pulled in doctors, a medical ethicist and an attorney from the Duke University School of Law who specializes in medical issues.

The result of their discussions is the article, which teases apart some of the ethical, legal and policy considerations of doctors signing off on concealed weapons permits.

“Federal law, for example, prohibits gun sales to felons, persons found to abuse controlled substances, persons with a history of domestic violence, and persons deemed dangerously mentally ill,” Goldstein wrote. “But it’s … difficult to assess mental competence and current or future risk for violence. Even with drug testing, it’s often difficult to detect clinically whether a person is abusing illegal substances, controlled prescription drugs or alcohol.”

Goldstein and his colleagues wondered what would happen to a doctor who signs off on someone who then commits a heinous crime, or commits suicide, using the weapon. Is that doctor liable?

“There’s no evidence that physicians can accurately assess patients’ ability to use weapons competently and safely,” Goldstein and his colleagues wrote.

They pointed out that over a five-year period in North Carolina more than 2,400 permit holders were convicted of crimes, including more than 900 offenses for driving while impaired and more than 200 felonies.

“There’s no evidence that doctors know anything unique of gun safety,” Goldstein said. “It’s not a part of our training.”

Establishing competency, protecting privacy

“Doing this is unlike things such as a physical to get a commercial license or sports physicals or even camp physicals, where you’re given guidance,” Goldstein said. “How do you establish competence in this case?”

During his research on the issue, Goldstein found a tremendous variation between North Carolina counties when it comes to approving permits. In some counties, it seems, sheriffs routinely contact the physicians listed on the permit application. In others, that’s not the case.

“You’ll find a county where the approval rate is 10 times another county,” Goldstein said. “One believes that the distribution of illness is somewhat even, so it seems that the sheriff or the law-enforcement agency responsible for approval is using radically different standards.

“In some circumstances, they’re relying on doing deeper checks, and in some counties it’s almost never denied.”

Goldstein and his co-authors concluded that lawmakers need to clarify a doctor’s responsibility when it comes to approving a concealed carry permit.

“There are not independently licensed doctors who do this for a living,” and perhaps there should be, Goldstein said. Legislators should at least establish standards for doctors to follow, he added.

Goldstein and his co-authors also considered the problems of maintaining patient privacy.

“What happens if I know but don’t want to disclose that this person had a trauma as a kid, and I don’t want to approve the application?” Goldstein asked. He said it’s unclear if disclosing that kind of information could violate patient privacy laws.

“What about if their heart rate isn’t controlled? Or if they’re taking an anti-depressant or Ambien? I can’t tell you what’s the right answer,” Goldstein said.

Doctors need more guidance from policy-makers about what constitutes mental and physical competence to carry a concealed weapon, he said, and those policy-makers need to set standards and protocols to help guide physicians’ decision-making.

Photo courtesy KOMU News, flickr creative commons

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