The Wrong Hands

In the context of the recent horrors in which deranged persons have shot and killed scores of innocents, we have renewed discussions of gun control legislation in hopes of averting such tragedies in the future.

After the assassinations of Martin Luther King, Jr. and Bobby Kennedy, Congress passed the Gun Control Act of 1968.  Attempts to assassinate American presidents, including one that was very nearly successful in ending Ronald Reagan's life in 1981, continued unabated.

There is a common theme in these tragedies, whether it's John W. Hinckley, Jr. (who shot Reagan), or Seng-Hui Cho, who killed 32 and wounded 17 on the campus of Virginia Tech in 2007, or James Eagan Holmes, who killed 12 and injured 58 in a movie theater in Aurora, Colorado earlier this year ... the list seems endless.  And that common theme is mental illness.

Anyone who could shoot a classroom full of kindergartners is insane beyond our ordinary capacity to fathom madness.  Mental health professionals understand the disconnection from reality that occurs in the minds of the psychotic.  The rest of us can only shake our heads in bewilderment.

On December 7, 1993 (yes, a day that will live in infamy) Colin Ferguson opened fire on passengers on the Long Island Railroad.  Among his victims were Dennis and Kevin McCarthy.  Dennis was killed, and his son Kevin was seriously injured. Dennis's wife, Carolyn, a nurse, was elected to Congress three years later, on a mission to promote gun control legislation.

In the 16 years since her election, Carolyn McCarthy has introduced many gun control bills.  Most have languished in House committees.  But after the Virginia Tech shooting, McCarthy realized the shooter could have been disqualified from purchasing firearms if there had been a more robust database of mental health history to be queried by dealers.  The National Instant Check System (NICS) was created to assure that people with felony records who are prohibited by federal law from purchasing guns cannot obtain firearms from licensed dealers. McCarthy's bill became the NICS Improvement Amendments Act of 2007 and included funding to beef up the system of getting information about disqualifying mental illness into the database.  It was strongly supported by the National Rifle Association and signed into law by President George W. Bush.

Doesn't the NRA oppose all gun control legislation?  Obviously not.  The NRA is just as keen as everyone else on keeping guns out of "the wrong hands."  But McCarthy's bill was opposed by organizations of mental health professionals, including psychologists and psychiatrists, who complained that it would only add to the stigma of mental illness.

Under current federal law, persons who have been hospitalized involuntarily because they are a danger to themselves or others and persons who have been adjudicated mentally incompetent are disqualified from buying guns.  The key element is that this has gone through the legal system, which has due process and safeguards against infringing upon the rights of persons who aren't really crazy.  This is important, because in many states people can be involuntarily admitted to psychiatric facilites on the say-so of just about anyone.  If your spouse thinks you are suicidal and fills out the papers, a constable will take you into custody, and you will be placed in a psychiatric bed somewhere until a judge holds a hearing on the matter within a statutorily specified time, typically 24 hours. Before the hearing, you will be interviewed by a mental health professional.  At the hearing, you will be represented by legal counsel.  If you are not, in fact, dangerously mad, that will be determined at the hearing, and you will be released. If the judge says you are a danger to yourself or others as a consequence of mental illness, you are then disqualified under federal law from owning firearms. Not only are you prohibited from future purchases, but guns in your possession are to be confiscated.

You can see, quite easily I'm sure, that this approach will fail to identify many people who are mentally ill and potentially very dangerous, because most such people are never processed through the legal system and thus never disqualified from gun ownership.

If you are a patient in my emergency department who suffers a loss of consciousness as a result of some medical condition, such as a seizure, or intoxication, or a precipitous drop in your blood sugar, I am required to fill out a form saying whether the Commonwealth of Pennsylvania should initiate a proceeding to determine whether your driving privileges should be restricted. Most states do not have such laws, and where such laws exist they certainly have unintended consequences, such as deterring patients with seizures from seeking medical care when they should.

Why not have a requirement that I fill out a form for every crazy person I see that indicates whether the state should initiate a legal proceeding to determine whether such a person is dangerous and should be disqualified from possessing firearms?

Essential features of such a system would be the involvement of the legal system, with guaranteed due process and rights of appeal, and the entry into the NICS database of determinations that persons have been disqualified.  The role of the legal system is crucial, because a system that disqualified people based on the opinion of a psychiatrist would result in many disqualifications by mental health professionals who simply don't like guns and think people - all people - shouldn't have them.

News reporting and the blogosphere, not to mention innumerable postings on social networking sites, have already made the point that our mental health system is woefully underfunded and inadequate to meet the needs of the population.  Ask any emergency physician or nurse about schizophrenics living under bridges, people who in generations gone by would have been long-term residents of state mental hospitals.  Might some of those who were "deinstitutionalized" really have been much better off living in group homes instead of state institutions?  Absolutely.  But what about the ones who are living in large cardboard boxes, with the occasional stint in a homeless shelter or an acute care psychiatric facility, only to wind up back on the street, seeking shelter under a bridge or the warmth of air rising from a grate over a city subway?  While our mental health system struggles and fails to meet their needs, how many people who are less overtly crazy get no care at all because the resources simply don't exist?

We can pass all the gun control laws we want with no effect whatsoever on the problem.  Until we commit far more resources to our mental health system and devise a mechanism that identifies those too dangerously insane to own firearms, we will have many more tragedies like those in Aurora, Colorado  and Newtown, Connecticut.