Monday, December 14, 2015

“When logic, and proportion, have fallen sloppy dead”

These lyrics are from Jefferson’s Airplane’s White Rabbit, the classic 1967 psychedelic song based on Lewis Carroll’s Alice in Wonderland (and a thinly veiled reference to the rampant drug use of the times).

But I think the lyrics also describe today’s political discourse: on so many issues, “logic, and proportion, have fallen sloppy dead.”  We live in a time when evidence is disregarded, fact checkers ignored.  When confrontation is favored over conversation.  When moderation, in tone and substance, is considered to be weakness; and over-the-top rhetoric, strength.  When you don’t just disagree with someone, you hate them, or at least, you hate what they stand for.  When social media allows people to rant and rail, and shame and bully others, hiding their identities behind anonymous Twitter handles.

Take the issue of preventing injuries and deaths from firearms.  Logic tells us that when a typical day, more than 90 Americans are killed by firearms, we have a problem and the status quo of firearms policy isn’t working.  Logic tells us that when more than 20,000 people each year kill themselves with a gun, we have a problem and the status quo of firearms policy isn’t working.   Logic tells us that when hundreds of children each year get shot or shoot others because of unsecured and loaded guns in their homes, we have a problem and the status quo of firearms policy isn’t working.  Logic tells us that when our own workplaces, malls, city streets, colleges and elementary schools are not safe from firearms-related violence, we have a problem and the status quo of firearms policy isn’t working.

Yet even the most modest of efforts to address the problem of firearms-related injuries and deaths—by allowing the scientists at the NIH and CDC to research its causes and effects, just like they research the impact of smoking on health—has attracted a storm of opposition from the NRA and politicians aligned with the organization.  In fact, at the NRA’s urging, Congress since 1996 has flatly prohibited the agencies from using any funds to conduct research on gun violence.  On December 1, ACP joined with dozens of other health-advocacy organizations to urge Congress to lift the gun violence research ban.  On December 9, we sent our own letter to House and Senate appropriators on our funding priorities that included a request that they end the research ban, and on Thursday, we issued an advocacy alert asking our members to call their representative and Senators to urge the same.  At the time this blog was posted, the fate of the ban was the subject of negotiations between House Republicans and Democrats, with the outcome still to be determined.

But what I do know is this:  all of the logic, and all of the evidence we have for allowing government scientists to research how to prevent gun violence, won’t sway those who are opposed to any and all efforts that, in their minds, might lead to restrictions on guns.  Just like all of the logic and evidence that ACP has marshaled on the broader issue of reducing injuries and deaths from firearms, and the modest and sensible and, according to the American Bar Association, constitutional solutions to gun violence that we and 59 other health advocacy groups have put forward (like closing the  private sale loophole in the federal background check system), won’t sway those who view any limits on guns, no matter how modest and sensible, to be an unacceptable assault on their freedom.

Rather, our efforts to apply logic and evidence to reducing firearms-related injuries and deaths often are greeted with vitriol.   Typical was an email we received after we sent out our  call to action on the gun research ban: “You people are pathetic. The last 3 terrorist (can I use the term) attacks were in GUN FREE ZONES. More people die in Chicago every weekend another gun free zone. What weapons are worse AR 15’s or AK 47’s. By the way ,by definition) neither one is an assault weapon. Stick to medicine you morons!”  Similarly, when I tweeted about the need for evidence based policies to address gun violence through my @bobdohertyACP twitter account, I got many mentions and retweets, but also dozens of anonymous posts that ranged from dismissive to insulting to threatening.

I have a thick skin and I am well aware that anonymous Twitter posts are not representative and can bring out the worst in people; what is more concerning to me is that our elected representatives also seem impervious to the logic and evidence on the need to reduce gun violence, just like they are on so many issues.  I am also concerned about the seeming lack of proportionality in the reaction of many of those who oppose even the most modest of gun restrictions: universal background checks to keep guns out of the hands of convicted felons, folks, is not Nazi-style tyranny.

The United States is facing huge problems that need to be addressed through calm, reasoned discourse, informed by evidence and analysis.  Sure, we can and should have a healthy debate over how best to prevent firearms violence—each side should put their facts, their evidence, and their supporting rationales out there, let’s respectfully dissect and challenge each other, and then, let’s decide on a sensible and informed course of action.

But if in the debate over guns we allow logic and proportion to fall sloppy dead, then the status quo will prevail and tens of thousands will die as a result.

Today’s question:  Can’t we at least agree that allowing the CDC and NIH scientists to conduct research on the causes and effects of gun violence would be a good starting point?


Jay Larson MD said...

The greatest portion of gun related deaths is at one's own hand. Half of suicide deaths are by guns. Half of gun deaths are by suicide. Montana has the distinction of having the highest suicide rate in the country. It has been in the top 5 for the past 40 years. 62% of suicides in Montana are by guns, typically hand guns. Montanans love their guns. Yes the NIH and the CDC should look into this, but what can be done about it? There are over 300 million firearms in this country. Limiting access will be very difficult.

PCP said...

No we cannot agree Bob. And the reason is quite simple, the well known incrementalism of the left is legend. You start with an inch and before long there is a mile. That is the reason a solid segment of the population does not even want to have this conversation.
What better example do we need than healthcare, we went from little gov't involvement pre medicare, to 'usual and customary' to now a monopolistic, price setting, dictum passing CMS that has misdirected resources, choked the medical profession out of the driving seat in health care, resulted in chaos and poor outcomes with inflated costs, price opacity and a bevy of power brokers that schmooze the DC elites and get rules and laws written to favor them. We are left, along with our patients to pick ip the pieces.
So not just no, hell no to the incrementalism. Thats why compromise has become such a dirty word in DC. Thats precisely what happens when the pendulum keeps swinging in one direction for such a long time.

Harrison said...


Imagine, if you will, where we would be without Medicare.
We may have similar technological advance but the target population unable to afford it and millions of elderly people living in poverty because of health care costs, or dying younger because of no access....
Or we would have none of the technological advances and their accompanying expectations because those procedures would never have been a lucrative venture.

Either way we would have elderly people who are poorer and sicker.

I would not defend the notion of mission creep that you describe.
Of course bureaucracies can get over bearing....

But if we hold leaders to keep to ideals and good intentions, then the outcomes can be good.

And for our patients, Medicare is not the problem.
We see it as a problem and it can be a problem for us, but patients get better care with it than they would otherwise.

As far as gun control is concerned, there are practical things that can be done and should be done and that garner support even in Montana.
Closing the gun show loophole for background checks is a good idea.
Also there is support for putting smart technology on guns so that they can only be used by the owner. And not by everyone who picks it up or steels it.
Also, serial numbers on ammunition would be good.

Veterans are often victims of suicide. And their families.
Supporting mental health programs in our VA system would be good.

Ranting about how the government cannot be part of any answer, well that seems like no help at all..


Jay Larson MD said...

It is very unlikely any form of gun control will happen in Montana. I wrote the governor of the state about a gun safety campaign, but he does not want to pursue it because people may think this is a form of gun control. Gun safety is a huge issue when it comes to safety of children and adolescents. In Montana 9% of high school students have attempted suicide. If they have access to a gun then the odds of being successful is much higher. Of the teen suicides in the state 82% were by a gun owned by a relative. When looking across the country, the states with the tightest gun control have the lowest suicide rates and those with the least gun control (like Montana) have the highest suicide rate.

Harrison said...

Dr. Larson,

You have just made a pretty good argument that gun control works.
Observational data, I agree, but that's about all we will be able to get.


PCP said...


I'm not as pessimistic in my assessment of the landscape sans medicare as you are. The truth is of course that none of us know for certain.
I believe that price inflation would not be what it is, as drug companies and other medical technologies would then not be able to price their innovations at whatever they wish but be more cognizant of market affordability. People would also be cognizant of their own mortality and frailty and save and plan for their needs, professionals would practice more cost effectively and not just order a CT scan for every little ache.
Do you see the overspecialization and overcapacity of medical care as having benefitted seniors? That is highly questionable as not all interventions done today are yielding the same bang. I believe the right and needed innovation would still occur without medicare.
What's worse is you have said absolutely nothing to disprove that the over bearing bureaucracies cannot ever be reined back. History teaches us that they overarch and collapse under their own weight once unleashed.
Noone is ranting. People want to prevent things from deteriorating further. If gov't wants to regain the publics trust they must first improve their functioning and efficiency. All I see the left do is to want to expand the gov't despite the inefficiency and 'soak the rich' rhetoric. They do this by appealing to peoples envy and such similar sentiments. Meanwhile as national debt and deficits pile up, we risk destabilizing the whole ship as I've noted many times before.