Gun concerns: Why doctors should not always speak out
As calls are made for tighter gun licence controls in the wake of Derrick Bird's rampage in Cumbria, during which 12 people died, doctors' leaders have been in talks about when to raise concerns over the mental health of patients.
In this week's Scrubbing Up, Dr Michael Devlin says the public may expect a doctor to always speak out but warns there is a risk a patient could feel his confidentiality had been breached and not seek the treatment they need.
It is commonly accepted that it is more difficult to obtain a certificate for a shotgun or firearm in the UK than many other countries.
However, the application process and the monitoring of existing certificate-holders have come under scrutiny in the wake of the Cumbrian tragedy, although there was no indication that Bird was mentally ill.
And there have been calls for gun control laws to be tightened.
Home Secretary Theresa May has said that "it would be wrong to react before we know the full facts".
But if, as has been suggested, GPs are given a greater role, it is important that their responsibilities are made clear and that appropriate guidance and advice is available to them.
Individual police forces have a statutory obligation to deal with applications for firearms or shotgun certificates from individuals living in their area - but they may need the professional opinion of the local GP on the mental state of the applicant, which can create a confidentiality dilemma.
Prospective gun owners are asked to give their written consent to this disclosure and provide details of their GP when completing the application form.
But problems can arise for the GP if the patient develops a new illness (such as becoming addicted to drugs or alcohol or developing a mental health problem) after a certificate has been granted or renewed.
This can create an ethical dilemma and more information or guidance is needed to help the GP come to the right decision.
The Medical Defence Union receives on average at least one call a month from doctors seeking advice about the confidentiality of patients who wish to own a gun, hold a shotgun or firearms certificate or who may have access to them.
The most common queries relate to what patient information they can disclose to the police and whether the confidentiality of patients can be breached if a patient with access to a gun gives cause for concern.
Most people will expect GPs to raise concerns about a patient with access to guns or co-operate with the police if they ask for medical information about a gun owner but it is not always straightforward.
The difficulty is that they have a duty of patient confidentiality which is central to the success of the doctor-patient relationship and means that patients feel able to confide honestly with their GP.
For example, one might see a patient being treated for depression expressing angry resentment towards his ex-wife following an acrimonious divorce and threatening to "wipe the smile from her face". At the end of a consultation he may say he is going pheasant shooting that weekend and had owned a shotgun for several years.
Would the GP be justified in breaching patient confidentiality and reporting his threats to the police in these circumstances?
It may be that in doing so the GP could prevent a crime but equally the patient may have felt that the GP's surgery was a safe place in which he could express his frustrations and would never have acted upon his threats.
In going to the police, the GP could arguably have destroyed the patient's faith in him and may have deterred the man from getting treatment for his condition.
The General Medical Council says doctors can disclose patient information without their permission where necessary "to protect individuals or society from risk of serious harm such as... serious crime".
The GMC's guidance continues to explain that doctors should usually seek the patient's consent or tell the patient they are going to disclose information without their consent, unless to do so would put others at risk or would undermine the prevention or detection of a serious crime.
Any new government guidance for GPs could further assist doctors in making such difficult decisions.