The Ethics and Politics of Gun Violence Research

Overview of Gun Violence

The United States has more guns (393 million) than people (327 million) and is arguably the most violent industrialized nations in the world. ¹ Among high-income countries, the United States accounts for >80% of all firearm deaths, with 86% of women and 87% of children (up to age 14) killed by firearms. ² From 1968 to 2015, the total firearm deaths in the United States (1.516 million) exceeded the combined casualty toll from all wars ever fought by the United States (1.396 million). ³

The Dickey Amendment, a rider to the 1996 federal spending bill, stymied gun violence research in the United States. From 1996 to 2018, Centers for Disease Control and Prevention (CDC) funding for gun injury prevention decreased 94%. ⁴ In 2011, the Congress took similar action impairing the National Institutes of Health's (NIH) ability to conduct gun violence research. The negative impact on firearm-related deaths is evident today.

Seven percent of American children live in a home with a loaded and unlocked firearm. ⁵ More than 2800 children are shot unintentionally, leading to 86 deaths from unintentional gunfire each year. ⁶ The toll from intentional gunshot wounds to children is even more staggering: >4800 children less than the age of 17 are intentionally shot each year, resulting in 1400 deaths. ⁶

In 2017 there were 39,773 adult deaths from gun violence in the United States. ⁷ There were 1543 deaths in the state of Illinois, 30% of which were in the city of Chicago. ⁸ However, these deaths do not represent the full burden of disease from gun violence. For every firearm death, there are two nonfatal firearm injuries. ⁹ Furthermore, it is nearly impossible to quantify the impact of psychological trauma on both those who directly suffer physical injury from gun violence and those who witness gun violence.

Gun violence is a public health epidemic that affects a multitude of people from all fabrics of society. Proponents addressing the root causes of gun violence cite this public health epidemic as reason enough to advocate for more federally funded research. As physicians, we cannot passively accept this and sit by idly while our patients die. Research must be performed on the root causes of gun violence and we must find evidence-based approaches to prevent unnecessary harm to the population. We posit that research to reduce firearm injuries and deaths is our ethical obligation to the American citizenry.

Physician-Led Public Health Campaigns

There has been a long history of physician-led public health campaigns leading to both research and legislation, and improving care of patients nationally by decreasing both mortality and morbidity. In the 1950s, physicians and surgeons increasingly recognized the danger that cars posed to the health of the American public and were among the first to raise concerns.^10,11 A growing awareness of the hazard posed by automobiles was bolstered by Ralph Nader's indicting book, Dangerous at Any Speed. ¹² By 1966, the Congress convened and passed the National Traffic and Motor Vehicle Safety Act, which created federally mandated safety standards for cars and driving. The National Highway Traffic Safety Administration was created and accelerated safety research efforts. Despite previous reluctance to intervene, the motor vehicle industry responded and began to enact measures such as improved seatbelt technology, child safety seats, and airbags that created safer cars. It has been estimated that >600,000 lives have been saved since 1960 because of vehicle safety technology. ¹³

Smoking and tobacco are another area where physician voices were instrumental to change. Throughout the 1920s to 1940s, smoking became progressively more popular in the United States. This was, in part, because of aggressive advertising campaigns by tobacco companies that glamorized smoking. The U.S. Army distributed cigarettes to soldiers during World War I and as soldiers came home to the United States, they continued to smoke. In the 1930s, physicians began informally recognizing an increase in lung cancer. Several correlative factors were initially suggested, but in 1939, Drs. Alton Ochsner and Michael DeBakey published a landmark article proposing that the inhalation of tobacco smoke lead to lung cancer. ¹⁴ A flurry of research followed.^15–17 However, owing to aggressive pushback from the tobacco industry, the impetus to change was not as easy as with motor vehicles. Nevertheless, physicians recognized their ethical responsibility not just to treat their patients, but also to understand the underlying pathophysiology through research. Initial data did not establish a clear link between the two, but by the 1950s, both retrospective studies and prospective cohorts were published linking the use of tobacco products to cancer. By 1964, there were overwhelming data prompting the Surgeon General of the United States to issue their report on “Smoking and Health.” ¹⁸ Legislation followed with the Labelling and Advertising Act that enforced warnings on cigarette packaging, increases in federal taxes on tobacco products, and the Family Smoking Prevention and Tobacco Control Act that limits tobacco marketing to minors. Since the Surgeon General's Report in 1964, an estimated 8 million lives have been saved because of tobacco research and tobacco control. ¹⁹

A more recent example of physician-led public health success has been the opioid epidemic. Throughout the 1990s and 2000s, there was an increase in opioid prescriptions and opioid addictions and opioid-related deaths. ²⁰ It may be difficult to argue that physicians are not partly responsible for this ongoing epidemic. However, lawsuits in multiple states against Purdue Pharma, Teva Pharmaceuticals, and Johnson & Johnson have argued that these companies aggressively marketed opioids to doctors to influence their opinions. Oklahoma was the first state to successfully sue pharmaceutical giant Johnson & Johnson for fueling the opioid epidemic, in large part by deceiving physicians about their product's potential for addiction. ²¹ In fact, recent data have shown that increased spending on these marketing campaigns was associated with increases in both opioid prescriptions and overdoses. ²² In the case of opioids, like motor vehicle and tobacco, data proved to be a powerful motivating tool. Public and social outcry fueled an increase in opioid research efforts and clinical practice changes. The American Medical Association formed an Opioid Task Force aimed at increasing physician education and decreasing overall opioid use. Their 2018 report showed a 22.2% decrease in the national rate of opioid prescription in the five preceding years. ²³

Gun Violence Research

The public health threat posed by gun violence should be analogous to motor vehicles, tobacco, and opioids. Despite its sharp increased lethality, there has been a dearth of research looking at the causes of and solutions to gun violence. However, gun violence research has not always been at a standstill. In 1993, Dr. Arthur Kellerman published a landmark article that assessed whether firearms in the home are protective or harmful. The study's multivariate analysis demonstrated that the presence of a firearm in the home was strongly associated with an increased risk of homicide within that home. This finding was not affected by gender, age, or race. In addition, owning and maintaining a gun at home did not demonstrate a protective benefit. ²⁴ The National Rifle Association (NRA) recognized the threat of decreased revenue and increased legislation. They launched an aggressive public relations campaign to reframe the issue and potentially bias the American public. The NRA shifted the focus to human factors rather than guns as the problem.

As the NRA lobbied more aggressively against gun control, the battle between gun research and gun rights moved to the Congress. In 1996, the Dickey Amendment, which was part of that year's Omnibus Consolidated Appropriations Bill, specifically stated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention (CDC) may be used to advocate or promote control.” ²⁵ Although the original intent of the bill may have been to ensure that federal funds were not used for lobbying purposes, in effect, the Dickey Amendment imposed fear upon the CDC and served to stifle gun research. In the following years, the CDC was stripped of nearly $2.6 million and the NIH offered no research funding awards to study gun violence.^26,27 Stark et al. studied this decline in funding in 2017 by comparing the predicted mortality rate for the top 30 causes of death in the United States versus their federal funding over an 11-year period. They found that gun violence research had 1.6% of the funding predicted for its mortality rate. ²⁸ Without funding, the collection and distribution of data are, at best, difficult. There were only 4.5% of the predicted rate of research publications studying gun violence in that 11-year period. ²⁸

As an ethical issue, it is highly concerning that private groups such as the NRA have the ability to lobby politicians to ban research into public health concerns that affect all Americans. Lobbying is the act of attempting to influence the actions, policies, or decisions of government officials such as legislators or members of regulatory agencies. The potential conflict of interest can lead to agent misdirection or the intentional failure of a legislator to represent the interests of their constituents. Federal lobbying has been in existence as early as 1869 in the United States for the purpose of supporting industry. ²⁹ Although lobbying has been considered by some as an extension of the First Amendment, in the contemporary era it is not enjoyed by the masses as a form of participatory democracy, but rather a right exercised mainly by corporate interest groups. Specific to firearms, the overall spending done by lobbying groups (1998–2018) for gun rights outpaces gun control groups by a factor of seven. ³⁰ Gilens and Page investigated which political players had the most influence over public policy in American politics. ³¹ On multivariate analysis, economic elites and business interests were found to have substantial independent impacts on U.S. government policy—because of lobbying. They found that average citizens and mass-based interest groups have little or no independent influence over public policy. Despite the poor having negligible influence over policymaking, they are disproportionately affected by gun violence. It remains to be seen if lobbying has been beneficial or detrimental overall to the public health of the American people. The question remains, in fact, whether lobbying and its industrial influences, are a threat to advancing public health initiatives. The lack of research into one of the most urgent public health issues of our time, gun violence, should be a matter of concern to all citizens.

The NRA's lobbying power was strengthened with the Citizens United landmark 2010 ruling of the Supreme Court, which granted corporations, nonprofits, and unions unlimited political spending power, federal election spending. ³² Only in 2018 has the NRA's spending been outpaced by the firearm violence prevention community given the shift in public opinion toward the NRA and internal financial difficulties. ³³ The NRA only represents 6%–7% of American gun owners. ³⁴ There is a broader opinion that the NRA is misdirected, as 59% of gun owners feel that the NRA has departed from its original purpose of promoting gun safety, and has been overtaken by lobbyists and the interests of gun manufacturers. ³⁵ Nonetheless, over the years the NRA has played a significant role in stifling research and continues to do so. The ability of a corporate lobbying group to effectively control and terminate the funding of research scientists in the United States is a larger issue that requires analysis. Academic freedom aside, the ability of corporate lobbying groups to influence health policy, now with unlimited federal election spending, represents a threat to public health. As with any other public health issue, funding for firearm prevention research must be made available to study its root causes and cannot be restricted by the lobbying of corporate, special interest groups.

Call for Research and Action

What does the future of gun violence research and control look like? Certainly in today's polarized political climate, actionable change will not happen without consensus. Research is needed to reach that political consensus. In 2013 after the Sandy Hook school mass shooting, President Obama signed an Executive Memorandum that seemed to open the door to conduct gun violence research. It stated that “the Centers for Disease Control and Prevention…shall conduct or sponsor research into the causes of gun violence and the ways to prevent it.” ³⁶ From 2007 to 2013, the National Institute of Justice awarded zero grants to study gun violence, but since a 2013 Executive Memorandum, 37 grants have been awarded. ³⁷ The 2018 Congressional Spending Bill seemed to clarify portions of the Dickey amendment by stating that “the Secretary of Health and Human Services has stated the CDC has the authority to conduct research on the causes of gun violence.” ³⁸ The American College of Surgeons Firearm Strategy Team (FAST) agreed that studies should address firearm safety, violence intervention and control, serious mental illness, and the root causes of violence. This research cannot happen without appropriate funding, and the FAST workgroup recognized that “research…must be federally funded at a level commensurate with the burden of the disease without restriction.” ³⁹

We know that gun violence research and legislation regulating the use of guns can be effective at reducing the totality of injury. Childhood access prevention (CAP) laws are one such example. These laws hold gun owners responsible for injury if their improperly stored firearm is used in a shooting. Recent data have shown that states with felony prosecution laws had lower rates of unintentional death from firearm than states with misdemeanor prosecution. ⁴⁰ In addition, research on the Federal Assault Weapons Ban, which was in place from 1994 to 2004, has shown that the ban period was associated with significantly fewer mass shooting-related deaths. ⁴¹

One hundred lives are claimed by firearm violence in the United States every day. ⁴² There is an urgent need to fund firearms research now. Despite the challenges and limitations of our academic freedom as trauma surgeons, we must mobilize both the political will and financial resources to address this issue. No human being remains untouched by gun violence in the United States. Gun violence is destroying the social fabric of our communities. From the structural violence of economically devastated urban communities throughout the United States to individuals affected by intimate partner violence and homicide, or hate-based mass shootings, suicide or nonintentional injury or death, individuals everywhere remain at risk. Gun violence has reached epidemic proportions in the United States. and we have no research on this issue that is commensurate to the damage it has caused society. The American College of Surgeons Committee on Trauma (ACS-COT) has a clear position statement on firearm injuries. They advocate approaching firearm violence as a public health issue while joining other national organizations in the pursuit of decreasing firearm fatalities and injuries. ³⁹ Although large databases in the United States include firearm-related fatalities and injuries, a comprehensive or dedicated firearm database to inform research is nonexistent. ⁴³ The burden for funding this important issue cannot rest simply with nonprofit organizations, universities, or individual states. A federal spending package is desperately needed to study the underpinnings of firearm violence and death in the United States.

Conclusion

Research is essential to developing data-driven solutions to public health epidemics, and gun violence is no exception. Physicians have long lent their voices to concerns of public health. ⁴⁴ As trauma surgeons, we have a unique perspective because of our daily work with the victims and survivors of gun violence. Downstream surgical intervention on the gunshot wounds of our patients is meaningless without upstream research into injury prevention. We must advocate for the health of our patients. Much like the physicians who worked to research motor vehicle accidents, tobacco, and opioids, we must fight for the fundamental gun research that will produce actionable change. If barriers exist to fulfilling this research mandate, owing to corporate lobbying efforts that block our academic freedom, surgeons have a duty to speak truth to power. It is our ethical responsibility as physicians to advocate for robust gun violence research to address this growing public health epidemic that claims tens of thousands of American lives a year.