Dr. Margulies Mentors the American College of Emergency Physicians—Part 3

(from drgo.us)

(from drgo.us)

[Editor:  Dr. Margulies’ shares his thoughts about the whole frustrating experience with ACEP.  He refers to the letter he sent ACEPNow August 2, in response to their invitation for members to contribute to the discussion begun in the ACEPNow debate.] 

My letter was written in response to a biased discussion of firearms in the weekly ACEPNow. Shortly after that, the then president of ACEP issued a highly disparaging statement about police in the United States. That was promptly retracted after an intense response by the ACEP Section on Tactical Medicine.

Many of us in that section are emergency physicians or trauma surgeons, and commissioned police officers.  The second release was written by a member of the Tactical Section and approved by the Section by acclamation.

This pattern reflects attitudes that echo policy statements that have been released by the American Academy of Pediatrics, the American College of Internal Medicine and the American Academy of Family Physicians. All have been advocating the elimination of firearms from honest citizens. The political left is making the statement that violence in the United States is a firearm problem. Their proposed solution is to impose obstructions and sanctions on the honest citizens who own and use firearms legally. Firearms ownership is an enumerated constitutional right, and the infringements are all being imposed upon honest citizens.

We daily see apprehension of criminals with firearms. Are these firearms owned in compliance with already existing laws? Of course not.  Criminals do not obey existing laws. They are criminals. Honest citizens do obey the law. We pay for our firearms and ammunition, but criminals do not. We have laws against the misuse of firearms. Armed robbery, murder, forcible rape, firearms intimidation, etc., are all illegal. When criminals commit these crimes, why are they not swiftly removed from society? It is only honest people occasionally making mistakes who seem to be prosecuted and make the news. It is notable that the recent presidential commutations and pardons, ostensibly for those who have misused drugs, include more than 20% who also feloniously possessed or used firearms while misusing illicit substances.

Suicide is a serious problem but not just for the reasons usually touted. There are approximately 22,000 firearm suicides in the United States each year. Since these are intentional and the perpetrators only hurt themselves, laws against suicide are not practical.  A law that cannot be prosecuted or enforced is folly.

Firearms are a more efficient way to suicide than other potentially more reversible methods.  But intent matters more. 44,000 other Americans who suicide choose other methods. People kill themselves with knives, medications, illicit substances, automobiles, aircraft, ropes and almost anything that the human mind can conceive of.  The concern is for the mental state of the individual.

The remaining firearms associated deaths fall into three categories. The first is accidental deaths due to firearms, which have been constantly decreasing over the past 30 years, as the number of legal civilian firearms has more than tripled. It would be wonderful if we were able to eliminate all accidents. Motor vehicle accident reduction is frequently cited as a model.  But we see that despite all of the technological safety advances regarding motor vehicles that have been made in the past 30 years, the recent reduction in number of deaths involving motor vehicles seems to have been related more to the number of miles driven than to the safety devices.

We also know that many motor vehicle crashes are the result of misuse of intoxicants, of other distractions or are masked suicides. That is no reason to remove safety devices from motor vehicles, but it makes the point that the human factor is key, not the tool.  It is a serious conflict that society accepts increased risk from motor vehicle accidents by allowing intoxicants to be used.  Despite all the laws against drug and alcohol use and texting while driving, those deadly behaviors continue.

That brings us to the next category of firearms associated deaths. These are the legal uses, both lawful personal self-defense and justified shootings by police. That takes them out of the discussion, unless we plan to have an unarmed police and civilian population, leaving everyone to the mercies of criminals.

The last group of firearm-associated deaths is those that occur when criminals use guns. We know that criminals do not usually obtain firearms by passing background checks and purchasing them legally. In countries such as France, Germany, the United Kingdom and Australia, which have very strict firearm laws, civilians are vigorously prosecuted who have no malicious intent.  Yet criminals and terrorists seem to bypass such laws easily. Laws do not prevent crimes or acts of terror. Laws just prescribe penalties for violation if one is caught, prosecuted and convicted.

In the United States, we find that the politicians frequently use the term “children” with firearms. The CDC breaks the term “children” into several age categories. One of these is 14 to 18 years. Most of these turn out to be our 14 to 18 or 19-year-old gang members who for the most part use firearms against each other and the families of other gang members. Unfortunately, innocent people are too often victims in gang shootings.

It is important to know that I was asked to remove one fact from my letter.  I did, so that it would be published. That fact is that our society contains small populations that are disproportionately responsible for crime. In many cases that crime involves the use of firearms. It is not politically correct, but it is accurate to state that most firearms deaths in the United States occur in several inner-city environments, and are predominantly black on black crime using firearms. We also have a very serious drug gang problem which in many cases involves Mexican-origin gangs in turf wars.

If we cannot state facts, we are going to see the continuation of what is an extraordinary increase in firearm crime in Chicago, Baltimore, Cleveland, Houston, Milwaukee, Nashville, and Washington, D.C.

I find it appallingly that leaders of medical societies pontificate irrationally on subjects they don’t understand and haven’t experience. They are simply grandstanding.  Since most firearms deaths are intentional, as in suicide or crime, there is no reason to increase infringement on honest people.

As physicians, we are supposed to be grounded in science and social ethics. Science does not provide any reason for increasing the already onerous requirements on people who wish to legally own and use firearms. The ethical question revolves around whether or not we should seek to eliminate firearms from society. That was a failed experiment in the countries noted above and in many other cases in fairly recent history. This includes the massacres that occurred in the Soviet Union after firearms were confiscated from civilians; in the Mideast around World War 1 when the Turks massacred disarmed Armenian subjects; during World War II when the Germans eliminated populations they conquered and disarmed; and more recent events in Cambodia and in Rwanda. The only reason to disarm the citizenry is to control the disarmed.

That leaves us with the question of how physicians should be involved in these issues, especially psychiatric issues that may risk patients hurting themselves or others. As an emergency physician who has treated many psychiatric patients, I find I cannot do much to help the psychotic except with medications and by arranging psychiatric help for them. I can ask reasonable questions and provide helpful advice to non-psychotic patients. For those of my colleagues who do not have experience with psychiatric patients, I suggest correcting that deficit. That allows us to ask questions and sometimes provide helpful advice in a non-invasive, non-threatening manner.

If physicians wish to discuss firearms with patients, they need to become knowledgeable and experienced in the practical and legal arenas that they are entering.  Grandstanding is neither scientific nor ethical, and doesn’t help anyone.


RobertM—Robert A. Margulies, MD, MPH, FACEP, FACPM is an emergency medicine specialist, retired Navy Medical Corps captain, sworn peace officer, and firearm trainer with multiple certifications from the NRA and the Massad Ayoob Group.

All DRGO articles by Robert A. Margulies, MD, MPH.