Is Gun Control a Health Care Issue?

In October 2018, the American College of Physicians (ACP) clarified its stance on whether gun control should be treated as a public health issue: It updated its firearms policy paper, offering nine evidence-based strategies to help reduce firearms-related injuries and deaths by keeping guns out of the hands of those at risk for harming themselves or others.¹

Shortly after, the National Rifle Association tweeted out a link to an article criticizing the ACP’s position paper, writing that “someone should tell self-important antigun doctors to stay in their lane.”² This tweet prompted a viral response from doctors and health care professionals. Clinicians started sharing photos, tagged with #ThisIsOurLane, of the aftermath of caring for patients who were victims of gun violence.

Despite the response from doctors on social media, it is unclear exactly where most physicians and medical professional societies stand on the controversial topic of gun control.

For example, a February 2019 study analyzed campaign contributions from the 25 largest physician organization–affiliated political action committees (PACs) to see if their established positions on firearm safety aligned with their support for political candidates.³ These physician-affiliated PACs gave more money to political candidates who oppose evidence-based policies to reduce firearm-related injuries than to those who support such policies. According to its authors, the study is not meant to suggest that these groups actively sought to support these candidates because of their firearm policies, but that these PACs have not yet made candidates’ stances on firearm policy a high-priority issue.⁴

The American Society of Hematology (ASH) has not released an official position on the topic of gun control but did sign on as an endorsing organization to the ACP’s initial call to action on firearm-related injury and death in 2015.⁵

In this edition of Drawing First Blood, ASH Clinical News invited Alan E. Lichtin, MD, from the Cleveland Clinic, and Bart Lee Scott, MD, from Seattle Cancer Care Alliance, to answer the question, “Should gun control and gun safety be treated as health care issues?”

Alan E. Lichtin, MD: Gun violence is a very worrisome cultural phenomenon. People who are shot, depending on the part of the body, can require massive amounts of blood for transfusion. Blood is a resource that is not readily available in many locations. Blood banks are good about providing blood, but one gunshot wound to the liver, for example, can deplete a blood bank.

So, yes, guns are a health care issue from that perspective, and also from a mental health perspective. We have these dramatic episodes – mass shootings – that are usually promulgated by someone motivated by hate. As a society, we need to do better in finding out who these people are before they hurt so many others.

Bart L. Scott, MD: Personally, I think we should recognize that gun violence is primarily driven by suicide. Two-thirds of deaths from gun violence are suicide attempts.⁶ Guns are an inanimate object. Death is an issue and suicide is an issue. There was never a question that suicide is a health care issue. It is primarily a mental health issue, but also [with violent means of suicide attempts] a bleeding issue. The debate is not about whether suicide is a health care issue, but about whether physicians and medical societies should take a political position on gun control.

I would support any hematologist getting involved with any political debate he or she wishes to be involved with. There is a difference, though, between an individual physician being involved versus a collective organization. If a professional society gets involved, it invariably will be seen as a partisan issue. When that occurs, it will diminish the potential role that an organization has in the issues with which it should be more directly involved; for ASH, that means funding for research of blood cancers and blood diseases.

Dr. Lichtin: ASH represents hematologists. When I was chair of the Society’s Committee on Government Affairs, we debated this, and I appreciated the idea that maybe ASH, representing all hematologists, should not weigh in on this issue. However, there are many hematologists who feel that gun safety is something that our organization should take a position on. The vote was split, but the majority did vote in favor of signing onto ACP’s initial call to action.

While ASH debates this issue, other medical professional societies have come forward with propositions to change the way guns are handled, bought, and sold in this country. I believe ASH should look at what other organizations are doing and decide whether it is time for ASH to agree or not, as the representative body for hematologists.

Dr. Scott: Also, there are other public health issues that are more pressing from the standpoint of how they affect global health. For example, childhood obesity is much more of a threat to overall health in the U.S.

I am sure most of our readers are aware of the Dickey Amendment, a provision in the 1996 federal omnibus spending bill that restricts the Centers for Disease Control and Prevention (CDC) from performing research on projects that are seen as advocating or promoting gun control.⁷ I would say, however, that research on the causes of suicide is very important, and we need to be careful with the language we use.

Dr. Lichtin: I think if a researcher wants to examine a topic, he or she should not be inhibited by law to do that research. In terms of forwarding human progress, the idea of laws that prevent research is a bad one. If it is a moral or ethical dilemma, like research with fetal or embryo tissue, that is a different discussion. Research on guns, gang violence, suicide, use of guns by anyone motivated by hate … personally, I think that type of research could be very valuable.

Research is being done in this area within private institutions. There is a 2018 study about blood use and mortality in victims of gun violence published in Transfusion.⁸ The conclusions were that “compared with other traumatic injuries, gunshot wound injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating gunshot wound injuries should have ready access to all blood components and ability to implement massive transfusions.” I think further research into this, nationwide, may benefit us all.

There is no question that gun-related suicide has a major impact on health care costs. Information from the Suicide Prevention Resource Center indicates that average cost of one suicide is $1.3 million, and the total cost of suicides and suicide attempts in 2015 was $93.5 billion.⁹

Dr. Lichtin: I view it from the perspective of a hematologist treating patients with leukemia or anemia. They need blood products. Gunshot violence depletes blood banks of resources needed to treat our patients. We should be somewhat concerned about the use of blood products for people who are otherwise healthy except that they have been shot. … It should be part of our conversation.

Dr. Scott: What physicians do in their personal life is their own decision. The issue that I disagree with is a professional medical organization making a political statement on a political issue.

Dr. Lichtin: I would like to think that there is enough concern about gun violence, and not just with suicide. When parents send their kids off to school, they are not worried a child will commit suicide. When people are going to their house of worship, they are not thinking of suicide as a problem. People are worried that violence is going to enter their house of worship. These things are more of a pressing social problem.

Believe me, nobody is advocating for more people to die from guns, but I also think it is important that we be honest about why most people die from gun violence, and that is suicide.

Dr. Lichtin: The Hippocratic oath commands physicians to primum non nocere, above all else do no harm. But one can do harm by omitting a voice in a public discussion. I think we are both saying the same thing: There is nothing in the Hippocratic oath pertaining to gun violence exactly, but physicians should always advocate for a safer society.

Dr. Scott: Yes, the first written record of the Hippocratic oath is from A.D. 275, so of course there was nothing mentioned regarding gun control. And, from a larger social perspective, should physicians be involved in population health? Absolutely. I would not argue against that. It is an important area of research. It contributes to large changes in care, delivery of care, and quality of life. I do believe that physicians have a social obligation to improve population health.

But, at the end of the day, people have different thoughts and ideas. As people who are involved in science and research, we should be prepared for the fact that people don’t always agree. No one who has goodness in their heart wishes for more death from gun violence.

References

1. American College of Physicians press release. ACP Calls for Sweeping New Policies to Keep Guns Away From Those a Threat to Themselves, Others. October 30, 2018. Accessed July 3, 2019, from https://www.acponline.org/acp-newsroom/acp-calls-for-sweeping-new-policies-to-keep-guns-away-from-those-a-threat-to-themselves-others.
2. National Rifle Association Twitter account, November 7, 2019. Accessed July 3, 2019, from https://twitter.com/nra/status/1060256567914909702?lang=en.
3. Schuur JD, Decker H, Baker O. Association of physician organization-affiliated political action committee contributions with US House of Representatives and Senate Candidates’ stances on firearm regulation. JAMA Netw Open. 2019;2:e187831.
4. Brown University press release. Doctor-affiliated PACs fund political candidates who oppose firearm safety policies. Accessed July 3, 2019, from https://www.brown.edu/news/2019-02-22/firearmsafety.
5. Weinberger SE, Hoyt DB, Lawrence HC 3rd, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6.
6. Centers for Disease Control and Prevention. National Center for Health Statistics. Suicide and Self-Inflicted Injury. Accessed July 3, 2019, from https://www.cdc.gov/nchs/fastats/suicide.htm.
7. 104th Congress. Public Law 104-208. Accessed July 3, 2019, from https://www.gpo.gov/fdsys/pkg/PLAW-104publ208/pdf/PLAW-104publ208.pdf.
8. DeMario VM, Sikorski RA, Efron DT, et al. Blood utilization and mortality in victims of gun violence. Transfusion. 2018;58:2326-34.
9. Suicide Prevention Resource Center. Costs of suicide. Accessed July 5, 2019, from https://www.sprc.org/about-suicide/costs.
10. The Atlantic. The Disturbing Trend Behind America’s Soaring Gun Deaths. Accessed July 6, 2019, from https://www.theatlantic.com/health/archive/2018/12/gun-deaths-city-murders-suicides/578812/.