An ER Doctor’s Cure for America’s Gun Epidemic

In 2020, while the Covid-19 pandemic raged, a steadily growing epidemic continued to burn its path across the United States. Gun violence stole the lives of 45,222 Americans that fateful year, the worst year on record for gun deaths to that point.

The path leading to each one of these deaths is layered and complex. Each American killed by a bullet, each family grieving their loved one, deserves their own book. I never once thought that I would be one to write such a story.

I’m a gun-owning emergency physician, a father, and the cousin of a man who was shot to death. If it wasn’t for the National Rifle Association declaring in 2018 that physicians, like me, should “stay in their lane” and keep quiet about the toll of this plague, I wouldn’t have written about this subject. Yet gun violence consumes my life. I see victims of gun violence from family tragedies—children, adolescents, and adults—almost every day.

Addressing violence and death is the duty of anyone who has ever had to mend the wounds of a gunshot victim, to attempt heroic measures in the trauma bay, to meticulously care for the injured in the intensive care unit, or admit defeat in front of their loved ones. I have found no worse feeling than having to tell a mother or a father that their child has been killed by a bullet. We have practiced and perfected evidence-based medicine for decades. We should similarly practice evidence-based health policy. As it pertains to guns, some of that evidence already exists.

As a physician, I understand the limitations of science. The best research, at least in the biomedical sphere, usually requires the findings of randomized clinical trials, but running those for policymaking often isn’t feasible. In public health, the next best option is a natural experiment, in which one jurisdiction implements a policy and a similar, nearby jurisdiction does not, and policy makers can observe the difference.

The RAND Corporation’s The Science of Gun Policy—a synthesis of research into US gun policy—typically relies on these types of studies to inform its analysis. It is sometimes inconclusive, sometimes weak, sometimes strong in its assertions about the impacts of various policies that might impact lives in this epidemic of gun violence, but overall its analysis describes myriad policy levers that our current lawmakers could, and in my opinion should, swiftly implement at the federal, state, and local levels. The evidence states that we can save lives through the following:

• Background checks through federal firearms licensed dealers for every firearms purchase
• Licenses and permits for individuals who want to buy guns
• Raising the minimum age for all firearm purchases to 21
• Strong child access prevention laws
• Brief waiting periods
• Domestic violence restraining orders that require the relinquishing of existing firearms.

But I also believe there are two additional laws that should be repealed. Their presence in society should alarm physicians, advocates, and the people who write the laws.

Policy Prescription #1: Reverse Stand-Your-Ground Laws

On February 26, 2012, Trayvon Martin, a Black kid my height and with a similar build, was walking through a neighborhood in Sanford, Florida, after purchasing a bag of Skittles and a drink. He was essentially stalked by the captain of a local neighborhood watch patrol. Following an altercation—one that a 911 dispatcher urged the overly zealous neighborhood watchman to avoid—Martin lay on the ground, shot dead by a single bullet that traversed his heart and lung.

All of that young man’s hopes and dreams of one day becoming an aviator were struck down by a man who would eventually be acquitted of murder because of Florida’s stand-your-ground statute that created a culture of approach, provoke, and kill. Stand your ground certainly contributed to the young boy’s death.

Every state has some form of this doctrine embedded in common law, something that recognizes that an American man or woman inside their home has the right to defend themselves. But how far does that right travel outside the home? Obviously, if someone approached you attempting to harm you, no one would blame you for defending yourself. But what happens when you initiate the incident and instead of retreating, escalate a situation that never needed to exist in the first place?

The castle doctrine permits a person who is in his or her home to defend it and themselves from harm without any duty to retreat to safety. But a duty to retreat when in public exists in many states. Ohio, Wisconsin, and North Dakota, however, extend the castle doctrine to one’s personal vehicle. In some locations, largely in the South, this doctrine extends to anyplace a person has a legal right to be. Vermont and Washington, DC, remain the only two jurisdictions where a duty to retreat remains supreme.

Stand-your-ground laws clearly increase the risk of homicides, specifically firearm homicides, and have no beneficial impacts on other forms of violent crime, suggesting that these laws have not lived up to their purported deterrent effect. Lawmakers should repeal them and revert to a more limited use of the castle doctrine to prevent the deaths of their constituents.

Policy Prescription #2: Concealed Carry Laws Should Adhere to the ‘May-Issue’ Standard

Concealed carry rights are nearly universal, although 23 states and the District of Columbia require a permit to do so as of 2023. The other 27 states do not require a permit, and individuals there can concealed-carry without any form of vetting.

Concealed carry laws differ in several distinct ways, ranging in order of least to most restrictive, from permitless carry to shall-issue to may-issue laws. Among the states that require a permit for someone to carry a concealed weapon, the permitting entity, often law enforcement, must issue it to anyone who meets minimum standards in shall-issue states. In may-issue states, there is some additional leeway for law enforcement to prevent issuing a permit to people who might be a threat to themselves or others, even if they otherwise would be eligible.

Shouldn’t a small-town sheriff who knows his community well have some discretion when reviewing applications? What if there was a violent man in that community who has been drinking when he walks through the door and who, in anger, strikes his wife repeatedly, but each time the cops come out for a domestic disturbance they are told that she simply fell down the stairs? If that man applied for a concealed carry license in a shall-issue state, he would easily receive it. In a may-issue state, the sheriff might wisely reject the application and potentially save the life of that man’s wife.

Lonny Pulkrabek, a Jefferson County sheriff who laments that his state legislature voted to make Iowa a shall-issue state in 2011, no longer has any discretion when issuing a concealed carry permit. He reported that in 2018, “I’ve already got 140 people through May that have criminal records that have permits, that were issued permits to carry. We’ve seen a lot more people with lengthy criminal histories who in fact are willing to go through and jump through the hoops and get the permit to carry it legally.”

Sheriff Pulkrabek maintains a “wall of shame” of the several hundred concealed carry permits he has been forced to issue to Iowans with criminal records because the state elected to follow an inferior law over a decade ago. Researchers, utilizing the natural experiment set by the various policies in force in different states, have detected differences between states with divergent legal frameworks as they pertain to concealed carry. The Science of Gun Policy indicates that shall-issue laws, such as Iowa’s, may increase overall violent crime compared to may-issue laws. Based on the underlying research, scientists estimate that in 10 years following a transition to the more permissive type of concealed carry law, violent crime increases by up to 15 percent.

Since concealed carry laws have been shown to increase violent crime, shouldn’t we have some say about who walks around town with a hidden firearm? Unfortunately, many state legislatures haven’t been following the science. Iowa recently went even farther afield, along with Tennessee and Texas, by weakening their laws to allow for permitless carry beginning in the summer of 2021. I worry that it will lead to more crime and more bloodshed.

In the Covid pandemic, the average American learned what public health can and cannot do. We’ve witnessed the scientific method unfold before our eyes as we waited for vaccines and treatments to be created in record time. Just as public health measures—such as staying at home in the early phases of the Covid crisis, wearing masks once society began to open, and vaccination—tamed this most recent pandemic, I have faith that science can do the same thing for endemic gun violence in America.

The science compiled by the RAND Corporation suggests a series of potential legislative approaches that will save the lives of some of the over 45,000 Americans who die by firearms each year. We cannot eliminate every injury, every death, or every shooting, but we must recognize that we can positively impact our fellow Americans, save lives, and relieve suffering by implementing some very simple laws that I describe.

Adapted from Under the Gun: An ER Doctor's Cure for America's Gun Epidemic, by Cedric Dark, MD, MPH, with Seema Yasmin. Copyright 2024. Published with permission of Johns Hopkins University Press.