Firearm-Related Injury and Death in the United States

This article was originally published in Annals of Internal Medicine, published by the American College of Physicians (ACP). This article is copyrighted by ACP and reprinted with the express written permission of ACP. Any further use or reproduction of this article in whole or in part requires the copyright permission of ACP (permissions@acponline.org): Weinberger SE, Hoyt DB, Lawrence HC, Levin S, Henley DE, Alden ER, 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;162:513–516. For the full article includingreferences, author information, conflict disclosures, comments, and related articles go to: http://annals.org/aim/article/2151828/firearm-related-injury-death-united-states-call-action-from-8.

Abstract

Deaths and injuries related to firearms constitute a major public health problem in the United States. In response to firearm violence and other firearm-related injuries and deaths, an interdisciplinary, interprofessional group of leaders of 8 national health professional organizations and the American Bar Association, representing the official policy positions of their organizations, advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal back ground checks of gun purchasers, elimination of physician “gag laws,” restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths. The health professional organizations also advocate for improved access to mental health services and avoidance of stigmatization of persons with mental and substance use disorders through blanket reporting laws. The American Bar Association, acting through its Standing Committee on Gun Violence, confirms that none of these recommendations conflict with the Second Amendment or previous rulings of the U.S. Supreme Court.

Across the United States, physicians have first hand experience with the effects of firearm-related injuries and deaths and the impact of such events on the lives of their patients. Many physicians and other health professionals recognize that this is not just a criminal violence issue but also a major publichealth problem

Because of this, we, the executive staff leader ship of 7 physician professional societies (whose members include most U.S. physicians), renew our organizations’ call for policies to reduce the rate of firearm injuries and deaths in the United States and reiterate our commitment to be a part of the solution in mitigating these events. We represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, and the American Bar Association (ABA), which is committed to helping lawyers and the public understand that the Second Amendment does not impede reasonable measures to limit firearm violence, join the physician organizations in articulating the principles and consensus-based recommendations summarized herein.

The recommendations presented here are based substantially on the various positions approved and adopted by our organizations.

Background

In the United States, firearm-related deaths and injuries are a major public health problem that requires diligent and persistent attention. Each year, more than 32,000 persons die as a result of firearm-related violence, suicides, and accidents in the United States; this rate is by far the highest among industrialized countries. Firearms are the second-leading cause of death due to injury after motor vehicle crashes for adults and adolescents. What’s more, the number of nonfatal firearm injuries is more than double the number of deaths. Although much attention has been given to the mass shootings that have occurred in the United States in recent years, the 88 deaths per day due to firearm-related homicides, suicides, and unintentional deaths are equally concerning.

Approximately 300 million guns are owned by U.S. civilians, ranking the United States first among 178 countries in terms of the number of privately owned guns. Although some persons suggest that firearms provide protection, substantial evidence indicates that firearms increase the likelihood of homicide or, even more commonly, suicide. Access in the home and general access to firearms have also been shown to increase risk for suicide among adolescents and adults. This violence comes at a substantial price to our nation, with a total societal cost of $174 billion in 2010.

Our organizations support a public health approach to firearm-related violence and prevention of firearm injuries and deaths. Similar approaches have produced major achievements in the reduction of tobacco use, motor vehicle deaths (seat belts), and unintentional poisoning and can serve as models going forward. Along with our colleagues in law and public health, those of us who represent the nation’s physicians are aware of the significant political and philosophical differences about firearm ownership and regulation in the United States, but we are committed to reaching out to bridge these differences, with the goal of improving the health and safety of our patients and their families. We strongly support a multifaceted public health approach.

To reduce firearm-related injuries and deaths, it is essential to address culture, firearm safety, and regulation that maximizes safety while being consistent with the Second Amendment. In addition, improving the diagnosis and treatment of persons with mental and substance use disorders is critical, especially because of the risk for firearm-related suicides in persons with these conditions. However, we believe that efforts to address firearm-related violence should focus on reducing availability to persons who may pose a threat to themselves or others and not simply single out persons with any mental or substance use disorder.

On the basis of this background and our organizational policies, we believe that the following recommendations appropriately integrate the multidisciplinary perspectives of medical, public health, and legal professionals.

Background Checks for Firearm Purchases

Our organizations strongly support requiring criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, and private sales between individuals. Although current laws require background checks at gun stores, purchases at gun shows do not require such checks. This loophole must be closed. In 2010, of the 14 million persons who submitted to a background check to purchase or transfer possession of a firearm, 153 000 were prohibited purchasers and were blocked from making a purchase. Background checks clearly help to keep firearms out of the hands of persons at risk for using them to harm themselves or others. However, 40% of firearm transfers take place through means other than a licensed dealer; as a result, an estimated 6.6 million firearms are sold annually with no background checks. The only way to ensure that all prohibited purchasers are prevented from acquiring firearms is to make background checks a universal requirement for all gun purchases or transfers of ownership.

Physician “Gag Laws”

Patients trust their physicians to advise them on issues that affect their health, and physicians can answer questions and educate the public on the risks of firearm ownership and the need for firearm safety. Often, these confidential conversations occur during regular examinations and are a natural part of the patient–physician relationship. Because of this, our organizations oppose state and federal mandates that interfere with physician free speech and the patient–physician relationship, including laws that forbid physicians to discuss a patient’s gun ownership.

When appropriate, physicians can intervene with patients who are at risk for injuring themselves or others due to firearm access. To do so, physicians must be allowed to speak freely to their patients in a nonjudgmental manner about firearms, provide patients with factual information about firearms relevant to their health and the health of those around them, fully answer their patients’ questions, and advise them on the course of behaviors that promote health and safety without fear of liability or penalty. Physicians must also be able to document these conversations in the medical record as they are able and required to do with discussion of other behaviors that can affect health.

Mental Health

Although mental and substance use disorders in and of themselves are only a small factor in societal violence, they can be a significant factor in firearm-related suicide. Access to mental health care is critical for all persons who have a mental or substance use disorder. The health professional organizations represented in this article support improved access to mental health care and caution against broadly including all persons with any mental or substance use disorder in a category of persons prohibited from purchasing firearms. We also support adequate resources to facilitate coordination among physicians and state, local, and community-based behavioral health systems so they can provide care to patients, raise awareness, and reduce social stigma.

Early identification, intervention, and treatment of mental and substance use disorders would reduce the consequences of firearm-related injury and death. The overall proportion of violent acts committed by persons with mental or substance use disorders is relatively low, and those who receive adequate treatment from health professionals are less likely to commit acts of violence. Reducing firearm-related violence and suicide requires keeping firearms out of the hands of persons who may harm themselves or others, but it is important that restrictions be applied appropriately by limiting access to such individuals rather than limiting access solely on the basis of a mental or substance use disorder.

Reporting Laws

Blanket reporting laws that compel physicians and other health professionals to report patients who are displaying signs that they might cause serious harm to themselves or others may have unintended consequences. They can stigmatize persons with mental or substance use disorders, create a disincentive for them to seek treatment, and undermine the patient–physician relationship. The health professional organizations represented in this article urge legislators considering such proposals to do so in a way that protects confidentiality and does not deter patients from seeking treatment of a mental or substance use disorder. For persons whose right to purchase or possess a firearm has been suspended on grounds relating to a mental or substance use disorder, there should be a fair, equitable, and reasonable process established for restoration that balances the individual’s rights with public safety.

Assault Weapons

The need for reasonable federal laws, compliant with the Second Amendment, about “assault weapons” and large-capacity magazines has been debated recently. We believe that private ownership of military-style assault weapons and large-capacity magazines represents a grave danger to the public, as several recent mass shooting incidents in the United States have demonstrated. Although evidence to document the effectiveness of the Federal Assault Weapons Ban of 1994 on the reduction of overall firearm-related injuries and deaths is limited, our organizations believe that a common, sense approach compels restrictions for civilian use on the manufacture and sale of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. It seems that such restrictions could only reduce the risk for casualties associated with mass shootings.

Need for Research

As data-driven decision makers, we advocate for robust research about the causes and consequences of firearm violence and unintentional injuries and for strategies to reduce firearm-related injuries. The Centers for Disease Control and Prevention, National Institutes of Health, and National Institute of Justice should receive adequate funding to study the effect of gun violence and unintentional gun-related injury on public health and safety. Access to data should not be restricted, so researchers can do studies that enable the development of evidence-based policies to reduce the rate of firearm injuries and deaths in this nation.

Constitutionality of These Recommendations

These recommendations do not come solely from a group of health organizations without expertise in constitutional law but have been developed in collaboration with colleagues from the ABA, which has confirmed that these recommendations are constitutionally sound. For 50 years, the ABA has acknowledged the tragic consequences of firearm-related injury and death in our society and expressed strong support for meaningful reforms to the nation’s gun laws, as well as for other measures designed to reduce gun violence that do not fall under Second Amendment scrutiny. Because the courts have repeatedly held that the Second Amendment is consistent with a wide variety of laws to reduce gun-related deaths and injuries in our nation (yet confusion exists among the public about whether the Second Amendment is an obstacle to sensible laws), one mission of the ABA has been to educate its members, as well as the public at large, about the true meaning and application of the Second Amendment.

The Supreme Court, in its controlling 2008 decision, District of Columbia v. Heller, concluded that Second Amendment rights are not unlimited with regard to who may possess firearms, what kinds of firearms they may possess, or where they may possess them. The Court made clear that the Second Amendment should not be understood as conferring a “right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose”; identified a nonexhaustive list of “presumptively lawful regulatory measures”; and noted that the Second Amendment is consistent with laws banning “dangerous and unusual weapons” not in common use, such as firearms that are most typically used by the military.

Further, after Heller, more than 900 court decisions have upheld a wide variety of regulations to reduce gun violence, and only a few rulings have struck down certain types of firearm laws. No ruling of the Supreme Court (or any other court, for that matter) calls into question any of the specific proposals that we recommend.

Conclusion

We believe that multidisciplinary, interprofessional collaboration is critical to bringing about meaningful changes to reduce the burden of firearm-related injuries and death on persons, families, communities, and society in general. We are committed to working with all stakeholders to find effective solutions through reasonable regulation to keep firearms out of the hands of persons who are at risk for using them to intentionally or unintentionally harm themselves or others, as well as prevention, early intervention, and treatment ofmental and substance use disorders.