“Happiness is a warm gun” Bioethics and Gun policy

1. “Happiness is a warm gun” Bioethics and Gun policy Steve Miles, MD Center for Bioethics, University of Minnesota Producer George Martin showed me the cover of a gun magazine saying “ 'Happiness Is a Warm Gun.’ I just thought it was a fantastic, insane thing to say. A warm gun means you just shot something.” ---John Lennon. b. October 9, 1940  d. December 8, 1980, 10:50 PM– Shot in the back at close range with 4 hollow-point bullets from a Charter Arms Undercover .38 Special.

2. Gun Violence: A Public Health Approach The link between Medical Ethics and Gun policy

3. a public Health Approach to Gun Violence? • Research who, when, and where of gun related injuries, considering the gun user, the gun, and the setting. • Identify factors associated with more / less risk of injury or death. • Risk factors are not “causes.” • Risk factors do not mean that a person always has morbidity. • Prevention decreases risk; it is not always successful. • Use lessons from other public health campaigns (e.g. tobacco, etc.) • Develop, demonstrate, implement morbidity prevention strategies. J Pub Hlth Pol 2001; 22:381-402.

4. NRA Tactically USES Anti-Science. Am J Pub Health study shows  risk to gun carrier who is assaulted- funded by Nat Instit Alcohol Abuse and Alcoholism. CDC funded studies in N Engl J Med show guns in home associated with homicide & suicide. 1992, 1993. 2009 1996 2013 2011 NRA successfully lobbies to instruct CDC: "None of the funds made available ... may be used to advocate or promote gun control.” Gun research  96%. NRA successfully lobbies to bar Bureau of Alcohol, Tobacco, Firearms and Explosives from using gun data to make conclusions about gun crimes. CDC research ban extended to Dept Health and Human Services agencies, (e.g. NIH).

5. “Our concern is not with legitimate medical science.” “Our concern is they were promoting the idea that gun ownership was a disease that needed to be eradicated.”

6. More GUN Households: More Gun Deaths. “The only way to stop a bad guy with a gun is with a good guy with a gun,” NRA Executive Vice President Wayne LaPierre. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.1286

7. Gun Deaths • 31,000 deaths per year. • 75,000 Emergency Room visits per year.

8. 39,000 total suicides Suicide

9. Suicide and Gun Ownership Rate of Non-Gun suicides Rate of Gun suicides Gun Ownership % of households Rate of All suicides Am J Epi 2013;178:946-55.

10. Suicide by Gun: Older, Male US Suicide: 7th cause of death for men, 15th for women. Charlton Heston, NRA President

11. higher risk of suicide in Gun Owning household not explained by More Mental Illness In the households. • People in homes with guns are no more likely to have anxiety, mood disorders, substance dependence, or suicidal ideation or planning. • Having made a suicide attempt over the previous year was the only mental health factor more common among people who lived in a home without firearms. • Injury Prevention. 15(3):183-7, 2009 Jun. Household survey of 9282 adults. Multivariate logistic regression analyses controlled for age, sex, race/ethnicity, educational attainment and poverty.

12. Suicide After Gun Purchase: • Suicide leading cause of death of handgun buyer during 1st year after purchase. • N Engl J Med 1999; 341:1583-9. • Background checks delayingacquisition of a gun in some studies decreasedeath by suicide. Months after Purchase

13. Teen Suicide: Accessand Impulse Southgate — 300 students, parents and staff gathered Thursday night for a vigil honoring an eighth-grader who shot himself to death. Police said he took the gun from a family member's home. The firearm, a .40 caliber Glock handgun, was legally registered. • Handguns used in most teen suicides. • Teen gun suicide attempts are 80-90% lethal. • Youth Suicide by Firearms Task Force. http://www.pbs.org/thesilentepidemic/riskfactors/guns.html • 80% of 14-19 year olds’ suicides take place at home. • A home with a handgun is 10 times more likely to have a teen suicide. Most guns owned by parents. • Suicide & Life-Threatening Behavior. 40(6):609-11, 2010 Dec. • Children who commit gun suicide have fewer risk factors for suicide, such as expressing suicidal thoughts.  Gun suicides appear more impulsive than suicide by other means. • Suicide and Life Threatening Behavior. 2004; 34:36-43.

14. When Guns leave Households: Fewer People, especially teens, Suicide. When there are guns in the home, womens’ risk of suicide increased 5 fold. Each 10% decline in percent of homes with children andguns, is associated with 8.3% drop in child firearm suicide. • Inj Prev. 2006 June; 12(3): 178–182. Multivariate population study, US. • See also: J Trauma 2007;62:1029-35. NB: Studies suggest that handguns are a greater risk than long guns and that guns stored unlocked are a greater risk than guns stored locked.

15. Prevalence of Guns and Prevalence of Gun Suicide. Fred Roff, Pres. Colt Firearms Data compiled by Gunpolicy.org Gun possession is per 100 left axis. Gun suicide are /100,000 persons on right axis.

16. Bottom Line: Suicide • Suicide is the most common lethal event with a gun. • The biggest risk factor for suicide by gun is having one in the house. • The availability of a gun potentiates the lethality of suicidal impulses.

17. Homicide

18. Homicide trends and weapon used. Bureau of Justice http://bjs.gov/content/pub/pdf/htius.pdf

19. Association between Household Gun-Ownership and Homicide rates. States with higher levels of household gun ownership had higher rates of firearm and overall homicide.  There is no association between gun prevalence and non-firearm homicide. SocSci & Med 2007 64;656 – 64., Multivariate analysis for rates of aggravated assault, robbery, unemployment, urbanization, alcohol consumption, and resource deprivation (e.g., poverty), genders and all age groups.

20. Guns and Intimate Murder Bureau of Justice http://bjs.gov/content/pub/pdf/htius.pdf

21. Guns and Intimate Murder • Gun owners are 8 times more likely to threaten their partners with a gun than non-gun owners.  • threaten to shoot them • threaten to shoot a pet or person the victim cares about, • cleaning, holding or loading a gun during an argument, • shooting a gun during an argument. • J Am Med Women Assn, 2005; 60:62-8. 8,000+ men in a batterer intervention program in MA, 1999-2003.  See also  Evaluation Review. 2006; 30:283-95.

22. Guns and Intimate Murder • Gun in the home: 3times more likely a person will be murdered by a family member or intimate partner. • Gun intimate assaults: 12 times more likely to result in death than non-firearm associated assaults. • http://www.silentwitness.net/sub/violences.htm 1,100

23. Prevalence of Guns and Prevalence of Gun Homicide. Fred Roff, Pres. Colt Firearms Data compiled by Gunpolicy.org Gun possession is per 100 left axis. Gun homicide are /100,000 persons on right axis.

24. Bottom Line: Homicide • Guns in homes • highly correlated with the risk they will be used for any homicide. • the most powerful predictor of domestic intimate violence becoming a homicide. • The availability of a gun potentiates the lethality of homicidal impulse.

25. 14,675 wounded but survive (1/5 under 19 years old). NCIPC GUN Accidents

26. Gun Accidents • Fatal gun accidents are 1% of all lethal home accidents(poisonings 43%, falls 34%, burns 9%). • BUT: 14,675 wounded but survive (1/5 under 19 years old). NCIPC • BUT: Preventable • Accidental lethal shootings 8 X more common in the 4 states with the most guns compared to the 4 states with the fewest guns • Acc Anal Prev 2001;33: 477-84. • Adults with a gun in the home have a 4 fold higher risk of dying of an accidental gunshot. • AccAnal Prev35(2003)711-716

27. 350 160 Children (<14 Years) Deaths per year Children

28. Relative Risk of Gun Homicide, Suicide and lethal Accident for 5 to 14 year olds in High and Low Gun states J Trauma2002; 52:267-75. Ratio of High Gun Sts to Low Gun Sts for Non-Gun deaths High Gun States are LA, AL, MS, ARK, WV Low Gun States are HI, MA, RI, NY, DEL 1

29. Gun deaths for Children • 5 to 14 year olds: US unintentional gun death rate 11 times higher than combined rates of 22 other high-income countries. • J Trauma 2011;70:238-43. • 2011: 2,886 children treated in ER for unintentional gun injury. • NCIPC • 0 to 4 year olds: gun deaths 17 times more common in high gun states than low gun states. • 5 to 14 year olds: gun deaths are 14 more common in high gun states than low gun states. • Acc Anal Prevent 2001;33: 477-84

30. Gun Locks: UNDERUSED Less than half of home guns are secured. Toddler shot in St. Paul as kids play with handgun PRICELESS CHEAP

31. Bottom Line: Child GUN Deaths • Guns in the home are the most powerful predictor of lethal gun accidents, suicides, and homicides of children.

32. Kokapo— rara avis Guns Prevent Victimization

33. Study cited by those who say Gun Possession is used to stop Crimes. Kleck, Gertz. J Crim Law Criminology 1995;86.150-87. • 222 of 4799 (which was 20% of total responding sample) reported at least one Defensive Gun Use (DGU) in 5 years. • After correcting for regional oversampling, this drops to 66 DGUs in preceding year, showing that 1.326% of adults nationwide had at least one DGU. • When multiplied by 1.478 (the number of DGUs reported per DGU claimant) and by the adult population, an estimate of 2.55 million DGUs/ year was calculated. Our survey was “free of the taint of being conducted by, and on behalf of, the federal government, and it was completely anonymous.”

34. From 2.55 million Defensive Gun Uses per year to…. Cato Institute. Tough Targets. 2012. 8 years of news clippings. • 277 reports where intend-ed victim disarmed criminal. • 25 armed rape attack victims got upper hand. • 65 armed carjack victims prevailed. • 11 out of 4,699 where criminal took gun away from a defender. Bureau of Justice http://bjs.gov/content/pub/pdf/htius.pdf

35. gun possession: protection in an assault? • Persons possessing a gun were 4.46 (P < .05) times more likely to be shot in an assault than those not possessing. • Among gun assaults where the victim had at least some chance to resist, this adjusted odds ratio increased to 5.45 (P < .05). • Am J Public Health. 2009 Nov;99(11):2034-40.

36. Bottom Line: Guns for self Protection from harm. • An armed citizen is vastly more likely to commit homicide or to suffer harm to him/her-self or those in his/her household than he/she is to benefit from gun protection.

37. The Doctor’s Office

38. American Academy of Pediatrics (paraphrased) • Pediatricians should counsel parents to guard access to their guns inside and outside the home. • Pediatricians should ask about presence and availability of firearms …and urge parents who possess guns to prevent access to these guns by children. • Clinicians should counsel parents of all adolescents to remove guns from the home or restrict access to them. This advice should be reinforced for patients with mood disorders, substance abuse problems (including alcohol), or a history of suicide attempts.

39. “The Affordable Care Act does not prohibit or otherwise regulate communication between doctors and patients, including about firearms.” • –White House “Doctors are being ordered, instructed to talk to patients and get information from them about gun ownership, where they are in their house, who has access to them, where the ammunition is kept.  Doctors are now "permitted” to do this. It makes 'em deputies, agents of the state.”

40. Minnesota LAWs: (in a D- Class) Gun Dealers Gun Owners • No permit to purchase or license to posses, no fingerprinting. • No duty to report thefts. • No ban on assault rifles, large clips. • No disarming of prohibi-ted handgun possessors. • No dealer license. • Dealers not required to retain records for guns /ammo sales. • No mandatory theft reporting, • No ID stamps on semi-auto handguns. • No bar on bulk sales of handguns. • No background checks on gunshows or interpersonal sales. • No mandated sale of locks with handguns.

41. Gun Death in Minnesota: the Headlines

42. Gun Death in Minnesota: the Rest of the Story

43. Gun Death in Minnesota: the Rest of the Story

44. http://data.huffingtonpost.com/2013/03/gun-deaths

45. Prevalence of Guns and Prevalence of Gun Death. Fred Roff, Pres. Colt Firearms Data compiled by Gunpolicy.org Gun possession is per 100 left axis. Gun homicide and suicide are /100,000 persons on right axis.

46. 4-year-old accidentally kills wife of a Tennessee sheriff's deputy 9:32 PM EDT, April 8, 2013 (CNN) -- A pistol in the hands of a 4-year-old boy went off during a cookout, killing the wife of a Tennessee sheriff's deputy who was showing his guns to a relative. The couple was hosting family and friends when Daniel Fanning and a relative went into a bedroom to check out some of Fanning's guns. Josephine Fanning and the boy walked into the room and at some point the boy picked the loaded pistol up off the bed. The gun was Fanning's personal weapon, not his service pistol. Slides Available on Request.Steven Miles, Miles001@umn.edu