AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2001, Volume 3, Number 10.

Perspectives

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Through the Physician's Eyes: AMA President's Inaugural Address, 2001

Commemorative Issue: Strengthening the Social Contract

Richard F. Corlin, MD

With the preponderance of weapons these days, it comes as no surprise that gun violence--both self-inflicted and against others--is now a serious public health crisis. No one can avoid its brutal and ugly presence. No one. Not physicians. Not the public. And most certainly not the politicians--no matter how much they might want to.

Now my speech today is not a polemic. It is not an attack on the politics or the profits or the personalities associated with guns in our society. It isn't even about gun control. I want to talk to you about the public health crisis itself and how we can work to address it, in the same way we have worked to address other public health crises such as polio, tobacco, and drunk driving.

At the AMA, we acknowledged the epidemic of gun violence when, in 1987, our House of Delegates first set policy on firearms. The House recognized the irrefutable truth that "uncontrolled ownership and use of firearms, especially handguns, is a serious threat to the public's health inasmuch as the weapons are one of the main causes of intentional and unintentional injuries and death." In 1993 and 1994, we resolved that the AMA would, among other actions, "support scientific research and objective discussion aimed at identifying causes of and solutions to the crime and violence problem." Scientific research and objective discussion because we as physicians are--first and foremost--scientists. We need to look at the science of the subject, the data, and--if you will--the micro-data, before we make a diagnosis. Not until then can we agree upon the prognosis or decide upon a course of treatment. First, let's go straight to the science that we do know. How does this disease present itself? Since 1962, more than a million Americans have died in firearm suicides, homicides and unintentional injuries. In 1998 alone, 30,708 Americans died by gunfire.

Now, we don't regulate guns in America. We do regulate other dangerous products like cars and prescription drugs and tobacco and alcohol--but not guns. No federal agency is allowed to exercise oversight over the gun industry to ensure consumer safety. In fact, no other consumer industry in the United States--not even the tobacco industry--has been allowed to so totally evade accountability for the harm their products cause to human beings. Just the gun industry. In a similar pattern to the marketing of tobacco, which kills its best customers in the United States at a rate of 430,000 per year, the spread of gun-related injuries and death is especially tragic when it involves our children. Like young lungs and tar and nicotine, young minds are especially responsive to the deadliness of gun violence.

I want you to imagine with me a computer game called "Puppy Shoot." In this game puppies run across the screen. Using a joystick, the game player aims a gun that shoots the puppies. The player is awarded 1 point for a flesh wound, 3 points for a body shot, and 10 points for a head shot. Blood spurts out each time a puppy is hit, and brain tissue splatters all over whenever there's a head shot. The dead puppies pile up at the bottom of the screen. When the shooter gets to 1000 points, he gets to exchange his pistol for an Uzi, and the point values go up.

If a game as disgusting as that were to be developed, every animal rights group in the country, along with a lot of other organizations, would protest, and there would be all sorts of attempts made to get the game taken off the market. Yet, if you just change puppies to people in the game I described, there are dozens of them already on the market, sold under such names as "Blood Bath," "Psycho Toxic," "Redneck Rampage," and "Soldier of Fortune." These games are not only doing a very good business, they are also supported by their own Web sites. Web sites that offer strategy tips, showing players how to get to hidden features like unlimited ammunition, access more weapons, and something called "first shot kill," which enables you to kill your opponent with a single shot.

We do not let the children who play these games drive because they are too young. We do not let them drink because they are too young. We do not let them smoke because they are too young. But we do let them be trained to be shooters at an age when they have not yet developed their impulse control and have none of the maturity and discipline to safely use the weapons they are playing with. Perhaps worst of all, they do this in an environment in which violence has no consequences. These kids shoot people for an hour, turn off the computer, then go down for dinner and do their homework.

If this was a virus--or a defective car seat or an undercooked hamburger--killing our children, there would be a massive uproar within a week. Instead, our capacity to feel a sense of national shame has been diminished by the pervasiveness and numbing effect of all this violence. We all are well aware of the extent of this threat to the nation's health. So why doesn't someone do something about it? Fortunately, people are. People we know, people we don't know, and people we have only heard about are working hard to abolish the menace of gun violence--of all forms of violence--from the American scene.

The question remains: what are we, the physician community, going to do about it? I can tell you first what we're not going to do. We're not going to advocate changing or abolishing the Second Amendment to the Constitution. We really don't have to, to make our point.The gun lobby loves to use the Second Amendment as a smokescreen to hide the reality of the damage that guns do and to prevent our looking any deeper into the facts and statistics of that damage. We've all heard that tired old statement: guns don't kill people--people kill people. But how does that explain these facts? A gun kept in the home for self-defense is 22 times more likely to be used to kill a family member or a friend than an intruder. The presence of a gun in the home triples the risk of homicide and increases the risk of suicide fivefold. We, the American Medical Association, are going to take a different route--not just calls for advocacy, but for diplomacy and for statesmanship and for research as well. And make no mistake about this: We will not be co-opted by either the rhetoric or the agendas of the public policy "left" or "right" in this national debate about the safety and health of our citizens. One of the ways we will do this is to help assemble the data. Current, consistent, credible data are at the heart of epidemiology. What we don't know about violence--and guns--is literally killing us. And yet, very little is spent on researching gun-related injuries and deaths. A recent study shows that for every year of life lost to heart disease, we spend $441 on research. For every year of life lost to cancer, we spend $794 on research. Yet for every year of life lost to gun violence, we spend only $31 on research--less than the cost of a taxi ride here from the airport.

That's bad public policy. It's bad fiscal policy. And it certainly is bad medical policy. If we are to fight this epidemic of violence, the Centers for Disease Control must have the budget and the authority to gather the data we need. The CDC is intent on doing its job and is now heading up the planning for a National Violent Death Reporting System--coordinated and funded at the federal level--and collecting data at the state level. Because knowing more about the who, what, when, where, why and how of violent homicides, suicides, and deaths will help public health officials, law enforcement, and policy makers prevent unnecessary deaths.

We will not advocate any changes at all based on urban legend, anecdote or hunch. We will only base our conclusions on evidence-based data and facts. It's just good, common sense--the kind of solid epidemiology that has been brought to bear on other public health hazards, from Legionnaire's Disease to food-borne illnesses to exposure to dioxin or DDT. Trustworthy science that can help us prevent harm before it happens.

For, as we physicians know, prevention is usually the best cure. One of the giants of American medicine, Dr. William Osler, proposed using preventive medicine against serious public health threats like malaria and yellow fever. And the tools he advocated--education, organization and cooperation--sound like a pretty good definition of diplomacy to me. We will put these same tools to use in removing the threat of gun violence from our society.

People have told me that this is a dangerous path to follow. That I am crazy to do it. That I am putting our organization in jeopardy. They say we'll lose members. They say we'll be the target of smear campaigns. They say that the most extremist of the gun supporters will seek to destroy us. But I believe that this is a battle we cannot not take on.

While there are indeed risks, the far greater risk for the health of the public, for us in this room, and for the AMA, is to do nothing. We, as physicians and as the American Medical Association, have an ethical and moral responsibility to do this, as our mission statement says, "to promote the science and art of medicine and the betterment of public health." If removing the scourge of gun violence isn't bettering the public health--what is? As physicians, we are accustomed to doing what is right for our patients and not worrying about our comfort, ease or popularity. Our goal is to help cure an epidemic, not to win a victory over some real or imagined political enemy. Anyone who helps us in this fight is an ally--anyone.

We don't pretend to have all the answers. Nor do we expect the solution to be quick, and we certainly don't expect it to be easy. In fact, I am certain that we will not reach the solution during my term as your president. But together as the American Medical Association--guided by our stated mission--we recognize our obligation to contribute our voice, our effort and our moral imperative to this battle. And we will.

Almost a century ago, in his book Confessio Medici, Stephen Paget, the British physician and author, referred to medicine as a divine vocation. This is part of what he said:

Every year young people enter the medical profession . . . and they stick to it . . . not only from necessity, but from pride, honor, and conviction. And Heaven, sooner or later, lets them know what it thinks of them. This information comes quite as a surprise to them . . . that they were indeed called to be doctors. . . . Surely a diploma . . . obtained by hard work . . . cannot be a summons from Heaven. But it may be. For, if a doctor's life may not be a divine vocation, then no life is a vocation, and nothing is divine [2].

We are here today as the guardians of that divine vocation and as such are dedicated to do what is right, whether or not it is comfortable, whether or not it is easy, and whether or not it is popular.

Stephen Paget, you can rest well tonight. Your divine vocation is in good hands. We will guard it well. We will live up to our mission--we will do what is right.



References

  1. Excerpted from Dr. Corlin's Presidential Inaugural Address, presented at the AMA Annual Meeting, June 20, 2001, Chicago, IL
  2. Paget S. Confessio Medici. London: MacMillan & Co.; 1909.

Questions for Discussion

In the face of a serious threat to the health of the public, is the individual physician obligated to support the position taken by his or her professional association? Are professional responsibilities acts that we "must do" or acts that we should "try to do?"

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