Before Orlando I had not thought about gun violence in the same way I think of other public health hazards. My response to such an outrageous and seemingly avoidable disaster was to advocate that the only appropriate response would be to remove guns from our society to prevent more events like the mass killings in Columbine, Aurora, Virginia Tech, Newtown or San Bernardino. That strategy and more moderate versions have been repeatedly rejected in favor of doing nothing. Indeed, we seem to be losing ground in our search for an acceptable strategy as the episodes continue to occur with increasing frequency and severity.
It is time to rethink how to approach this problem that will not go away. Gun violence seems to be moving from an act of the insane and socially isolated fringe members of our community to a strategic act of an increasing number of disgruntled, isolated political fanatics who either pose as terrorists with foreign allegiances or are perhaps agents financed and controlled by those with radical views of world order who want to destroy the West.
As was true of the medical response to the Boston Marathon bombing in 2013, I do feel awe and a great sense of appreciation and pride for the nationwide demonstration of the foresight and competence that has prepared almost every community in America to be able to respond to the sudden challenge of caring for a large number of victims from a bombing or mass shooting. The medical community of Orlando was ready when the challenge came. We live in an age when for almost every other public health threat, be it AIDS, the opiate epidemic, or the developing concerns about zika, we develop two processes. We have learned that to focus only on immediate response and treatment after the fact is never as effective as coupling acute responses with a plan for prevention. I can think of no menace or threat to the health of the public other than gun violence where we have not been able to generate and deploy some effort at prevention.
Healthcare providers have a unique position in our society and should be leaders who can move beyond treating victims to informing policy and shaping preventative strategies. We know how to understand and respond to epidemics. We provide care to everyone without prejudice despite any difference between our own political and religious perspectives and the preferences of our patients. We have wisdom gained from experience that needs to be considered as the discussion progresses.
Many people listen with respect to their healthcare providers. Individually, we have the responsibility of any ordinary citizen to participate in the important conversation about guns in our society. Individually and collectively we have a larger professional responsibility to our community. How do we help broker a productive discussion in response to the threat to the the health of the public posed by easily available military grade weapons?
In his first statement after the massacre at the Pulse, President Obama was chilling in his direct but truthful statement about the need to control the access to firearms and the collective concessions that we must make to each other if we are going to achieve an improved, if not ideal state. He said:
“…we have to decide if that’s the kind of country we want to be. And to actively do nothing is a decision as well”.
I was moved by the President’s demeanor, earnest expression of frustration and concern as he addressed us for the fourteenth time, the sixth time in the last year, to once again inform us of a mass shooting. The reasoning expressed as he concluded his remarks, reminded me of the way my father would end most of his sermons. For him “proclaiming the truths of the gospel” was always preparatory to the presentation of the question, “What are you going to do?”. His thesis was that to do nothing was to do something. At important moments in life inaction is action.
I learned years ago trying to help patients to quit smoking that I had more success if I used a carefully aimed questions that were part of a process of honest inquiry. We rarely convinced a person who enjoys smoking, and has been doing it for years, that they should give up the pleasure by saying that they should stop before they have a fatal complication. After decades of warnings from the Surgeon General, as well as the pleading of concerned family members, those who could quit on the basis of dire warnings and the requests of loved ones have probably already done so. If you are still smoking, it is a combination of a choice and physical addiction. Information and exhortation are insufficient to motivate you to change.
Questions to smokers about why they are smoking are more effective than data proving how dangerous the behavior is to their health. I learned that my questions were still insufficient if I did not prepare the moment. My patient needed to trust that I cared. They needed to trust that I would respect them and not reject them, no matter what they did. My inquiry needed to be sincere. I could not ask questions that were a setup for a “gotcha” conclusion.
When the right moment came, I would ask my patient to tell me about the benefit or satisfaction and the joy they received from smoking. My questions would explore those benefits and pleasures. Eventually, I would ask them for a value judgement about the cost benefit trade off from their perspective. Finally, I would ask them if they would like to work with me to find alternatives that might provide an acceptable replacement for what smoking did for them. If they were interested, before starting we would talk about previous failures to see if their experience could inform what we tried. We talked how we would deal with failure. After all the questions were considered, the work would begin.
If you clicked on the links above you might have read one analysis that said:
It wasn’t the first time President Obama denounced a hate crime in the aftermath of a mass shooting, and it wasn’t the first time he expressed resolve in the face of a terrorist attack. And it certainly wasn’t the first time he called for action to keep firearms out of the hands of would-be killers. But Sunday’s remarks following the Orlando nightclub shooting were the first to incorporate all three of those themes.
I believe that the majority of people across all political groups reject hate crimes. To say that a person does not reject hate crimes because they do not want to limit gun ownership in any way is a non starter for any productive conversation. I reject the idea that more than an infinitesimally small minority harbor enough hate or have enough xenophobia, homophobia, or religious or political intolerance to advocate murder. We all share a deep concern about the existence and persistence of terrorism. In contrast to some consensus about a rejection of hate crimes and terrorism we are stalled in our search for any consensus on the issues of gun ownership and the proper place of firearms in our society.
I applaud comments made by Bill O’Reilly on Stephen Colbert’s late night program on the Monday night after the Pulse shootings. It was not a discussion that was totally harmonious, to my surprise after the predictable declarations of certitude from both men, O’Reilly extended an opportunity to find some common ground. In the link above the author says:
Interestingly enough, the two found common ground during the conversation, with O’Reilly admitting that the government needs to dictate which guns should be banned in the United States, namely high-capacity rifles.
Another glimpse of hope could be seen in a New York Times report that reviewed the Senate debate and filibuster on a bill to limit access to assault rifles. Both Hillary Clinton and Donald Trump were mentioned.
Democratic presidential candidate Hillary Clinton joined Senate Democrats’ call for action. Presumptive GOP presidential nominee Donald Trump weighed in with a tweet suggesting he would meet with the NRA and support efforts to keep guns out of the hands of terrorists. Exactly what he would support was unclear.
As with smoking cessation, I believe respect and inquiry offer more opportunity for progress than contempt and the recitation of grievances. The example of O’Reilly and Colbert may be worth more of us studying and emulating. I am a progressive Democrat. I have often been unsympathetic and disrespectful of people who see the world differently. I need to recognize that divisiveness and increasing rancor in our political conversations is going no where any of us want to go. I need to change my perspective if I am asking other people to do the same thing.
I know many people who have worries and concerns that are diametrically opposed to my own position on many subjects. I have been disrespectful and contemptuous at times and they have reciprocated. I think that with this election we are at risk of collectively going to positions of mutual contempt form which we may not return.
As healthcare professionals we can be brokers of a more respectful conversation about how to manage access to assault rifles and all the other issues that deeply divide us. Much of our current political debate is around two sets of issues. The first set contains very personal issues: the right to bear arms, the reproductive rights of women, the right to love and unite with the person of your choice, the right to be the gender you feel most comfortable being, and the right to pursue your religious convictions without the intrusion of the state.
The second set of issues and questions are connected in a web of complexity to the first set of issues and are equally important to our ability to pursue life, liberty and happiness. What is the proper role of government? What does equality of opportunity and responsibility mean for each of us? What is a proper safety net of social services? Do we provide housing, health services and nutritious food to the disadvantaged and disabled members of our society? How do we educate our children and to what level of achievement? How do we we best care for the old, the disabled, and the disadvantaged? What is America’s role in the wider world? How do we fairly assess individuals and enterprises or who gets taxed?
To name every issue is not the point. The point is that even an election will not definitively solve any of these complex problems. The road to resolution is a long journey that requires all of us to commit to a process of respect and inquiry. We must remember that we share an obligation to those who gave us the freedom we enjoy, as well as an obligation to preserve the progress that has been made for those who will follow us. We are struggling to adapt to a complex world that will get worse if we continue to go after one another in an environment of contemptuous disrespect.
The President and my father are both right. There are questions to be decided and a choice to be made about how we will search for solutions together. To make no choice is to make a choice. The first choice that I advocate is the choice to approach our problems with shared respect and a reciprocal process of inquiry with a willingness to compromise to find solutions that preserve and enhance for our children what we have inherited together from those who imagined a better future for us. The outcome of not embracing the choice to work together across differences as we foster continuing contempt for our neighbors with a different point of view is probably unacceptable to us all.
