American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, March 22, 2016

People and arms, rights, and reason

Scientists at the National Center for Health Statistics at the CDC just published a research letter in JAMA, reporting on a comparison of life expectancy at birth in the U.S. to peer countries, mostly in Western Europe. The U.S. lags behind many, and these researchers analyzed causes of death to explain why. Their data suggest that 3 factors are responsible for denying Americans the full measure of life enjoyed by our European counterparts: car crashes, drug abuse and poisonings, and firearms. Guns made the largest contribution of the 3.

If we were prone to value epidemiology over ideology, that might be a basis for action. As is, any meaningful response is very much in doubt.

Personally, I don't believe that the gun troubles in this country owe all that much to ideology. The ideologues who think they are doing us all a favor defending us and our liberty by hoarding weapons on their ranch in Idaho against the advent of our government running tyrannically amok are not the real concern. At the population level, they are a rounding error. There are other errors related to their thinking, from my perspective, but propriety dissuades me from noting them here.

The main argument is not between dueling sets of idealists, or ideologues. The main argument has little to do with ideology, or idealism. Rather, and inevitably, it has much to do with money. The NRA may cater to idealists, but it is run by devout capitalists.

Looking at NRA-related exchanges over a span of years, I am induced to think of other mighty, self-perpetuating institutions, like the hierarchy attached to any given religion. There are foot soldiers with genuine zeal, but those wielding the real power are much harder to gauge. Some may be true believers, but we have ample to cause to think that many may not.

Guns and bullets represent money, lots of money. Frankly, I think that's what our societal impasse is all about.

Those who want to assault my gun control advocacy as an expression of gullible trust in our government can't assign my distrust of the gun industry's motives to cynicism. There's no such thing as a gullible cynic. It's oxymoronic, give or take the oxy. Gullibility means trusting those you should not; cynicism means doubting everyone.

Sadly, I think I am more cynic than rube. Life has taught me to be less trusting than I would like to be. An excess of trust, in the government or anything, does not tend to be my problem.

I don't trust the gun industry. I think they are using the Second Amendment as a smoke screen, behind which lots of money is changing hands.

But let's pretend that's not the case. Let's pretend this is really a battle of ideals, or ideologies. I think we are getting it wrong even so.

The Second Amendment refers to people, and arms. It does not specify who is meant by the former, or what is meant by the latter.

In other words, no matter how we sanctify the sage counsel of our Founders, we are obligated to interpret it. There is no alternative.

Clearly, we don't take the Second Amendment to mean that the people have a right to nuclear launch codes, or even lesser, private caches of nuclear weapons. Clearly, we don't take the Second Amendment to mean that the people should be allowed to stockpile smallpox in their basements. We have arms the Founders likely never dreamed of, but either way, we are obligated to interpret “arms.”

We are no less obligated to interpret “people.” Surely, although they are people, the right does not extend to inmates in our prisons. Surely it does not extend to any given kindergartner on a playground, or their younger sibling in a crib. Surely, it does not extend to psychiatric in-patients.

But the Second Amendment specifies no such exceptions. These are all people, clearly, and thus part of “the people.” And so, arguably, the right in question extends to them all. Yet, we seem to have decided otherwise. Are we defying the Founders?

That we have decided anything at all, about people or arms, is telling. It tells us that we can't call this all the wisdom of the Founders, and punt. We are interpreting the applications of the Founders to our 21st century reality.

And so it is that the gun debate in America is well advised by an adage from our English progenitors: in for a penny, in for a pound. If the responsibility to interpret the words of the Founders resides with us, even a little, then what we do is not just a product of the Founders' brilliance. It is also a product of our own muddling efforts to interpret, and apply.

The interpretation with which we advocates of gun control are throttled, or shot perhaps, is that the Founders said just what they meant, and there is no counter argument. We should shut up, accordingly.

But that is, in a word, rubbish. They just said “people,” and “arms.” Our interpretations of both are on flagrant display. That we need to interpret is not theoretical; it's a done deal.

All that leaves for us to debate, and determine, is: interpret, based on what? If not all conceivable arms for all people all the time, then what restrictions?

I won't attempt to answer the question here. For one thing, there is no need. The validity of the question is the intended provocation. For another, I have painted a sufficiently bold bullseye on myself already, with predictable effects. But most importantly, I don't know the answer, and no one person does. It should best be based on data, such as the recent assessment in JAMA, and adjudicated by good people spanning the ideological spectrum who are actually willing to work hard, and listen to one another.

What that new analysis suggests is that our current interpretation of which arms for what people is costing us dearly, in the treasure of young people's lives. That seems an invitation to bridge the partisan divide and debate our way to a better interpretation. Instead, the Second Amendment is itself brandished like a loaded gun, and the very idea of interpretation is shot down. But as noted, that part is neither optional nor debatable. We are already interpreting. All that remains is to do so rationally, or irrationally.

Yes, we, the people, have the right to bear arms. But what that means in the real world is that it isn't just rights that reside with us. It is responsibility, too. It is the application of reason.

We may thank our Founders for the wisdom to impart to us Americans certain inalienable rights. We must acknowledge, however, that the renunciation of reason, the denunciation of sense, and the abdication of responsibility for our misapplications of their wisdom are certainly not among them.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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