There was a time in my country when, among other unpleasant duties, the prison doctor was required to assess prisoners for their fitness for execution. Needless to say, not much attention was paid in medical school to this particular skill: the physician was on his own because in those days there were no such things as official guidelines. The rough and ready rule was that a man was fit to be executed if he knew that he was to be executed and why. It was the death-penalty equivalent of informed consent to surgery.

One of the last British executioners, Albert Pierrepoint, who hanged about 600 people, wrote in his memoirs that he was often asked if people struggled on their way to the gallows. He replied that he had known only one do so; to which he added, by way of explanation, “And he was a foreigner.” However, foreign nationality was not in itself a contraindication to execution. Pierrepoint was one of the executioners at Nuremberg.

An article in a recent edition of the New England Journal of Medicine draws attention to the ethical and practical dilemmas of American physicians asked to assess people for fitness to carry concealed weapons. Again this is not a skill taught in medical schools. No firm criteria, beyond those of common sense (which have not been validated by research), have been laid down. It seems obvious that people with paranoid personalities or psychoses, gross depression or mania, those who take cocaine, amphetamines, or other stimulants, and alcoholics should be refused permission to carry concealed weapons. But many of those conditions (if taking cocaine can properly be called a condition) are easy to conceal or difficult to detect. How far is the doctor to go in attempting to detect them? Interestingly, or curiously, the authors do not mention hair or blood tests, which could certainly help the doctor detect drug and alcohol abuse. 

The authors draw attention to the fact that since 2005 more than 150 people in Michigan with licenses to carry concealed weapons have committed suicide and in a five-year period in North Carolina 2,400 permit holders were convicted of crimes, including 900 drunk driving offenses and more than 200 felonies. This is supposed to demonstrate that doctors have no particular skill in assessing the competence of their patients to carry concealed weapons, which may well be the case (I rather suspect that it is), but these raw figures prove nothing very much. As is all too often the way, they provide numerators which shock but no denominators which soothe or reassure. Nor is there any standard of comparison: it might be, for example (though I rather doubt it), that people with licenses in Michigan are less likely to commit suicide than an equivalent number of people of similar demographic characteristics without licenses. The connection between gun licenses and suicide might not be a causative one; and even if it were, it would still need to be shown that the type of people who have a concealed gun license and commit suicide are more likely to commit crimes with guns than they would otherwise be. For it is specifically gun crime that licensing is supposed to control, not suicide, drunken driving, or all felonies as such.

The authors fear that doctors who make assessments will be held legally responsible for the acts of those whom they have assessed. I suspect that they are right. I don’t want to sound paranoid, but the fact is that when things go wrong it is best (by which I mean most lucrative for lawyers) to blame the doctor. And no, I don’t want to carry a concealed weapon myself.

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