Saturday, January 19, 2013

ONE PEDIATRICIAN'S RESPONSE TO SANDY HOOK

     I am a practicing Pediatric Cardiologist and a member of the American Academy of Pediatrics (AAP). I am also a member of the National Rifle Association.

     How do we, as Pediatric physicians, respond to a tragedy such as the shootings at Sandy Hook Elementary School? As advocates for children and as scientists we are obligated to look at the events of that day with a rational, fact-driven perspective, rather than an emotional, agenda-driven viewpoint.

     In the wake of the school shooting in Connecticut, Dr Tom McInerny, the president of the AAP called on President Obama and congressional leaders to enact federal legislation banning sales of “assault weapons” and “high capacity magazines” as a “necessary first step”.   As an individual member of the AAP, I beg to differ.  Actually, the first necessary step in solving a public health problem is agreeing upon a clear definition of the problem in terms of frequency, extent and impact. The next step is reviewing the existing body of knowledge. Theories of cause and effect should be explored and hypotheses developed based on existing data. These hypotheses should be tested in a way that allows for meaningful measurement of results while minimizing the effect of confounding variables. Those results are then subjected to review and independent testing in order to establish a degree of scientific acceptance. Even then, the results should rightly be viewed with an element of skepticism.

     So how can we develop strategies that are logical, practical and affordable, without infringing on the rights of law-abiding citizens, whether at the local, state or federal level? Looking at the existing body of public health research regarding gun legislation the first thing I notice is that the body of existing knowledge is skimpy at best. The Centers for Disease Control (CDC) Community Preventive Services Task Force did an extensive review of the existing public health research and found insufficient evidence to draw any conclusions about the effectiveness of gun legislation (Hahn RA, et al. Firearms laws and the reduction of violence: a systematic review.Am J Prev Med 2005;28(2S1):40-71).


     Large population-based studies attempting to measure a particular outcome (e.g. decreased gun violence) as a result of a particular intervention (e.g. ban on high capacity magazines) are incredibly difficult to achieve. They take a long time, and the ability to draw conclusions is hampered by the size of the population, the length of time needed, the inability to compare to a control group (comparable population that was not exposed to the intervention), as well as a multitude of confounding variables both recognized and unrecognized. A rational approach requires the ability to 
               1) define and measure outcomes, and
               2) make observations about cause and effect
Neither of these is very likely in the case of a blanket federal policy. Going off half-cocked without a measurable goal is generally bad policy.

    A major barrier to valid scientific study of the effects of gun legislation as it relates to mass shootings in schools, is the extreme rarity of those events. But, let’s think about it logically. To develop a hypothesis about preventing mass shootings by deranged individuals there are two potential times for intervention- before the shooting starts or after.


  • PRE-EMPTIVE:
    • The field of mental health, particularly as it relates to predicting violent behavior and incarceration of “at risk” individuals is incredibly far from being a precise science. Our courts have accepted “expert” testimony in such cases as being the best information available, while simultaneously acknowledging the imperfect nature of such testimony even when applied solely to a population of known criminal offenders, those who are “in the system”. The notion of successfully predicting which individuals from the general population are mentally unstable enough to commit one of these heinous crimes, while possibly worth exploring, is nowhere near a practical reality.
    • Another possibility is to deny the perpetrator access to the target. This might entail physically reinforcing school buildings and security systems, although that may merely divert a deranged individual to a different, softer target, such as movie theaters, malls, parks or sporting events.
    • The other pre-emptive avenue, which is the one advocated by the AAP, is to try to keep the perpetrator from getting his hands on the instrument he intends to use for his evil deed. Previous gun legislation has emphasized this aspect. Measures have included bans on specific weapons or ammunition, barriers to acquisition (criminal and mental health background checks, waiting periods, registration), securing of firearms (mandatory trigger locks, gun safes), and gun-free zones.


  • REACTIVE:
    • The second way to stop a mass killing is by a proportional response in force once the massacre has started. Preventing responsible adults from having firearms in the school setting will not keep a determined law breaker from breaking the law. It merely provides him with a crucial time period in which to wreak maximum damage. The minutes that elapse between the onset of an attack and police arrival at the scene are crucial minutes. One observation from a review of the literature and numerous anecdotal reports (2012 Clackamas mall shooting, and 2012 San Antonio restaurant/theater shooting are two recent examples) is that deranged shooters do not tend to stop shooting because their magazine is empty. Three 10-round magazines equal one 30-round magazine and changing a magazine takes a matter of mere seconds. They do not stop shooting because they acquired the weapon illegally and have second thoughts about breaking the law. They do not stop shooting because it is illegal to possess that particular firearm in that particular jurisdiction. The fact is, deranged mass murderers stop shooting when they are confronted by proportional resistance. The presence of on-site adults with the ability to interdict immediately is a potentially very effective way to put a halt to a killing spree. Why would policy makers want to dismiss this possibly effective measure right off the bat? Where are the scientific studies sponsored by the AAP or the CDC analyzing the numerous incidents where a possible victim with a firearm altered a violent attack to prevent death or serious injury? An evidence-based approach requires looking at all the evidence critically, thoughtfully and with an open mind. Yet when the NRA calls for exploration of the feasibility of armed adults at schools they are derided as “unreasonable” (citations too numerous to count).
     In my opinion (based on years of observing human behavior) banning sales of so-called assault weapons will not prevent potential murderers from getting their hands on that style of firearm through illegal means. It will not prevent a mass killer from getting his hands on chains to bar an emergency exit and a few gallons of gasoline to ignite. It will not prevent a mass killer from using an automobile as a murderous weapon. In the hands of responsible, trained adults, firearms can be a vital tool of self-defense. Preventing law abiding citizens from possessing an efficient self-defense tool is like throwing the baby out with the bathwater and as a Pediatrician I certainly wouldn’t advocate that.

     We also must not forget the broader view of this issue. How do I reconcile my view of the Constitution with the desire to be a strong advocate for children? Part of our job as Pediatricians is to help children make the transition to adulthood. This transition includes developing a mature attitude regarding choices and consequences. Learning to drive, operate tools, manage finances and plan for one’s future are all important steps toward becoming an adult. Power tools, automobiles and firearms, while potentially injurious, are all useful tools when used responsibly. In this country though, the most important and simultaneously most powerful tool of adulthood is freedom. Helping them find the balance between individual freedom and responsibility is essential to raising our children into adult citizens. Freedom of choice includes the freedom to make mistakes. A large part of growing up is learning how to recognize the future consequences of present choices. We do our children a great disservice when we claim to protect them by absolving them of the consequences of their actions. We also do them a disservice by telling them the world is a safe place when we know for a fact that it is not. The desire to protect our children eventually must give way to a willingness to let them become adults.

     I understand that people are sometimes frightened by events that are seemingly beyond their control. The initial response to the events at Sandy Hook Elementary School was strong and visceral. I have been a Pediatric Cardiologist long enough to know that bad things happen to good people. The world is full of violence and people are imperfect. I have personally experienced the loss of a family member to a senseless murder. And yet, in the face of all that I would rather my grandchildren grow up in a country where they have the freedom to use tools such as automobiles and firearms responsibly as adults even with all of the messiness and uncertainty that is embodied in that freedom.

James K. Schroeder, MD, FACC, FAAP

(The views expressed in this blog post are solely those of the author and do not necessarily represent the official views of his employer.)

3 comments:

  1. Seamus is a member of FAAP --

    Go figure.

    Joking aside, well stated James.

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  2. I couldn't have said it better myself doc, but then you knew that.
    And thanks for all the work you put in to be a doc.
    Hurting people is easy. Healing people is hard.
    And what you do truly is "for the children".

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  3. I agree entirely. After my own many years of observing human behavior I find that shielding everyone from all possible harm is fruitless and emotionally crippling.

    ReplyDelete