Mass Shootings, Mental Illness and Stigma

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Devan Stahl, PhD

Over the past two months, we have witnessed two more mass shootings in Las Vegas and Sutherland Springs, TX. Once again, these incidents bring up the debates surrounding gun legislation and access to mental health care. In reference to the Texas shooting, President Trump commented, “This is a mental health problem at the highest level. It’s a very, very sad event.” Soon after, it was revealed that Devin Kelley, the Texas shooter, had briefly escaped from a mental hospital in 2012 after he made death threats against his superiors in the Air Force. Both the president and the media emphasized the connection between mental illness and mass shootings. In fact, Johns Hopkins University found that over one-third of all news stories about mental illness were connected to violence. Psychiatric journals are also more likely to publish articles connecting mental illness with aggression than mental illness and victimhood, even though persons with mental illness are ten times more likely to be victims of violent crimes, including police shootings. It is no wonder that 63% of Americans blame mass shootings on the failure of the mental health system.

When confronted with a mass shooting, it is hard not to assume that mass shooters are mentally ill. After all, what sane person could commit such a horrible act? The media and even psychiatric professionals are quick to look for associations between mental illness and mass shootings. After Adam Lanza took the lives of twenty children and six adults at Sandy Hook Elementary School, new research on the brains of mass shooters began. More recently, the brain of Stephen Paddock, who killed 59 people in Las Vegas, was shipped to the Las Vegas coroner’s office for a neuropathological examination to look for any “mental aberrance” to explain his behavior, even though neuropathologists admit correlating brain structures with behavior is “cloudy business.”

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Image description: a cardboard sign is tied to a tree, with lettering that reads “stop gun violence :(” in blue and red. Image source: Tony Webster/Flickr Creative Commons.

Research shows us, however, that the link between gun violence and mental illness is far more complicated than it would appear. In general, it is hard to generalize about mass shooters because they are relatively rare. Although there is some evidence to show persons with severe or untreated mental illness might be at increased risk for violence when experiencing psychotic episodes or between psychiatric hospitalizations, many of these studies have been heavily critiqued for overstating connections between serious mental illness and violence. On aggregate, there is not a strong connection between mental illness and gun violence.

Close to 18% (43.4 million) of adults in the U.S. have some form of mental illness, which is on par with other countries, yet Americans are ten times more likely to die from guns than other citizens in high-income countries. The American Psychiatric Association found that around 4% of violent crimes perpetrated in America are attributable to mental illness and only 1% of discharged psychiatric patients commit violence against strangers using a gun. Persons with mental illness are less likely than those without a mental illness to use a gun to commit a crime. The vast majority of people with severe mental illness, including schizophrenia, bipolar disorder, and severe depression are no more likely than any other person to be violent. There is simply no clear causal link between mental illness and gun violence.

On the other hand, research shows that there are much stronger predictors of individual gun violence than mental illness, including: alcohol and drug abuse, domestic violence, past or pending violent misdemeanor convictions or charges, and history of childhood abuse.

There are a number of problems with associating mass shootings with mental illness. First, it stigmatizes millions of people living with mental health conditions. Research shows that negative attitudes surrounding mental illness prevent people from seeking treatment. Linking mental illness with violence threatens to restrict the rights and freedoms we afford ordinary citizens. Second, the burden of identifying would-be shooters has now fallen on psychiatrists who are not necessarily equipped to identify violent gun criminals. A number of states now mandate psychiatrists assess their patients for their potential to commit a violent gun crime, but psychiatrists are not great predictors of gun violence, and some research shows they are no more able to predict gun violence than laypersons. Psychiatrists who fail to identify mass shooters may now be held liable for crimes they fail to predict. Third, linking gun violence to mental health therapies may not help to reduce gun violence. Few of the persons who are most at risk for committing a violent gun crime have been involuntarily hospitalized, and therefore would not be subject to existing legal restrictions on firearms. Finally, the focus on mental health obscures other reasons for our nation’s gun violence problem. By focusing almost exclusively on mental health, we fail to identify the myriad of other factors, including historical, cultural, legal, and economic conditions that contribute to gun violence in our country.

It is easy to blame mass shootings on the “abnormal brain”–it is far more difficult to uncover or come to terms with the systemic causes of gun violence that wreak havoc on our communities. There are good reasons to ensure all Americans have access to mental health services, but access to such care is unlikely to stem the tide of mass shootings in our country. Mental illness has become a convenient scapegoat for politicians on both sides of the aisle when it comes to mass shootings, but it is time we begin to look more closely at other culprits.

Devan Stahl photoDevan Stahl, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics and Human Development in the Michigan State University College of Human Medicine.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 30, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Stahl: Disability and the Decisional Capacity to Vote

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Dr. Stahl presents on hoping for “miracles” at annual MSMS bioethics conference

Devan Stahl photoOn November 11, Center Assistant Professor Dr. Devan Stahl presented at the Michigan State Medical Society 21st Annual Conference on Bioethics. Held in Ann Arbor, the conference’s theme was “First do no harm: Avoiding Overdiagnosis and Overtreatment in Medicine.” Dr. Stahl gave the talk “Responding to those who Hope for a Miracle.”

Dr. Stahl presented strategies for engaging patients and families who request aggressive care with the hope of obtaining a “miracle.” As discussed in her latest article*, Dr. Stahl laid out a taxonomy of how the term “miracle” is used in the context of health care, as well as tips for healthcare providers responding to those particular invocations. The audience was presented with case studies that highlighted the different ways in which a patient may use miracle language as well as communication strategies that can help further a dialogue about appropriate and inappropriate uses of medical treatments.

* Note: viewing this article may require MSU Library or other institutional access.

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Episode 3: The Medical Ethics Resource Network of Michigan

No Easy Answers in Bioethics logoEpisode 3 of No Easy Answers in Bioethics is now available! Guest Dr. Leonard Fleck, Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Philosophy, sits down with producer Liz McDaniel to discuss his involvement in the Medical Ethics Resource Network of Michigan (MERN), a non-profit organization that existed for about twenty years, beginning in 1986. Dr. Fleck discusses the reasons why there was a need for such a network, and provides insight into the work they did in sharing expertise and helping individuals develop skills that were needed to thoughtfully address ethics issues within a clinical setting.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Dr. Eijkholt presents at Upper Great Lakes Palliative Care & Hospice Conference

Marleen Eijkholt photoCenter Assistant Professor Dr. Marleen Eijkholt recently traveled to Marquette, MI to present at the Upper Great Lakes Palliative Care & Hospice Conference, hosted by Lake Superior Life Care & Hospice.

The conference brought together a wide variety of providers, including home health and hospice providers. Dr Eijkholt’s presentations touched on two controversial areas, through a mix of practical case samples and some theory. Her first talk, “Ethical dilemmas in advance care planning–Mom isn’t herself,” sought to engage participants with the different advance care planning options in Michigan and throughout the U.S. The presentation explored the challenges that come with advance care planning instruments and their application. In Dr. Eijkholt’s second presentation, “Mom wants to die–Professional and personal ethical dilemmas at the end of life,” the participants discussed different end-of-life scenarios, patient perspectives, and wishes. The presentation and discussion also explored distinctions and strategies for dealing with patient requests at the end of life.

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Center faculty presentations from ASBH 2017

ASBH logo blueThe 19th Annual American Society for Bioethics and Humanities (ASBH) Meeting was held October 19-22 in Kansas City, MO. Center faculty Laura Cabrera, Guobin Cheng, Marleen Eijkholt, Leonard Fleck, Devan Stahl, and Tom Tomlinson attended and presented at the conference. The post below includes abstracts for each presentation (abstracts have been edited for length).

Laura Cabrera photo

Laura Cabrera, PhD
Assistant Professor, Center for Ethics and Humanities in the Life Sciences, Department of Translational Science & Molecular Medicine
Dr. Cabrera participated in a law, public health policy, and organizational ethics paper session, presenting “Centering the Re-Emergence of Psychiatric Neurosurgery: A Cross-National Comparison of Ethical and Societal Concerns in Media Coverage.”
Abstract: In light of the dark history of many surgical approaches to treat psychiatric disorders, understanding contemporary trends around the re-emergence of different methods to which patients and the public are exposed is essential to understanding their views and receptivity to them, both for healthcare and society. We conducted an in-depth content analysis of media articles reporting on all types of psychiatric neurosurgery between 1960 and 2015 with a focus on North America (Canada and the USA), Germany and Spain. After manually curating for duplicates and irrelevant returns, 167 Spanish articles, 160 German articles, and 217 articles from North America were analyzed inductively for content and coded for the phenomena of interest. Overall, the tone across articles was positive across interventions; articles retrieved from the German press were generally the most critical of the sample. Identity and privacy were among the few noted ethical and philosophical issues, and again found mostly in German articles. References to earlier forms of psychiatric neurosurgery were common across articles published after 2005. The findings suggest that while modern press reports about psychiatric neurosurgery tend to be positive and reference to historical antecedents are made in contemporary news, there is limited ethical and philosophical reflection. Future studies will further inform the influence of these trends on centering stakeholder values, perceptions of risk, and hope for benefits.

Marleen Eijkholt photoMarleen Eijkholt, JD, PhD
Assistant Professor, Center for Ethics and Humanities in the Life Sciences, Department of Obstetrics, Gynecology and Reproductive Biology
Dr. Eijkholt participated in a clinical ethics paper session, presenting “Tools for Trouble: Pain as a Clinical Ethical Torment.”
Abstract: Pain is a complex phenomenon that entails many clinical ethical challenges. Heterogeneity of providers and patients in the USA makes the context of pain treatment a hotbed for troubling practices. The current spotlight on the “opioid epidemic” reveals some of these challenges. For example, an increasing amount of requests relate to questions about the provider obligations in pain management, specifically for uninsured patients who are of an ethnic minority group. Restrictive guidelines reduce the epidemic to a biomedical pain treatment problem and do not address pain as a social construct, impacted by culture, environment and gender. While anthropological studies examine different ethnic factors contribute to management, perception and expression of pain, the clinical ethical literature is silent on these issues. I ask: What tools exist to address the socially constructed dimensions of pain in the clinic, and how should these be evaluated or developed?

Leonard Fleck photoLeonard Fleck, PhD
Professor, Center for Ethics and Humanities in the Life Sciences, Department of Philosophy
Dr. Fleck participated in a capacity, informed consent, and the quality adjusted life year paper session, presenting on “Precision QALYs: Precisely Unjust.”
Abstract: A recent essay by Heale (Journal of Medical Ethics, 2016) argues for the moral legitimacy (utility and equity) of individualized and personalized QALYs. He contends, for example, that it would be unfair to deny a patient access to $100,000 cancer drug that would give this patient three extra years of life simply because the average patient with that cancer would only gain four extra months of life. He assumes, arguendo, that some biomarker would allow us to identify such a patient before the fact (which is one objective of the precision medicine initiative), and concludes, from a cost-effectiveness perspective, that it would be unjust to deny this patient that drug. I believe this argument is flawed for several reasons. Other justice-relevant considerations, not just cost-effectiveness and utility, are ethically necessary for making many allocation decisions that are “just enough.” “Ragged edges” and clinical uncertainty undermine the practical applicability of his individualized QALYs methodology. Irrelevant personal utilities are given undeserved ethical weight (Heale gives a Jehovah’s Witness example with this consequence). Ethically irrelevant features of an individual are given ethical weight by Heale that results in their being denied access to care from which they would otherwise significantly benefit. To illustrate, a cancer drug whose cost is related to dose size would be cost-effective for a 70 kg person but cost-ineffective for a 90 kg person, though both individuals would otherwise benefit equally. To conclude, precision medicine requires complex considered judgments of health care justice.

Devan Stahl photo

Devan Stahl, PhD
Assistant Professor, Center for Ethics and Humanities in the Life Sciences, Department of Pediatrics and Human Development
Dr. Stahl led the Christian Theology and Bioethics Affinity Group, discussing the recent book The Finest Traditions of My Calling with the book’s author Abraham Nussbaum. Dr. Stahl was also on the Religion, Spirituality, and Bioethics Affinity Group panel. The group’s focus was religious and spiritual aspects of clinical ethics consultation.

Tom Tomlinson photoGuobin Cheng photoTom Tomlinson, PhD
Director, Center for Ethics and Humanities in the Life Sciences; Professor, Department of Philosophy

Guobin Cheng, PhD
Adjunct Associate Professor, Center for Ethics and Humanities in the Life Sciences; Associate Professor, Southeast University, China
Drs. Tomlinson and Cheng participated in a panel session, presenting on “Clinical Ethics in China and the United States: Worlds Apart?”
Abstract: China can seem like (half) a world away from the United States. Different political and legal systems, different health care and insurance systems, different culture and social values. The list goes on. So one would not be surprised if similar clinical situations raised very different ethical questions, or led to different ethical conclusions, for different ethical reasons. And indeed this can be true. But one can also find the same questions, the same conclusions, and appeals to the same reasons. It is often claimed that Chinese people place more value on the interests of the family and less on the interests or rights of the individual. Some cases will be designed to explore this hypothesis. Others will aim to surface whether quality of life plays different roles in decisions about continued treatment, and in what ways Chinese and American parents are obligated to protect their child’s best interest in decisions about medical treatment.

Related reading: Center faculty present at 18th Annual ASBH MeetingCenter faculty presentations from ASBH 2015

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Humanity in the Age of Genetic Modification

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Jennifer Carter-Johnson, PhD, JD

Scientists have recently announced that they had used the new gene editing technique, CRISPR, to remove remnants of ancient viruses that had integrated into the pig genome. An amazing feat of genetic engineering to be sure—but the article is notable as a first step in “humanizing” pig organs for use in organ transplant by removing pig-specific viruses before they can infect human organ recipients. The idea of humanizing pigs should make us wonder—what does it mean to be human? How much genetic modification can pigs undergo and still be pigs? How do we define humanity for our neighbors and ourselves? How much genetic modification would it take to remove the label of humanity?

These questions are not asked in a vacuum nor is the research being conducted solely for philosophical inquiry. We need organs to save lives. There are over 116,000 people on the organ donor list and only 33,611 organ donations each year. About 20 people die every day in the U.S. waiting for a match so that they can receive a new heart, kidney or lung. Additionally, not everyone who actually receives a transplant has a successful outcome.

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Image description: a Lego figurine of a person dressed in a pig costume is shown in the foreground against a yellow and white background. Image source: clement127/Flickr Creative Commons.

Transplant rejection occurs because each person has a fairly unique set of signal markers on their cells that allow the immune system to identify “self.” Bacterial or viral infections trigger immune responses in part because they change the infected cell’s signal markers from “self” to “foreign.” A transplanted organ also looks “foreign” to the recipient’s immune system due to the difference in signal markers, and this immune response leads to transplant rejection. For instance, identical twins would have very little risk of transplant rejection, while two unrelated people of different backgrounds would likely be unable to donate to each other. Thus, doctors search for the greatest amount of match between recipient and donor, and then suppress the recipient’s immune system to further decrease the risk of transplant rejection.

Using animal organs introduces yet more foreign signals to the organ recipient, leading to the desire to humanize those organs with markers that signal “human” and “self” to the recipient. In fact, doctors have been using pig heart valves in transplants since the 1970s. These hearts valves are extracted and then stripped of live cells to decrease the risk of rejection. This preparation procedure limits types of transplants that can be performed, and even with preparation, rejection issues may eventually arise.

Therefore, today’s scientists are working to use genetic engineering to modify pig organs to express the same cell markers that signal “self” to a human recipient. The referenced article described the development of pigs without endogenous retroviruses that some fear could infect recipients. From that basis, scientists could use several different techniques to develop pigs with humanized organs. One technique would be to genetically modify an embryo such that the pig’s cells express more “human” markers and less “pig” markers. Another technique that has been pioneered recently would be to inject human cells into a pig embryo such that the resulting chimeric pig would grow a genetically human organ.

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Image description: three pigs are shown outside through metal fencing. The main pig appears to be smiling. Image source: Peppysis/Flickr Creative Commons.

Both of these techniques raise the question of what it means to be human. Merriam-Webster defines the noun human as “a bipedal primate mammal (Homo sapiens) : a person.” Furthermore, the adjective definition of the word human, “having human form or attributes,” broadens that definition in an ambiguous way that leaves us no closer to an answer than before. After all, the point of humanizing cells is to give them human attributes for organ transplantation. Surely, that isn’t enough to make the pig a human? Pigs with genomes edited to have organs that look more “human” will likely still act like pigs. But we don’t truly know how multiple genetic changes will present. Looking to the chimera technique, would a chimeric pig with the heart and kidneys of a human still be a pig? What if some of those human cells colonized the brain and some percentage of neurons were human? How do we answer the question of humanity? Do we ask what percentage of the body is human? Do we see if the animal still acts like a pig or test its skills on the SAT?

In contrast, does a person who receives a pig heart transplant cease to be human and become a pig? Humans do not have a great track record of recognizing humanity in others. Perhaps in recent times, we in the United States have not had to consider what qualifies as human. A baby born from a human mother is a human. But this concept has not always been so straightforward. Constitutional definition of a slave as 3/5 of a person and the idea of blood quantum to limit Native American rights go back to the beginning of our country. More broadly, Hitler wanted to develop a master race and viewed Jews as subhuman – leading to horrific abuses and mass murder. Today, some countries still view women as property rather than humans with rights.

Genetic technologies will challenge how we view ourselves, our neighbors, and the next generation. Genetic testing has revealed Neanderthal genetic code in many of us due to interbreeding thousands of years ago. CRISPR-based tools will eventually allow parents using artificial reproductive technologies to select genetic traits for their children. How many modifications would it take for a child to cease to be human? Perhaps super strength or gills to breathe under water sound like fantastic science fiction now, but so too did the tablets and communicators of Star Trek in the 1960s and the watch phone/TV from Dick Tracy in the 1940s. Returning to the idea of organ transplants, would a skin bag full of organs derived from a human’s cells but with no brain be considered a human? Would your answer differ if there was a brain but no higher order brain function? Such an option could reduce organ rejection to nil if a person’s cells could be used to create their own replacement organs.

The dangers of relegating a population to second tier status because they are genetically different from the norm have been explored across fiction from Animal Farm to the X-Men. Humanity’s history suggests that those stories are rooted in our inability to see humanity in those we deem as other. Advances in science mean that we need to define what it means to be human in order to avoid abuses equal to slavery or Nuremberg. Our world is changing and so too will humanity – whether or not we are prepared.

j-carter-johnsonJennifer Carter-Johnson, JD, PhD, is an Associate Professor of Law in the College of Law at Michigan State University. Dr. Carter-Johnson is a member of the Michigan State Bar and the Washington State Bar. She is registered to practice before the U.S. Patent and Trademark Office.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 9, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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Dr. Stahl presents at Michigan’s first statewide Advance Care Planning conference

stahl-crop-2015Center Assistant Professor Dr. Devan Stahl recently presented at the Michigan Advance Care Planning Conference: Strengthen Best Practices & Community Engagement. The conference was held October 13-14 in Lansing and presented by the Michigan Primary Care Consortium.

Dr. Stahl presented on “Recurrent and Neglected Ethical Challenges in Advance Directives.” The presentation reviewed the ethical challenges providers and surrogates face when implementing advance directives. Those in attendance discussed how to evaluate and resolve these ethical challenges that commonly occur in the acute setting, as well as how to develop strategies for helping patient patients to create meaningful and clinically useful advance directives. The group also discussed the potential use of patience preference predictors as described by Drs. Stahl and Tomlinson in their recent podcast episode: The Patient Preference Predictor: Tomlinson and Stahl – Episode 1.

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