Not since the 1981 attempted assassination of Ronald Reagan has someone shot at a current or former American president — until last weekend.
On Saturday, former President Donald Trump was shot at by Thomas Matthew Crooks with a legally purchased AR-style weapon at a political rally in Butler, Pennsylvania. The bullet pierced the tip of Trump’s ear as Secret Service agents ran to aid him. Three rally attendees were shot; one was killed.
Although the FBI has not yet determined Crooks’s motive, the finger-pointing predictably started in the immediate aftermath, with Republican leaders citing President Joe Biden’s critiques of Trump as the inciting event. Sen. Tim Scott (R.-S.C.) stated, “This was an assassination attempt aided and abetted by the radical left and corporate media incessantly calling Trump a threat to democracy,” while Sen. J.D. Vance (R.-Ohio), Trump’s VP pick, claimed that Biden’s rhetoric “led directly to President Trump’s attempted assassination.”
But to their credit, neither Trump nor President Biden fueled the political fire. They instead offered a unified response, calling for de-escalation of the violent rhetoric. And this is the crux of the issue: it doesn’t matter where you fall on the political spectrum — the attempted shooting of a former president should unilaterally concern the entire country.
If the shooting were an adverse event in a hospital, we’d sit down and do a root cause analysis (RCA): a systems analysis of active and latent issues underlying the event to detect safety hazards retrospectively. Taking this RCA perspective, we cannot assess underlying risks leading to the shooting without candidly discussing gun violence in our country.
I can already feel the defensiveness rising and I’d like to encourage us to pause and have a rational, fact-based discussion.
The Dickey Amendment
The concept of the “good guy with a gun” is integral to American culture and codified in our Constitution. It represents a courageous devotion to protecting the defenseless. In describing this construct, I am trying to understand our society’s cultural attachment to firearms, and, by extension, the emotional response that mere discussion of gun violence evokes in our society.
This emotional response manifests itself in many ways, including one pervasive in medicine: a hesitancy to discuss gun violence with patients. We would not hesitate to discuss any other risk factor, even when the topic is sensitive. We talk about substance use, obesity, and sexual histories — all highly relevant to health. Emotional discomfort around “sensitive information” is not a reason to stymie honest discussion. So why is firearm access as a mortality risk factor so different and so controversial?
To trace hesitancy around discussing gun violence, we have to go back to a critical 1993 study by Arthur Kellermann, MD, MPH, funded by the CDC, which showed that the presence of a firearm in a home increases homicide risk, contrary to the deeply-held belief that firearms necessarily confer protection. This is not a political statement; it is a statistically significant epidemiological association between an exposure and adverse outcome. We should welcome findings like this in medicine because they help us assess risk objectively.
Following the publication of the study, pro-gun advocates adopted the position that research on gun violence equated with elimination of gun rights. This position established a false dichotomy between public health research and constitutional freedoms, according to then-director of the National Center for Injury Prevention and Control (NCIPC) Mark Rosenberg, MD, MPP: “The opposing force was the NRA [National Rifle Association], and the NRA told everybody, ‘You either can do research, or you can keep your guns. But if you let the research go forward, you will all lose all of your guns.'”
In 1996, then-Rep. Jay Dickey (R-Ark.) incorporated the Dickey Amendment into the 700-page Omnibus Consolidated Appropriations Act, prohibiting the CDC from using federal funds to “advocate or promote gun control.” While the legislation did not explicitly ban research on firearms, it had a chilling effect on research; Congress cut funding for the NCIPC by $2.5 million and research came to a halt.
Dickey later expressed regret for the provision: “It wasn’t necessary that all research stop. It just couldn’t be the collection of data so that they can advocate gun control. That’s all we were talking about. But for some reason, it just stopped altogether.”
Dickey’s statement indicates a fundamental misunderstanding about the research process and shows why we need to be careful about how we legislate medical practice and research endeavors, especially when the legislation is not informed predominantly by medical experts.
Good medical research should not begin with preconceived notions or an agenda; it should seek to answer a clinically important question objectively. The problem with the Dickey Amendment is that it presumes that doctors researching guns are planning preemptively to use their findings to infringe on Second Amendment rights. They’re not. They are trying to collect more information and to mitigate risk appropriately. But the Dickey Amendment scared researchers away from the subject entirely. Concerned their research efforts would be construed publicly as “gun control” and therefore a violation of the law and a threat to their medical license, they stopped doing the research.
The Dickey Amendment was a poorly informed and emotionally driven measure that stifled medical research to patients’ detriment. It created a climate where mere discussion of a significant public health risk factor became controversial.
While this 1990s amendment may feel far behind us today, it’s anything but. As recently as 2011, a law was passed in Florida that fined doctors up to $10,000 and potentially stripped them of their medical licenses for discussing firearms with patients, sacrificing the First Amendment for the Second. While portions of the legislation were struck down in 2017, pro-gun activists continue to warn doctors to “stay in our lanes,” and fail to recognize that an apolitical discussion of firearms is a relevant healthcare conversation.
Gun Research and Gun Rights Are Not Inherent Opposites
Don’t get me wrong — there are occasions when I unequivocally support disarming people. For instance, if someone poses a significant violence risk or comes to the hospital after a high-lethality suicide attempt, I will not recommend they have continued access to guns. Similarly, I made my stance on U.S. v Rahimi clear that people under restraining orders for domestic violence should not have guns. This is an evidence-driven recommendation: research has shown that firearm access by perpetrators of domestic violence is the most significant predictor for intimate partner homicide.
But the vast majority of the time, when I have a patient who owns a gun, I’m discussing safety with them without advocating disarmament. We discuss safe storage. We discuss keeping the gun and ammunition separate. If they have a suicidal family member or a suicidal child in the home, we talk about minimizing risk and we safety plan collaboratively. I try to offer a well-informed discussion, not a draconian edict. My goal is to support my patient and to protect their safety, not to strip them indiscriminately of their rights.
As physicians, we cannot make sound suicide or violence risk formulations without data. And we cannot collect data with emotionally driven controversies, angry and fear-based attacks, or legal threats hanging over our heads. We also cannot keep patients safe if we’re discouraged from talking about gun violence as a real and deadly public health crisis.
You do not escape mortality risk by hiding information that is discomfiting to you. Whether Republican or Democrat, we can all agree that we want to protect innocent life. It starts with stripping away the politics and ad hominem attacks and embracing intellectual curiosity, open discussion, and unity.
Chloe Nazra Lee, MD, MPH, is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York.
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