A Well-Armed and Regulated Citizenry, Led by Heavily-Armed Teachers in Body Armor …

Gun rights advocates are correct: a well armed principal might have reduced the death toll from the tragic elementary school shootings in Connecticut last week.

Gun carrying citizens might also have been able to take down the shooters in Aurora and Virginia Tech. To most people, after all, guns are about self-defense, not about committing crimes. As the old saying goes: “There has never been a mass shooting at a gun show.”

On the other hand, gun control advocates are correct to point out that mentally disturbed people like Adam Lanza would not be able to commit massacres if they were prevented from getting their hands on high-powered, semiautomatic weapons. They are also correct to point out that Americans have staggeringly easy access to weapons that far exceed what any sportsmanlike hunter would use during deer season.

In other words, figuring out what to do in the wake of the Connecticut massacre means recognizing the truth in both of these views. It means considering the possibility that the answer to reducing gun violence is a matter of both having more guns and less.

To understand what I mean by “both more and less,” I offer two analogies: a straightforward one about airport security, and a more unexpected one about breast cancer screening.

For several decades now, experts have been working to reduce the chances that airline passengers will carry weapons on board airplanes. This strategy has been extremely successful in reducing airplane violence. But these measures have also been extreme – x-rays and metal detectors; long lines and pat-downs. But airport security does not stop with gun control efforts alone. After all, evil people do not need guns to commit violent acts. Organized martial arts experts could overpower airplane personnel with nothing but their limbs. So we have done something else: we have armed pilots and federal marshals with guns while they fly in airplanes. We have created policies that simultaneously decrease and increase the number of guns in airplanes, with a heavy emphasis on restricting guns, out of a recognition that zero guns is not a workable solution.

Of course airports and airplanes are uniquely vulnerable targets. We tolerate extreme gun-control measures in airports because we have become all too familiar with the consequences of allowing evil people to board planes with guns and even box cutters. We take some of the same measures in some schools, with metal detectors being an increasingly common sight on public school grounds. But there are limits to what we should do to restrict guns in our schools. I doubt any of us want TSA agents to replicate their airport security procedures outside of our nation’s elementary schools. What’s more, massacres have not been limited to school sites, but have also occurred in malls, post offices, movie theaters and college campuses. And finally, keep in mind that we have more guns in this country than we have people. We cannot expect even the most extreme gun-control laws to reduce the chance of massacres anytime soon.

Is more guns the solution to this problem?

The idea of arming US citizens with guns to prevent senseless massacres makes sense when we think of individual tragedies:

  • A well armed principal might have stopped Adam Lanza from killing all those children
  • A gun carrying movie theater manager might have been able to take out James Holmes

But this idea falls apart when we think beyond identifiable massacres, and consider the broader implications of a more heavily armed populace. And that is where breast cancer screening offers us guidance.

On The Diane Rehm Show on December 12, several experts debated the pros and cons of breast cancer screening. One of these experts was Dr. Wendie Berg, professor of radiology at the University of Pittsburgh. (In the spirit of full disclosure: I spent two years at Pitt in the early 90s and loved the place.) Berg urged women to get mammograms, with emotionally provocative language: “Women… may not see their child graduate from high school if they are diagnosed with advanced breast cancer.”

In addition to this emotional plea, Berg also appealed to a mathematical argument: “Out of, on average, 11 women who are diagnosed with breast cancer, one of these will have their life saved because of the mammogram.”

Let us accept these numbers for the purpose of discussion. Because even if these numbers are factually correct, they are the wrong numbers to think about when deciding whether mammography is a good idea. The numbers are flawed because they focus only on the population of women diagnosed with breast cancer. By contrast, screening mammograms are given to a much larger population of women, in hopes of identifying those who have silent breast cancer. It is impossible to understand the pros and cons of mammograms without looking at the entire population of women who receive this test.

Gil Welch did just this during this same discussion. Welch is a physician at Dartmouth and an expert on the risks and benefits of cancer screening. (He is an incredibly smart dude and, keeping up with this whole disclosure thing, is someone I’ve known for a couple decades now.) Welch acknowledges that mammograms save lives. Out of 1000 women screened annually for 10 years, approximately 1 will have a life saved because of her mammogram. But what about those other 999 women?

  • A few hundred will be subject to at least one false alarm
    Leading to anxiety and painful biopsies
  • As many as 10 will receive aggressive treatment for what would have been a harmless cancer

Too often after gun massacres, we think like that Pittsburgh radiologist. We think about the specific identifiable tragedy, the place where we know something bad happened, and we imagine how it could have been a different place if an honest citizen had been armed with defensive weaponry: “If we had had more guns in the hands of responsible professors, the Virginia Tech massacre might not have been so deadly.”

That is the wrong way to think. We need to reason more like Welch – and consider the population as a whole, not just the population unfortunate enough to be in the wrong place at the wrong time. Guns can and do prevent deaths, when used in defense of situations. But more often, guns kill in other ways – through accidents for example. Many more children are accidentally killed by guns they find in the home than by any homicidal maniac.

The same logic is crucial in evaluating well-intentioned policies, such as laws requiring that children be placed in a car seat while flying on airplanes. No doubt, if an airplane has a runway crash, toddlers strapped to car seats will be more likely to survive than those wriggling around on their mother’s laps. But we need to take a broader look before deciding whether this kind of policy would actually save lives. We can’t just think about the population of children, the very rare ones, who are on airplanes that experience runway disasters. We need to think about the entire population of traveling children, many of whom will now be strapped into car seats in their family automobiles because their parents can’t afford to buy them their own seat on an airplane. Highways are much more dangerous, per mile, than airplanes. If we forced parents to buy airplane seats for their toddlers, to make them safer on the planes, we would be killing children, because many of them would be rerouted to the highways with their families, where they are much more likely to die.

In the face of unfathomable tragedies like the Connecticut shooting, it is natural to jump to quick conclusions. That is why gun rights activists quickly imagine a world where well armed teachers defy such assaults.

Thinking that way would be a tragic mistake.

Peter Ubel is a physician, behavioral scientist and author of Pricing Life: Why It’s Time for Health Care Rationing and Free Market Madness and his new book Critical Decisions. He teaches business and public policy at Duke University. You can follow him on his personal blog.

31 replies »

  1. The medical side of the gun debate is a moot point until after someone is shot. The system, meaning the way society has been changed to a point where parents are almost forbidden to RAISE their children rather and just let them grow up is the bigger problem. Responsibilty for children needs to be given back to parents and taken away from after-care givers and teachers. People need to be educated on what having a child means and not playing Russian Rollette having unprotected casual sex just because it feels good at the time.
    Governements need to stop socieal engineering societies as they do as every plan they have is in direct opposition to nature and the evolution that got humans to be teh successful species we WERE before Progressive encroachment on liberty. Recall the carribou sent to the island in Canada to be safe until no predators thinned the herd and they starved after eating all the food. Leave nature alone as much as possible including human rearing and let us get back to some ideals in family that were the beginning success of the US and beyond.

  2. The “little g” denotes a god, not “the God”. Everyone likes to think of their god as the God. If the world was praying to the same god we’d have no religious wars. Maybe The God could make that clear to everyone and settle a lot of unnecessary killing.

    I personally don’t believe in any god, but everyone is entitled to their own superstitions.

    Merry Christmas MD

  3. I think Random Observer has it right, the question is where the line should be drawn. The NRA wants the line to be drawn very widely, gun control advocates much more tightly.

    These kind of issues typically call for some kind of compromise with neither side getting exactly what it wants.

  4. Good points.

    I believe that the NRA has moved public opinion by hiding behind the 2nd Amendment, effectively responding to gun control measures with the notion that the Constitution allows the right to bear arms. In reality they are also proponents of gun control that matches their beliefs (even if one has to take it to the absurd level of no personally owned rocket launchers). The debate needs to be changed not to whether someone can or cannot bear arms, but to what level they can bear arms.

    I believe majority public opinion is (1) There is a some right to bear arms (2) The right to bear arms should be more curtailed then it is today. By responding to questions around (2) with responses that evoke (1) the NRA has managed to be successful in the court of public opinion (this also influences the judicial courts).

    As an analogy, pretend the NRA was a pro-alcohol organization and another group wanted to stop drunk driving. If the other group campaigned “End Drunk Driving”, the NRA would respond with “Drinking Should Remain Legal”, obfuscating the issue and winning the majority opinion (who believe that drinking should remain legal…but also want to limit drunk driving).

  5. “Sad to see how nobody calls the NRA on their fallacy.”

    The NRA through private citizens has done pretty well in the courts. Goggle “Heller” decision.

    The court ruled against DC and their attempt at gun control, but the Justices stayed away from examining the type of weapons that could be banned.

    Mostly the NRA has stayed away from the Supreme Court to avoid being surprised by an unfavorable decision. They do better threatening legislators and spending money on campaigns. The last assault rifle ban was nothing but Swiss cheese and was later overturned. Supreme Court never needed to get involved.

    I think for real change we’d need a Constitutional amendment, but given the 50/50 split in our right wing, left wing voting patterns that would be very hard.

  6. Gun advocates are using the 2nd Amendment as a smokescreen. The full text says “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” There is nothing in the text about what kind of arms. Fully automatic weapons have been arbitrarily banned for many years. No citizen is allowed to own a nuclear suitcase bomb or rocket launcher despite those easily fitting in the modern-day realm of 18th century arms (think modern day cannons). The truth is that for whatever reason, the nation has decided there is a limit or “infringement” on what type or arms a person is allowed to bear. The NRA arbitrarily believes that the limit should be X, while other people believe it should be Y. Every time the NRA says, “The constitution allows us to bear arms”, what they are really saying is “The constitution allows us to bear arms and we believe the limit should be X”. There is no more constitutional backing then saying “The constitution allows us to bear arms and we believe the limit should be Y”.

    Sad to see how nobody calls the NRA on their fallacy.

  7. Gun violence injuries are a significant health care issue so is appropriate here. Should the 2nd Amendment allow citizen possession of high-capacity, military/police magazines in legally-obtained long guns or hand-guns where a mentally ill person or a criminal can discharge 30 (Newtown shooter) to 33 (Gifford shooter) rounds within 15 seconds, giving no time to escape or counterattack? The high-capacity magazines appear to enable mass casualties in a very short period of time at a very high cost to society and perhaps could be made illegal to possess, similar to recent the Supreme Court decision upholding restrictions on fully-automatic weapons.

  8. “I think we need God’s help. I know I do.”

    You mean the solution is to pray more? I wonder if the Newtown victims were praying. I guess God was preoccupied solving other world problems.

    I hope people are fed up with praying, and grieving, and mourning, and burying, and trying to recover.

    There are about 80 deaths each day (including children) by people who want to solve their problems with a gun. Yet we only get excited if the one time count creeps up to the level of “mass” shooting.

    The gun nuts seem happy to keep the single kill rate down, as if that’s acceptable casualty numbers. Carry a gun and maybe we can stop the killing at one or two – now that’s progress.

    The NRA are a bunch of facists and should be scorned for their unyielding extremist positions that keep mothers, fathers, sons, daughters and communities in constant fear of whose going to be next.

    Fear sells guns, fear cements power, fear divides us, and fear crowds out rational thinking.

    The NRA is fear and death and they should be hounded into oblivion.

    That’s my prayer and if there is a god he’ll answer my prayer.

  9. Still looking through the wrong end of the telescope.

    It eventually comes out that the shooter was identified as “troubled”, or with a history of something that made them, retrospectively, likely to commit the crime they eventually did commit.

    But even that is looking through the wrong end of the telescope.

    Eliminating guns would definitely change the mode of violence available to the mass murderer, but it would not eliminate the culprit.

    Mass murder or serial killer. Pick your poison.

    Prevention can only get you so far. Now we can have the deterrence debate about the death penalty. Whoops! We execute innocent people so we cannot have that either. (I am not an advocate of the death penalty.)

    As long as we are talking about the behavior of human beings, we must accept a degree of unpredictability, because it cannot be eliminated. It can only be observed after the fact.

    The increased purchase of firearms since Newtown also speaks to the behavior of humans who feel threatened. And so it goes.

    The Mom was not responsible with her guns. She should have secured them from her son. It was not the video games or the glamorizing of shooting that is to blame. No such quick fix.: Blaming those is only a misdirected “feel-good because we must do something” measure. Vengeance makes great headlines and fodder for media but bad policy.

    We all grieve for the victims. Neither side has a real monopoly on that. All the banter is about trying to be more affected and more righteous. Another predictable behavior.

    I think we need God’s help. I know I do.

  10. “go for it”

    That’s a challenge not a discussion point.

    I’m not the one determining the size of tax but I don’t think it’ll need to be huge to generate a lot of money. But the NRA’s history on this is to oppose any tax. Their view is even small changes to gun control are a foot in the door. Hell they even oppose and lobby against animal protection laws, that’s how rabid they are on anything they deem “liberal”.

    “This dismissive attitude”

    Well that’s the pot calling the kettle black. The courts don’t really care if you’re dismissive, they look at their interpretation of the law. History has proven that the Constitution is an interpretive document and the supreme court has done it share of wrong headed interpretations.

  11. Stepping aside for a moment from the gun control debate, I found it interesting to read an explanation of why small kids don’t have to be in “plane seats” while in the air – something that has always mystified me.

    “The same logic is crucial in evaluating well-intentioned policies, such as laws requiring that children be placed in a car seat while flying on airplanes. No doubt, if an airplane has a runway crash, toddlers strapped to car seats will be more likely to survive than those wriggling around on their mother’s laps. But we need to take a broader look before deciding whether this kind of policy would actually save lives. We can’t just think about the population of children, the very rare ones, who are on airplanes that experience runway disasters. We need to think about the entire population of traveling children, many of whom will now be strapped into car seats in their family automobiles because their parents can’t afford to buy them their own seat on an airplane. Highways are much more dangerous, per mile, than airplanes. If we forced parents to buy airplane seats for their toddlers, to make them safer on the planes, we would be killing children, because many of them would be rerouted to the highways with their families, where they are much more likely to die.”

    There is a small weak point in the above explanation in that we don’t know what percent of people would substitute a car for plane at what price points.

    Nevertheless, the above analysis is a fairly sophisticated and I would be very pleased if I thought TSA or the FAA had actually gone through such an analysis. The evidence suggests otherwise.

    1) There is no evidence that cell phones or other electronic devices have any effect on airplanes. Many people leave their cell phones on with the ringer off while in a plane. Cell phones don’t affect aviation radios, VOR signals, Radar, etc. etc.

    2) Small quantities of fluid carried on board cannot be mixed to make explosives. They are not restricted in Europe.

    3) Taking off shoes is not currently required if you are over 70 something? Also not required in Europe.

    4) Although TSA won’t admit or publicize it, plenty of weapons have made it through screening, perhaps as much as 40%.

    There is no better example of “power corrupts, absolute power corrupts absolutely” than Homeland Security and TSA. And these are probably mostly the same people who will be enforcing any new school safety laws that get adopted. Depressing …..

  12. actually in the post you’re replying to I said go for it, as in if it’s reasonable, do it. That is me stepping up and putting my money where my mouth is. I have made it very clear I’m willing to contribute my dollars to this problem, so please stop trying to caricaturize me as something I’m not.

    The rest of my comment was addressing your desire to make the tax unreasonable. It’s pretty simple, if you make the tax large enough to generate any real revenue, you run the risk of it being determined to be prohibitive and unconstitutional. You can dismiss this as just right wing bloviating if you’d like, this is generally how gun control advocates respond to second amendment arguments. This dismissive attitude is also probably why the gun control crowd is on such a losing streak in the courts.

  13. I really would like to know what it is that gun advocates expect to shoot with their military style automatic weapons. I inderstand that many feel it is an issue of “rights” and that the government shouldn’t take away the rights of the citizen. But we are not living in 1841, when people lived on farms, worried about bears and owned muskets.

    I work in a city where almost every weekend high vilocity bullets rip through the walls of innocent families. I can imagine the carnage if a homeowner began to shoot back. Is that how to protect the health of our nation?

    Do people really fear our own government that much?

    I find it interesting that when people came back from WWII, many of them brought home momentos of the struggle, but very few wanted to have working weapons in their homes.

  14. Obviously motored you don’t want any taxes on guns/ammo, no matter what it is for. In fact gun owners do not want to take responsibility for anything that might cost them more.

    The tax need’nt have to be to large considering the amount of ammo used and guns in circulation. I’d truly like to see punishing taxes (especially on AR rifles and big clips) but that’s not going to happen. You right wingers always cry about unfunded mandates, so put your money where your mouth is and step up with some responsibility.

    Most of our mental health treatment is done in the jails – I think you’d agree not ideal by any stretch. In fact more mental health counciling for the young will go a long way to reducing crime – with guns.

    If your in favor of an alcohol tax to help pay for its affect on society then why wouldn’t a tax on guns serve the same purpose?

  15. I agree, by no means do I think incidents like this are predictable or preventable, but I also know how hard it is for families to get care for mentally ill loved ones. I can’t tell you how many times I’ve heard someone tell a terrified mother/father/family member “we can’t force them to get treatment unless they make a threat.” Maybe we need to loosen that standard up a little bit? A thoughtful post on standards for involuntary commitment would be nice to see. The issue is far bigger than just being about funding.

    Peter, As far as taxing guns and ammo, if you want to put a reasonable tax on things with proceeds going towards mental health, go for it, but you have stated elsewhere that this tax would be rather large, at which point it stops being about helping those in need and starts being about making guns and ammo prohibitively expensive. There’s obviously some problems with putting prohibitive taxes on the one consumer good that people have a constitutionally guaranteed right to have. It also seems absurd to put the burden of funding mental health services on gun owners. As you have pointed out, very few mentally ill people actually go on to do things like this. I suspect your proposal has a lot more to do with punishing gun owners because you don’t like guns, and doesn’t have much to do with this being an honest solution to a problem. If there were a few high profile cases of mentally ill people using knives to attack people, I doubt you’d be proposing a silverware tax.

  16. I could get along just fine without a 2nd Amendment. No one’s yet come to confiscate my car because owning it isn’t constitutionally guaranteed.

    As one commenter tweeted:

    “I don’t know what the answer is, but I know I want it decided by frontiersmen who lived 230 years ago.”

  17. Maggie, there will never be a gun law that would keep a legal and mentally stable Nancy Lanza (shooters mother) from owning a gun unless the Constitution is amended.

    Using a tax on guns and ammo will bring in millions for mental health care which in this case may have helped Ms. Lanza get special counciling for her son. Something snapped in that boy’s mind, if he were in therapy he may not have snapped and his mother may have had the information she needed for intervention or even getting the guns out of he house.

    With all the extra money from the gun/ammo tax for mental health we may be able to discover a whole set of circumstances that lead to these incidences which may prevent all kinds of violence, including suicide by gun.

  18. On Teachers– three thoughts.,

    First, on the idea of arming teachers:
    Teachers, like all of us, are human beings and thus vulnerable to mental illness.

    Imagine a 24-year-old 1st grade teacher who has a gun in his desk. One day
    some combination of his body chemistry, his childhood, genetics, and the pressure of spending 8 hour days, alone, in a room with 24 six-year-olds catches up with him and he snaps. He opens his desk drawer and . .

    Alternatively, a junior high teacher keeps his gun locked in his desk.
    He leaves his classroom briefly. An emotionally disturbed 13-year-old gets into a fight with a classmate. He breaks the lock on the drawer (trust me, all of the kids would know where the gun is) and . . . .

    Finally, as I read the stories about the teachers in Connecticut, I couldn’t help but wonder: Why do so many Americans hate public school teachers,, heap scorn on them, and resent any pay hikes or benefits that they receive?

    These teachers showed that they are true professionals–they put their kids’ interests ahead of their own, and in some cases, gave their lives.
    I’ve never heard of a teacher running away, trying to protect herself rather than her students, have you?

    In most situations, if a shooter opens fire in a workplace,it’s every man for himself. But not in a classroom–Even when the students are Young Adults (College Students) teachers almost invariably respond in the same way–as if they were parents. I think of the college teacher who had been shot, in the head, with a bow and arrow, and nevertheless wrestled with his attacker, giving his students time to run . . .

    Yet the Tea Party website actually accused “teachers and teachers’ unions”
    of helping to cause this tragedy..

    These are the true crazies in this country –the people so filled with hate that they hate teachers.

  19. motomed–

    The problem is that we don’t have :”cures” for such severe mental problems– and often, these shooters show few (if any) signs of being a threat to others,

    Yes, in the aftermath of a shooting, people may report that they were :strange” or “kept to themselves” but you can’t put someone in a hospital, tie him to a bed and medicate him because he’s odd.

    Some of these shooters have actually been in therapy, but at these extremes, talk therapy is not going to cure their problems. Typically, the therapist is just as shocked as everyone else.

    He or she never saw it coming. .

    In early adulthood schizophrenic “breaks” can appear seemingly out of nowhere.. We have medications that can help–but unless we institutionalize these patients and force them to take their meds, they are likely to go off them. . .

    More funding for mental health could provide better conditions for those who must be institutionalized –and this would be a good thing.

    But it wouldn’t prevent these massacres.

    The bottom line: there is a limit to what medicine can do. It is an infant science, And when it comes to mental illness, we have only the mind with which to study the mind. This tends to lead to a standoff. (Over time, I have hope that we will learn more about how to help people suffering from illnesses ranging from depression to schizophrenia, but I’m talking about a very long time)

    Other countries don’t have better treatments for serious mental illness than we do. But they do have gun laws. .
    . .

  20. @ Motomed:

    We’re working with several people to develop posts that look at this side of the story. We’re interested in exploring all sides of this story. If you know of a good post that you think would be good for our audience. Submissions and tips to editor@thehealthcareblog.com please

    On the gun control side. Sorry. There’s too much going on here to ignore.
    Michael’s piece was too powerful to pass up and has a strong prevention focus that we thought was perfect for THCB.

    At a time when people are seriously considering ideas like arming teachers and principals, Peter is giving the suggestion a fair treatment, I think.

  21. But I’m not advocating banning guns or alcohol, you’re intentionally changing the argument.

    If you haven’t noticed there are taxes on alcohol which help to fund DUI prevention and enforcement and prosecution. Not all people who drink are DUI and we can argue that most drinks are responsible, however all people who buy alcohol pay the same taxes.

    Taxing guns and ammo is the perfect fit to address a problem that even gun owners must agree they don’t want to see happen.

    By the way a Libertarian would not support a government system to address mental illness – that would be against their beliefs.

  22. There are plenty of gun owners who will join you in supporting increased funding for mental health. I’m as libertarian as anyone on health care and would be happy to pay into a government organized system that seeks to care for the mentally ill. The lack of funding for mental health is one of the tragedies of the entitlement society, I guess the mentally ill don’t represent a large enough voting bloc.

    Gun owners take no more responsibility for this than people who like to enjoy a glass of wine with dinner take for drunk driving deaths. What better way to prevent those deaths than to ban alcohol? Some people can’t handle it, so clearly we must make it harder for everyone to get! Do you know how many children were killed because a TV fell on them last year? As a TV owner, why aren’t you taking responsibility for this? Absurd logic, right?

  23. I think we should arm the nurses and the day care center workers – only then will we have attained our full potential as a free society ..

  24. But gun owners want guns to be easily available which means available as well to people with mental illness. What better method exists to get treatment to people who have the potential to buy a gun and kill than to tax the vehicle for their murder. Mental illness treatment is expensive and underfunded, there needs to be a system to pay for it.

    What exactly will gun owners take responsibility for?

  25. People who have committed mass murder like Jared Loughner, James Holmes, and Adam Lanza had guns. But hardly anyone who has guns commits mass murder.

  26. To me this post does address mental health by describing how to begin reasoning our way to targeted and smart policies. Consider the population as a whole like Ubel and Welch say.

    People who have committed mass murder like Jared Loughner, James Holmes, and Adam Lanza had mental health problems. But hardly anyone who has mental health problems commits mass murder.

  27. “Two of the last three posts are on gun control, and not a post yet dedicated to ways to improve mental health care.”

    I’ve already offered a solution in another discussion. Mental health care costs money as do measures to prevent guns from getting into the wrong hands. Tax bullets and guns based on their killing power and use that money for mental health and enforcement.

  28. Sad that a healthcare blog is choosing to spend so much time addressing the gun control issue and so little time addressing the issue they should be experts in, mental health. Two of the last three posts are on gun control, and not a post yet dedicated to ways to improve mental health care. There is no shortage of people banging the drum for gun control, we could use some more outspoken voices offering clear solutions to the mental health issues. If not a healthcare blog, I’m not sure who is going to do that?