From the Editor
Jan 2018

Violence as a Public Health Crisis

Lilliana Freire-Vargas
AMA J Ethics. 2018;20(1):25-28. doi: 10.1001/journalofethics.2018.20.1.fred1-1801.


Violence, overall, has become a public health crisis. The three leading causes of death in the United States for people ages 15-34 are unintentional injury, suicide, and homicide [1]. These violent deaths are, more often than not, directly associated with firearms. The US has a homicide rate 7 times higher than other high-income countries, with homicides committed by firearms being 25 times higher than in other high-income countries [2].

According to the National Violent Death Reporting System, violence is preventable [3]. Supportive relationships can decrease violent behaviors and disrupt a “cycle of violence” [4]. Education on life skills and conflict resolution at an early age can also prevent violence [5]. The Centers for Disease Control and Prevention (CDC) states, “By understanding … types of violence, we can take action to stop them before they start in our communities” [6].

This issue of the AMA Journal of Ethics examines the scope of physicians’ duty to support and counsel patients afflicted by any form of violence, as well as other ethical questions raised in the course of responding to victims of violence and preventing violence. The case commentaries and articles are meant to increase readers’ awareness of, and to provide guidance on, violence as an epidemic with features of ethical, clinical, and public health relevance.

According to Gary Slutkin, violence should be treated as a disease [7]. In this issue, he and Charles Ransford and Daria Zvetina explore the analogy between violence and contagious processes. If violence is a disease, then physicians need to step in and provide preventative care, especially since physicians are among the first professionals victims present to, if they choose to seek treatment at all [8]. In the podcast, Slutkin discusses what would it mean to treat violence —including mass shootings—primarily as a health problem, while Robert Torres describes the health impact of violence within communities in Chicago. But physicians also need to respond to violence on an interpersonal and ecological level. Anita Ravi explores how drawing comics has helped her to provide more sensitive care to survivors of sexual trauma. And Bandy X. Lee and John L. Young discuss the need to focus on “caring well” to reduce violence in our communities.

Research indicates that some physicians feel unqualified to hold conversations with patients about gun violence and safety protocols [9], despite feeling ethically obligated to do so. Nicole D. Damari, Karan S. Ahluwalia, Anthony J. Viera, and Adam O. Goldstein present the results of a survey demonstrating that continuing medical education in firearm safety increases physicians’ confidence in their ability to counsel their patients on the topic. And Alexander D. McCourt and Jon S. Vernick discuss legal and ethical concerns that tend to arise when speaking to patients about firearm storage, transfer, and safety.

Intimate partner violence has been a public health issue since the 1960’s [10]. A World Health Organization multi-country study found that the prevalence of intimate partner violence for women is 15 to 71 percent [11]. Rape is now known to occur more frequently than reported, with only 36 percent of victims reporting to police [12]. Reasons for not reporting include victims’ lack trust in the justice system or not wanting others to know [13]. Michelle Bowdler and Hannah Kent discuss a sexual assault case involving a minor and argue that any victim of sexual assault should be allowed to refuse forensic-related treatment, even if the victim’s legal guardian disagrees. And Melinda Manning discusses how institutions that train medical students and residents can fulfill their Title IX obligations to resolve allegations about sexual discrimination in ways that support trainees who have been victimized.

Three articles discuss physicians’ roles in working with community services and law enforcement to prevent gun violence. Amy Barnhorst, Garen Wintemute, and Marian E. Betz examine the conflict between mandatory reporting requirements and the need to protect patient confidentiality in a case of a firearm-owning patient who might pose a danger to himself and others. Jennifer L. Piel and Rejoice Opara show how the Washington State case of Volk v DeMeerleer, which arguably encourages clinicians to breach confidentiality by broadening the definition of potential victims, conflicts with the AMA Code of Medical Ethics’ opinions on clinicians’ ethical obligations to preserve patient confidentiality. Taking a normative position, Nora Jones, Jenny Nguyen, Nicolle K. Strand, and Kathleen Reeves argue that physicians should not serve as “gatekeepers” of gun privileges by assessing a patient’s fitness to carry a concealed weapon; rather, they suggest physicians should advocate for policies and interventions that reduce gun violence.

Injuries and deaths might be prevented if there were more education about gun safety protocols, but studies are not being conducted with federal funds, as Congress has ensured that no Centers for Disease Control and Prevention funds can be applied toward gun violence research [14]. Kelsey Hills-Evans, Julian Mitton, and Chana A. Sacks focus on the need to develop gun safety guidelines and violence risk assessment tools while also discussing the importance of resuming and continuing research on the implementation of gun violence prevention interventions in clinical practice.

Finally, two contributions to this issue address representations of violence. Jessica C. Tomazic, Joy O. Ogunmuyiwa, and Gretchen A. Ferber examine how physicians, with their intimate awareness of the vulnerabilities of patients with mental illness and their caregivers, can help to combat popular misconceptions of the mentally ill as violent by promoting stories of mental illness recovery. Finally, Dino Maglic explores how clinicians—such as the University of Utah Hospital nurse Alex Wubbels—serve patients well by protecting those patients’ rights, even when doing so puts them in harm’s way.

This issue brings attention to the ethical dilemmas clinicians encounter when responding to victims of violence. It seeks to provoke thought about the ethical, legal, and policy dimensions of violence reduction and prevention efforts, with the aim of helping clinicians to consider how to draw upon their social and cultural influence to promote patient- and community-centered policy and legislation.


  1. Centers for Disease Control and Prevention. 10 leading causes of death by age group, United States—2015. Updated May 2, 2017. Accessed September 27, 2017.

  2. Grinshteyn E, Hemenway D. Violent death rates: the US compared with other high-income OECD countries, 2010. Am J Med. 2016;129(3):266-273.
  3. Centers for Disease Control and Prevention. Violence prevention—National Violent Death Reporting System. Updated September 18, 2017. Accessed October 14, 2017.

  4. Jaffee SR, Bowes L, Quellet-Morin I, et al. Safe, stable, nurturing relationships break the intergenerational cycle of abuse: a prospective nationally representative cohort of children in the United Kingdom. J Adolesc Health. 2013;53(4 suppl):S4-S10.
  5. World Health Organization. Violence prevention: the evidence: preventing violence by developing life skills in children and adolescents. Geneva, Switzerland: World Health Organization; 2009. Accessed November 20, 2017.

  6. National Intimate Partner and Sexual Violence Survey. Facts everyone should know about intimate partner violence, sexual violence, and stalking. Centers for Disease Control and Prevention. Published September 2014. Accessed November 20, 2017.

  7. Slutkin G. Violence is a contagious disease. Cure Violence. Published May 2015. Accessed November 20, 2017.

  8. Weiss GG. Doctors vs domestic violence: yes, you can make a difference. Medical Economics. October 23, 2000. Accessed November 20, 2017.

  9. Pierson J, Viera AJ, Barnhouse KK, Tulsky JA, Richman BD, Goldstein AO. Physician attitudes and experience with permit applications for concealed weapons. N Engl J Med. 2014;370(25):2453-2454.
  10. Blair-Merritt MH. Intimate partner violence. Pediatr Rev. 2010;31(4):145-150.
  11. García-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. WHO Multi-country Study on Women’s Health and Domestic Violence against Women study team. Prevalence of intimate partner violence: findings from the WHO Multi-country Study on Women’s Health and Domestic Violence. Lancet. 2006;368(9543):1260-1269.
  12. Rennison CM. Rape and sexual assault: reporting to police and medical attention, 1992-2000. US Department of Justice Office of Justice Programs Bureau of Justice Statistics. Published August 2002. Accessed September 27, 2017.

  13. Cohn AM, Zinzow HM, Resnick HS, Kilpatrick DG. Correlates of reasons for not reporting rape to police: results from a national telephone household probability sample of women with forcible or drug-or-alcohol facilitated/incapacitated rape. J Interpers Violence. 2013;28(3):455-473.
  14. Omnibus Consolidated Appropriations Act of 1997, Pub L No. 104-208, 110 Stat 3009. Accessed November 20, 2017.


AMA J Ethics. 2018;20(1):25-28.



The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.