March 2014, VOLUME133 /ISSUE 3

Firearms, Children, and Health Care Professionals

  1. Michael L. Nance, MDa,
  2. Keith T. Oldham, MDb, and
  3. Thomas M. Krummel, MDc
  1. aUniversity of Pennsylvania School of Medicine, and The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
  2. bPediatric Surgery, Medical College of Wisconsin, and Children's Hospital of Wisconsin, Milwaukee, Wisconsin; and
  3. cStanford University School of Medicine, and Lucile Packard Children's Hospital, Stanford, California
  • firearms
  • children
  • policy
  • Abbreviation:
    American Pediatric Surgical Association
  • Firearms claim the lives of >30 000 Americans annually; frequently among these are children.1 This problem is not new; it has existed for decades. One of the most publicly visible physicians of our time, C. Everett Koop, a pediatric surgeon and former Surgeon General of the United States, recognized that violence was a public health problem, and in 1985 convened a workshop to address this problem. In a follow-up editorial regarding violence, he admonished, “We can wait no longer to act” to address firearm violence.2 Nearly 3 decades later, little has changed. In that time, there have been >900 000 firearms deaths, including 100 000 children in the United States.1 Koop recognized that, “In science, you can’t hide from data.”3 Regarding pediatric firearms mortality, the data are indisputable. The recent mass shooting event at Sandy Hook Elementary School, which claimed the lives of 20 children, was compelling.

    The American Pediatric Surgical Association (APSA) is a professional organization composed of >1200 surgeons dedicated to the care of ill and injured children. We belong to the broader health care community whose job it frequently is to care for children injured by firearms. We have a perspective on the problem that is unique and persuasive. We have a perspective that differs from that of policy makers who are in a position to enact change in the capitals of our states and the nation. We see the lives of the victims and families altered forever by gun violence. We as a health care community should share our perspective and provide a voice to the violence that we witness.

    In response to the tragedy at Sandy Hook, APSA updated its position statement on firearm injuries and children.4 The association also took the unprecedented step of obtaining, through a vote of affirmation by the membership, an endorsement of these position statements regarding firearm injuries and children. This process included a period of public (association-wide) review followed by an open discussion at the business session of the annual meeting. The measures passed with overwhelming support of the membership (Table 1). Adding the affirmation of an entire association strengthens the message, and we encourage other professional organizations to consider a similar process. In addition to commonsense measures that have broad popular support (eg, universal background checks, improved mental health services), the policy statement highlighted several issues particularly relevant to health care providers caring for victims of firearms violence: the freedom to pursue research, the wounding capacity of civilian weaponry, and the sanctity of the physician-patient relationship.

    TABLE 1

    Policy Statements Endorsed by the APSA

    As physicians and surgeons, we strive to practice evidence-based medicine. Data and experience drive the clinical decisions we make every day. In addressing firearms-related injury, data are no less important. Current federal legislation, however, specifically prevents the Centers for Disease Control and Prevention from funding firearms-related research.5 A broad interpretation of this law has effectively eliminated funding through all branches of the National Institutes of Health as well. Without research, claims regarding the efficacy of existing, former, or proposed firearms-related legislation are largely conjectural. Without federal funding, research vital to understanding the problem cannot move forward. The current language impeding access to funds for firearms research must be removed so that data can inform patient care, injury prevention, and policy decisions.

    The wounding capacity of weaponry available to civilians is astounding. Consider the differences in 2 mass-casualty school shootings. In December of 2012, Adam Lanza murdered 20 children at Sandy Hook Elementary School. Six years earlier, Charles Roberts shot 10 girls in a 1-room schoolhouse in Nickel Mines, Pennsylvania. Both shooters acted alone. However, Adam Lanza used an assault-style rifle with a high-capacity magazine, killing all children involved (18 of 20 children had multiple gunshot wounds).6 Charles Roberts, by contrast, used a 9-mm handgun, and only half of his victims died despite being shot “execution style.” The high muzzle energy, large-capacity magazine, and rapid firing (Lanza reportedly fired >150 shots in less than 5 minutes) of the firearm used at Sandy Hook undoubtedly played a role in the absolute lethality of the incident.6 In the United States, we have a robust trauma system that is well suited to expeditiously care for victims of firearm violence. At Sandy Hook, no child survived to receive care. In the absence of federal guidance, many states and municipalities have enacted legislation to curtail firearm violence. The salutary benefit of these laws (including an assault-weapons ban) was recently underscored at the state level by researchers (without the benefit of federal funding) who demonstrated an inverse relationship between firearms-related mortality and the number of firearms-related laws (ie, more laws equal lower mortality).7 These laws can be crafted without infringing on Second Amendment rights. In his majority opinion upholding the right to bear arms, Supreme Court Justice Scalia clarified, “like most rights, the Second Amendment right is not unlimited. It is not a right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose.”8 As a nation, we must choose where to draw the line. As health care providers, we must help inform that decision.

    A fundamental role of the physician is to counsel patients (and parents) about potential risks in the environment. Firearms in the home pose a risk. Recent laws at both a state and federal level have been crafted to limit that physician-patient relationship with respect to firearms. Notably, the Patient Protection and Affordable Care Act includes language that could be interpreted as prohibiting conversations with families regarding firearms and their risk:(c) PROTECTION OF SECOND AMENDMENT GUN RIGHTS—(1) WELLNESS AND PREVENTION PROGRAMS—A wellness and health promotion activity implemented under subsection (a) (1) (D) may not require the disclosure or collection of any information relating to—(A) the presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property of an individual; or (B) the lawful use, possession, or storage of a firearm or ammunition by an individual.9

    The physician-patient relationship should remain inviolate. As health care providers, we should vigorously challenge efforts to legislate our interactions with patients and their families.

    During the contentious 8-month-long senate confirmation hearings for C. Everett Koop to become Surgeon General, he vowed to set aside personal beliefs and do what was best for the individuals he represented. We as a professional association have chosen to do the same. We encourage other health care professionals and professional organizations, adult and pediatric alike, to consider the important role they might play in this ongoing national dialogue. This is not a pediatric surgical issue, this not a pediatric issue, this is a public health issue. We all have a role to play. And like the systematic reduction in motor vehicle–related morbidity and mortality achieved through a traditional public health approach, we should push for similar efforts as we tackle the burden of firearms-related injury. With >300 000 000 firearms estimated to be in circulation in the United States, efforts to eliminate guns seem misguided. Rather, we as health care practitioners should shift the paradigm from efforts to live in a world without guns to ensuring we can live safely in a world with guns.


      • Accepted October 4, 2013.
    • Address correspondence to Michael L. Nance, MD, Children's Hospital of Philadelphia, Department of Surgery, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: nance{at}
    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.


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