Philosophy, Mental Illness, and Mass Shootings

This post is a part of our Bioethics in the News seriesBioethics in the News logo

By Robyn Bluhm, PhD

Over the past month, mass shootings have occurred in Gilroy, CA, in Chicago, in El Paso, and in Dayton. Most recently, the FBI has arrested a man in Las Vegas who had been planning a shooting spree. It’s common, after such a shooting occurs, to speculate about the mental health of the shooter. In a way, this is understandable: we cannot help but feel that anyone who could do such a thing is not mentally well. We can’t imagine what it would be like to be someone who is capable of meticulously planning and carrying out a mass killing like the one in Charleston, or Parkland, or Sandy Hook, or Pittsburgh, or Las Vegas, or so very many other places in the United States.

It’s true that some of the people who have become mass shooters have been diagnosed with a serious mental illness. But there are many reasons to reject the narrative of the mentally ill mass shooter. For one thing, it does not really fit the facts: the relationship between mental illness and mass shootings is murky at best. For another, it does a grave disservice to people who have a mental illness. As Devan Stahl has shown, associating mass shooting with mental illness stigmatizes people living with mental health conditions, who already face significant stigma.

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Image description: multiple rifle-style gun are shown laying on a green surface. Image source: Phanatic/Flickr Creative Commons

Mental illness stigma is a complex phenomenon reflecting multiple beliefs. Research has shown that people tend to view those with mental illness as dangerous and unpredictable. Biological explanations of mental illness, in particular, can lead people to think that those with mental illness are fundamentally different from those who do not have such a diagnosis. Again, these beliefs are not supported by data. But they do provide people with the comforting sense that there is an explanation for mass shootings. Notably, it’s an “internal” explanation that focuses on the shooter himself, rather than on broader social and policy issues relevant to the phenomenon. And for some, that fact, too, is comforting.

How philosophy can help us think about mass shootings and mental illness

But, I think, there is another way of thinking about the link between mental illnesses and mass shootings that may actually be helpful. Rather than focusing on whether individual mass shooters (or the majority of mass shooters) are mentally ill, we can think about the similarity between mass shootings and (some) kinds of mental illness. The philosopher Ian Hacking has written about the phenomena of transient mental illness, by which he means: “an illness that appears at a time, in a place, and later fades away. It may spread from place to place and reappear from time to time. It may be selective for social class or gender, preferring poor women or rich men. I do not mean that it comes and goes in this or that patient, but that this type of madness exists only at certain times and places.”

Two aspects of his analysis may be useful here. First, he draws an analogy between these conditions and the concept of an ecological niche, which provides a place in which a species can thrive, whereas other places do not allow it to live at all.

Second, he emphasizes that categories of human beings are different from other categories: a tiger, for example, does not care whether we classify her as a tiger, whereas human beings often care deeply about how we are categorized. Because of this, categories of human beings are prone to what Hacking calls “looping effects.” He means that people and the categories into which they put them interact with and change each other. Once a category is “out there” in the world, people may come to identify with it and behave accordingly. During the 1980s, for example, mental health professionals began to see increasing numbers of people with multiple personality disorder, in part as a result of numerous books, televisions shows, and media stories that described this phenomenon. But groups of people also behave in ways that change the characteristics associated with a category. Over time, people who were diagnosed with multiple personality disorder began to exhibit more, and more differentiated, personalities.

Hacking’s analysis is useful even if we don’t think that “being a mass shooter” is a form of mental illness. (It’s also worth noting that even those who think that mass shootings are caused by mental illness don’t think that “being a mass shooter” is a kind of mental illness.) In fact, multiple personality disorder is not recognized as an illness by mental health professionals. Instead, what matters is that it was a recognizable way to behave, or, in Hacking’s words, to be a person – and also that it came into being in a particular kind of social context that, somehow, fostered this way of being a person.

Thinking about mass shootings in Hacking’s terms may help us to understand them. For one thing, mass shooters occupy a very specific niche: they exist almost uniquely in the United States during the past few decades. Appeals to mental illness as a cause can’t explain this fact. Moreover, mass shootings tend to follow a pattern – now that the category exists, members of the group tend to behave according to its rules. But (and this is the other half of the looping effect), we should also be alert to ways that the rules of the category may be changing over time. Recent mass shootings, for example, have been linked to white supremacy. It also seems to be becoming more common for mass shooters to leave a manifesto.

Perhaps most importantly, Hacking gives us a way to think about preventing mass shootings. Blaming mass shootings on mental illness implies that we can do nothing about them, especially if we view people who have a mental illness as essentially different from those who don’t have one. If men who become mass shooters do so in a very particular niche, then the way forward is to destroy the niche which lets them thrive.

Robyn Bluhm photoRobyn Bluhm, PhD, is an Associate Professor with a joint appointment in the Department of Philosophy and Lyman Briggs College. She is a co-editor of The Bloomsbury Companion to Philosophy of Psychiatry.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 29, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More Bioethics in the News from Dr. Bluhm: “Ask your doctor” – or just check Instagram?Antibiotics: No Clear CourseTo Floss or Not to Floss? That’s not the question

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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.

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

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Politics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence

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

By Sean A. Valles, PhD

This year’s presidential debates drew attention to gun violence in Chicago, as well as the (merely?) short-term reversal in the decades-long decline in US violent crimes. In the process, it reignited the smoldering political dispute over whether gun violence is a public health problem.

Every year, US hospitals and morgues see a stream of around 32,000 preventable deaths and 67,000 preventable injuries from guns. Indeed, hospitals and morgues are where one finds the consequences of public health problems. Yet, Surgeon General Murthy nearly had his Senate confirmation blocked by National Rifle Association lobbying in 2014, because he had once Tweeted: “Tired of politicians playing politics w/guns, putting lives at risk b/c they’re scared of NRA. Guns are a health care issue.” The debate continues.

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Image description: A bullet hole in a mirror. There are cracks extending out from the bullet, and a mirror shows the reflection of blue sky with clouds. Image source: Flickr user Jo Naylor.

Neglecting the medical and public health aspects of gun violence is a tragic lost opportunity to understand and respond to gun injuries and deaths. For example, only some jurisdictions require special permits to purchase handguns, but public health data indicate that adopting such polices helps to prevent both suicides and homicides. Thanks to NRA lobbying (again), the Centers for Disease Control is prohibited from doing any research that serves “to advocate or promote gun control.” The researchers who dare to work in the under-funded field “face emotional and financial demands” (Pettit 2016). Meanwhile, the 14-year-old National Violent Death Reporting System, the federal database for gun violence, still has zero data from ten states.

“Health in all policies”
Though its hands are partly tied, the CDC endorses the mainstream public health position that we must promote “health in all policies.” I.e. gun policies are (failed) health polices because the US continues to be plagued by gunshot wounds. Health is shaped by all manner of different causes, including laws and policies that were not explicitly designed to be health policies. For example, local commercial/residential zoning laws are public health issues. Why? Because they control the distribution of supermarkets, fast food restaurants and liquor stores in each neighborhood, affecting what the local population can/does eat and drink. Poorly designed city zoning laws are public health problems because they keep nutritious foods inaccessible and less nutritious alternatives abundant.

‘But, if guns are a public health problem then that would mean…’
The notion of promoting “health in all policies” has—surprisingly—faced some of the staunchest resistance from professional public health ethicists. Perhaps best illustrating the divide, the American Public Health Association has co-signed a letter with 57 other medical and public health organizations, calling for expanded gun violence monitoring data and gun control measures. Meanwhile, the ethics section editor of the association’s journal has opposed adding crime and other social ills “to the public health agenda”—doing so would make “public health… so broad as to be meaningless” (Rothstein, 2009). Similarly, an influential public health justice text resists calls to treat crime, war and various other social problems as public health problems, arguing that despite the desirability of a “broad scope of public health,” recognizing them as such would leave public health with “no real core, no institutional, disciplinary or social boundaries” (Powers and Faden, 2006).

Outside of the bioethics community, physician and free-market economics advocate Paul Hsieh echoes the idea that treating guns as a public health problem makes ‘public health’ unrecognizably broad, and it also “diverts us from genuine public health threats.” He scoffs that next we could even start thinking of issues like minimum wage and poverty as public health problems. Funny he should mention it; in fact, small differences in income are associated with drastic differences in life expectancy. An American man in the richest 1% has a life expectancy 14 years longer than a man in the poorest 1%! We now know that the causes of death and illness are complex and far-reaching—we must resist the urge to squeeze “public health” until its boundaries are neatly compressed and its efforts are hopelessly hobbled.

When the American Medical Association issued a statement in July that it considers guns “a public health crisis,” Keith Ablow, a member of the “Fox News Medical A-Team,” retorted that we don’t really know how many homicides could be prevented with gun control. But then he went on to say “they’re going to eat away at gun rights with medical research.” Like the NRA’s efforts to restrict CDC gun violence research, it appears that Ablow is very worried about what gun violence public health data would reveal. It would seem that he finds gun violence research more frightening than… gun violence.

It doesn’t have to be this way
But isn’t it foolish to think the medical and public health communities could help with a massive social problem like gun violence? It’s the reply I hear most often, and it always strikes me as an odd moment of pessimism. Odd, that is, in light of the widely-embraced moonshots of eradicating smallpox from every population on the planet (done!), and spending incredible sums to find treatments for the innumerable and mysterious varieties of cancer (optimistic!). Why do I so often see resigned shrugs when I insist we can make public health progress in the problem of Americans using guns to kill ourselves and each other almost five times more often than our Canadian neighbors? After all, when pediatricians talk to parents about gun safety during a child’s checkup, the parents become more likely to use a gun lock, which substantially reduces risks of gun accidents and gun suicides. Sounds like a good start.

We can do better, and some of my bioethics colleagues have been producing excellent work, making the case for why the deep-rooted social problems (violence, poverty, etc.) causing our public health ills must become national public health priorities, and also priorities for individual physicians. The first step though, is admitting that the roughly 100,000 people shot in the US each year each have gun violence medical problems, and that we in the US have a gun violence public health problem.

Sean Valles photoSean A. Valles, PhD, is an Associate Professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. He is a philosopher specializing in ethical and evidentiary issues in contemporary population health sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, December 1, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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After Newtown: Public Health and Bioethics Frameworks for Deliberating Gun Policy

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Ann Mongoven, PhD

The tragedy of the Newtown massacre has prompted national reconsideration of gun policy. But will it prompt reconsideration of the frameworks for that discussion? Or will continued questions about ambiguous constitutional parameters entrench the discursive cross-fire in which individual rights are pitted against public interest, hobbling meaningful response? By asking different questions, public health and bioethics offer alternative frameworks that could foster pragmatic balancing of individual rights and public interests. These frameworks enable new approaches to reduce gun violence without eliminating responsible gun ownership.

Public Health. The stranglehold of a discourse framed on individual rights, despite lack of clarity of constitutional dictates, prevents gun violence from being addressed as a public health challenge. Certainly that is odd, given the magnitude of the threat gun violence poses the public. Moreover, like other dangers perceived as public health issues, that threat is characterized by traceable patterns of vulnerability and spread. More than 30,000 Americans die annually from gun violence; gun violence ranks second among accidental causes of death only to car accidents; it is the leading cause for those who die in domestic violence; it is one of the highest-ranking causes of death among youth; it is the number-one cause for African-American teens. Indeed, if any disease posed an analogous threat it likely would be identified as the first priority of the public health community.

Yet legislative barriers impede federal public health agencies from analyzing gun violence using public health methods. In a recent editorial in Journal of the American Medical Association, Arthur Kellermann and Frederick Rivara describe the history of those barriers and how they curtailed gun violence research at the Center for Disease Control and National Institutes of Health(1). Post-Newtown Congress should rescind those obstacles to scientific research on gun violence. Meanwhile, public health leaders such as New York Mayor Michael Bloomberg and faculty at the Johns Hopkins School of Public Health Center for Gun Policy Research underscore the relevance of traditional public health questions(2). What is the epidemiology of gun violence? What are its common vectors (what types of individuals, institutions, practices, guns or ammunition)? What are the pathways of spread? What populations are particularly vulnerable? What targeted interventions could shut down those vectors, pathways, and vulnerabilities? Public health professionals assume that advancing public health can require restrictions on individual liberty, but typically they seek the most public health “bang” for the least “buck,” not only in terms of dollars spent but in terms of individual liberty constrained. Thus they pursue evidence-based, targeted interventions rather than broad, ideologically-based approaches.

Not only public health, but also the field of bioethics, offers frameworks for thinking about gun regulation that could move us beyond national paralysis.

Principlism. A commonly employed “principlist” approach to bioethics asks how we can balance diverse ethical principles that are individually cogent but that may press against each other in a tragic moral universe. These principles include respect for individual autonomy, beneficence, non-maleficence, and justice. With gun violence striking down innocent individuals and disproportionately affecting identifiable groups, respect for the autonomy of gun enthusiasts is just one factor among many to be balanced by principlism. Principlist reasoning has developed rigorous strategies to negotiate dilemmas between ethical principles that are in tension. These include proportional analysis of harms and benefits, consideration of least infringing alternatives when one ideal must be limited for the sake of others, and the continued maintenance of partially-implementable aspects of those principles that are deliberately subjugated. All these traditions of reasoning provide deliberative infrastructure for a new approach to gun regulation, conceived as something other than “a zero sum game.”

Cases and Beyond; Patients and Beyond: Multi-Level Ethical Analysis. Bioethics continually questions the relationship between cases, patterns, and policy. The field has a time-honored history of working at the case level, in all its specificity, while also discerning and addressing ethically relevant commonalities among cases. This back-and-forth has enabled policy initiatives that simultaneously respond to patterns while acknowledging the uniqueness of patients, families, and providers (such as living wills and durable powers of attorney). Gun policy discussions need a similar back and forth. While there may be truth to the adage “hard cases make bad law,” we cannot afford to ignore patterns at play from Columbine, to Virginia Tech, to Aurora, to Newtown. Nor can we ignore patterns in the “slow bleed” of cases that remain outside the national limelight while taking a greater aggregate toll, such as the use of handguns in individual suicides. One troubling pattern is the frequency with which guns legally owned by one family member become vehicles for tragic gun violence by another. Bioethics’ historically individualistic moorings have been stretched to recognize that patients come enveloped in diverse webs of family and community. We must recognize that gun-users do, too.  Rhetoric that treats cases as isolated events and gun-owners at atomistic individuals will no longer do.

Virtue Ethics. So-called virtue ethics have become increasingly prominent in bioethics. Virtue ethics ask: “What kind of community (clinic, health care system, etc.) do we wish to be? How can we become that kind of community?” Virtue ethics can change the nature of gun control debates by focusing on the character of communities rather than on  individual rights.  Do we wish to be a community in which there are more guns than people? In which gun violence is a leading cause of death, especially for youth? In which there are no “gun-free” zones? In which our children routinely watch gun murders and suicides enacted in diverse “entertainment” media? If not, how can we cultivate becoming a different kind of community?

We don’t just need a new conversation on gun policy. We need a conversation with new conceptual frameworks. We need frameworks that help us think through gun regulation that successfully balances multiple interests. Public health and bioethics offer several. By pushing us to ask different questions, they may help us arrive at better answers.

References:
1. Kellermann AL, Rivara FP. Silencing the Science on Gun Research. JAMA. 2012;():1-2. doi:10.1001/jama.2012.208207.
2. Johns Hopkins Bloomberg School of Public Health Center for Gun Policy and Research website.

mongoven smallAnn Mongoven, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Pediatrics at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, February 15. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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