A Resolution for Physicians: Time to Focus on the Public Health Threat of Gun Violence FREE

The December 14th shooting rampage in a Connecticut suburb that left 20 children and 8 adults dead (including the gunman and his mother) should motivate physicians to be vocal participants in discussions about U.S. gun policy. Many physicians see our primary role as maintaining health and treating disease in individual patients. Yet, physicians have been powerful voices in discussions about issues that threaten public health. We have mitigated these threats by helping to shape policies and practices regarding air pollution, bicycle helmets, drunk driving, motor vehicle restraints, secondhand smoke, tobacco advertising, water contamination, and vaccination. We are long overdue in directing our expertise, commitment, and passion to another public health danger—gun violence.

Why does gun violence deserve physicians' time and energy? Guns maim and kill. Even when we can repair torn tissue and prevent death, bullets permanently diminish the quality of life of persons caught in the line of fire. Gun violence also harms those close to the victims who often endure grief, depression, anxiety, and sometimes posttraumatic stress disorder. Furthermore, whether they experience single shootings or massacres, persons in affected communities and the widening circles around them suffer when gun violence makes them feel unsafe in their schools, streets, stores, workplaces, and recreational venues. Evidence documenting the gravity and prevalence of the problem—the same type of evidence that drives clinical decisions—tells us that gun violence warrants physicians' attention. The Centers for Disease Control and Prevention (CDC) reported that in 2009, firearms were used in 11 493 homicides (3.7 per 100 000 persons) (1) and 18 735 suicides (6.1 per 100 000 persons) (2). Sadly, this means that the U.S. rates of firearm-related homicide, suicide, and unintentional death are higher than in other high-income countries (3).

Just as physicians worked to safeguard public health by promoting smoking bans in public places, we should draw on similar motivations and strategies to promote sensible, evidence-based laws to decrease the harms associated with gun violence. It is our responsibility to do so. The American College of Physicians (ACP) Ethics Manual outlines physician responsibility regarding violence this way: “Physicians should help the community and policy-makers recognize and address the social and environmental causes of disease, including human rights concerns, discrimination, poverty, and violence” (4). The American Medical Association declares it our professional responsibility to “[a]dvocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” (5).

Advocates for fewer restrictions on firearms often invoke some version of the statement, “Guns don't kill people, people kill people.” Taken literally, this statement is true. However, without easy access to guns, people would be far less lethal. Also, many people who commit gun violence have mental health conditions. A 1990 survey found more than half of respondents reporting violent behavior during the prior year met Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), criteria for at least 1 psychiatric disorder (6). Those reporting substance abuse disorders were more than twice as likely as those with schizophrenia to report violent behavior. A 2009 systematic review confirmed these associations (7). Because mental health is so often implicated in gun violence, it is logical that physicians and other health professionals engage in discussions to better identify individuals suffering from mental health conditions and make guns less easily and effective treatment more easily available to them. Requiring mental health screenings before gun purchases may seem overly invasive. Yet, our society is quite comfortable requiring a medical assessment before granting privileges for other activities, such as driving. It seems incongruous that we prohibit an individual with epilepsy from driving while allowing an individual with psychosis to purchase firearms and ammunition. Given the difficulty in identifying individuals at risk for violent behavior (8), defining policies that balance personal freedom and public safety will not be easy and must not be left to politicians alone. Regardless of whether our views about guns align with the National Rifle Association, Doctors for Responsible Gun Ownership, the National Physicians Alliance (http://npalliance.org), or somewhere between, we will have better policies if physicians who understand the interrelationship of mental health and violence actively engage in the policymaking that President Obama has promised in the aftermath of the Connecticut massacre.

The relative silence of the health profession on matters related to gun violence is disturbing. The ACP last issued a position paper on firearm injury prevention in 1998 that identified gun violence as a public health issue, called for internists' involvement in firearm injury prevention, favored strong legislation to ban automatic and semiautomatic assault weapons, supported law enforcement measures to help identify weapons used in crimes, and called for restrictions on the sale and possession of handguns (9). A survey published at the same time demonstrated support for these recommendations among internists and surgeons (10). Yet, what followed has been lackluster. A search of the National Guideline Clearinghouse revealed no guidelines focused on firearm injury prevention. Firearm safety is not directly addressed in any current U.S. Preventive Services Task Force recommendation. There are many reasons for this unimpressive record, but one of the more important ones is politics. Before politics intervened, the CDC received funds for research related to gun violence. Reinstitution of funding to support evidence-based guideline efforts to reduce violence and gun-related injuries and deaths could be valuable components of the nation's response to these relentless and tragic shootings.

Within the medical profession, pediatricians have been the leaders. The American Academy of Pediatrics policy on youth violence recommends an organized approach beginning with counseling parents to reduce child access to firearms starting at age 6 months and continuing with firearm counseling during adolescence (11). We hope recent events energize those whose focus is the care of adults to advocate for screening for the risk for firearm injury and counseling to reduce this risk. The ACP's recent announcement about revisiting its 1998 policy is heartening in this regard (12). For such guidelines to be developed and implemented, the profession will need to fight legislative attempts to restrict research on firearm safety and to constrain physician–patient conversations about guns.

In the past, Annals has encountered difficulty in convincing experts who are passionate about public safety to write commentaries after mass shootings. These thoughtful people revealed that they declined to write about guns for fear that public funding supporting their research programs (which were not directly related to gun violence) might dry up if they advocated for stricter gun control. This situation raises the ominous possibility that our Second Amendment rights may be jeopardizing our First Amendment rights.

Developing effective policies to prevent gun violence will require review of existing evidence, new research to fill evidence gaps, thoughtful discussion to balance the risks and benefits of potential strategies, and evaluation of implemented policies. In other matters of public health, the medical profession has proved that it is up to these tasks. In the wake of the horrific deaths of 20 children, all of the other gun-related massacres, and the daily individual tragedies, physicians should resolve as we begin 2013 to raise our voices on the matter of guns.