How Physicians Can Combat Gun Violence: Lessons From Tobacco

Emotion not reason drives belief.

People defend their feelings with reasons, but they are really rationalizations —conscious explanations for unconscious causes.

That’s how we vote; that’s how we believe or disbelieve in religion; that’s how we take sides on a myriad of social and cultural issues.

A century of psychiatric knowledge and research, including twin studies, supports these statements. Twin research teases out genetic from environmental sources of behavior, and such studies have shown that social and political attitudes are almost purely familial, taken over from one’s family or immediate subculture. If you’re raised by people who love tobacco or guns, you’re much more likely to love tobacco or guns, and vice versa if you are raised by people who do not. It’s not a matter of personal decision-making, logic, facts, or reason.

Keep that concept in mind as we ask the question: What can physicians do to curb gun violence in the United States?

The physician’s role is not just to treat disease for a single patient but also to prevent the patient from entering the office in the first place. We have to promote health, not just treat disease. We have to prevent the gunshot wound from happening on the street corner, not just treat it once it reaches the emergency room. Public health is part of clinical medicine.

We’ve faced this kind of problem before, most successfully with cigarette smoking. Physicians were on the forefront of fighting tobacco in the face of a powerful and rich lobby, the tobacco industry. Its political allies were located mostly in the Southern states where tobacco was grown and were mostly on the conservative end of the political spectrum.

Gun violence is analogous. There’s a powerful industry lobby of gun manufacturers supported by political allies, mostly on the conservative end of the political spectrum and mostly located in Southern states.

I went to medical school in Richmond, Virginia — headquarters of the Philip Morris tobacco company, the largest in its industry. Tobacco was king in Virginia politics, but in our hospital at the Virginia Commonwealth University, most physicians wore a little button on the lapel of their white coats, which depicted a cigarette with a red diagonal line through it. The message was simple: Physicians opposed tobacco because it was harmful for public health; it killed people.

I imagine a similar possibility today. Physicians could walk around with a little button showing an AK-47 rifle crossed out by a red diagonal line. The message would be: Physicians oppose guns, especially semiautomatic rifles, because they’re harmful for public health; they kill people.

Like tobacco, guns shouldn’t be a political issue. Physicians aren’t a politically active lot, with lower voting rates than the general public.

Physicians are equally divided politically, with about one half of physicians making campaign contributions to Republicans and one half contributing to Democrats.

Medical political views the general population’s: Those with the highest income — surgeons — are the most conservative, whereas those with the lowest income — pediatricians and psychiatrists — are the most liberal. In short, as citizens, physicians reflect the general population; As twin studies show, they believe what their families believed. But as doctors, committed to the principles of science, we have other standards.

Whatever their personal political views, almost all physicians opposed tobacco. It should be the same with guns.

If we have learned anything from the COVID pandemic, it’s that the facts of science aren’t influenced by anti-science cynicism, whether held by supposed progressives who reject the “Medical Establishment” or by conservatives who distrust the government. It doesn’t matter: COVID infects progressives and conservatives alike. Guns kill anyone, irrespective of an individual’s social or economic status.

Physicians can undercut the false argument that guns are safe. Guns kill just as tobacco causes cancer and heart disease. There is nothing safe about either one. Of course, people use guns just as people smoke cigarettes. But the person doesn’t cause cancer, the person doesn’t kill; the gun and the cigarettes do. Of course, other factors are relevant, like psychiatric illness; Psychiatrists would be the first to welcome more funding to treat psychiatric illnesses. But research shows that people with mental illnesses aren’t more likely to be violent than others overall and that the final common pathway — excessive access to guns, especially of the semiautomatic type — is where intervention can be most effective.

The success of the tobacco campaign shows how things can go. Physicians influenced public opinion such that it became less popular; people know cigarettes are harmful for them and others. They may still choose to smoke but they can’t claim it’s safe.

Of note, tobacco use really declined not by moral persuasion but by coercion — the effect of class-action lawsuits against the tobacco industry by state attorneys general. But there was no scientific defense left for the tobacco industry. Eventually, the tobacco industry had to admit that cigarettes were harmful and that they had lied about it for half a century. The same could happen with guns.

It’s a free country, though.

I say that to my patients all the time. I’m giving you my best medical advice based on the best scientific evidence I know and my best clinical judgment and experience. I could be wrong, obviously, but I am giving you my best opinion in your personal interest, not mine. I’m not the patient, you are. But you are free to reject that advice. You are free to do, in my judgment, the wrong thing.

We can take the same approach to guns. You, as my patient, may love to hunt, so you have guns. You may feel, for whatever reason, that most people should have access to all kinds of guns, including semiautomatic rifles that are made for human warfare, not for hunting animals. You may choose to buy such guns. But I’ll still wear my little button and will tell you that excessive access to guns is harmful.

In other words, physicians can and should use their scientific knowledge to weigh in on the facts. We can’t tell people what to do, but we can tell them what is medically true. Guns are harmful to public health in the same way that tobacco is.

Our role isn’t moral: We’re not saying it’s evil to use guns nor that it’s evil to smoke cigarettes. Our role is informational: We are saying what is true and what is not true, as a matter of scientific fact.

We won’t convince most of our patients to change, because we humans don’t reason; we rationalize. No one will be convinced logically or by moral persuasion to change their stance on guns, just as they didn’t change their views on tobacco.

But by refuting the factual claim that guns are safe, physicians can remove one more piece of a crumbling foundation in defense of gun violence, and when the larger culture finally decides to coerce the gun industry, whether by lawsuits or some later change in legislation, it will be that much easier.

Humans will not change their minds. But physicians can convey the scientific truth until society forces a change in behavior.

It’s a free country, but scientific truth isn’t a matter of popular vote.

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