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83:

FIREARM-RELATEDDEATHS

101.314 No 24

REFERENCES

I.

Garber AM. Fuchs VR. Silverman JF . Case mi x. costs. and QUlcomes:

differencesbetweenfacultyandcommunityservices inauniversityhospital.

N EnglJ Med 1984;310:1231-7.

2. Cameron JM. The indireclcoslS of graduale medical educalion. NEnglJ

Med 1985 ;312:1233 -8.

J. SchroederSA.

0

Leaf)'DS.Differencesin laboraloryuseandlengthof Slay

belweenuniversilyandcommunityhospilals. JMed Educ 1977 ;52:418-20.

4.

Frick AP, ManinSG. Shwartz M. Case-mix andcostdifferencesbelween

lea

ching and nonleaching hospilals. Mcd Care 1985; 23:283-95.

5. Griner

PF.

Use of laboralory leSIS in ateaChinghospital :long-IermIrends:

reduclions in useand relative cos . Ann Inlem Med 1979;90 :243-8.

6. WilliamsSV. EisenbergJM, Kilz DS.el al. Teachingcosl-effeclivediag

nosliclesl use 10 medicalstudents. Med Care 1984;

22

:535-42.

7. SchroederSA. Kenders

K,

CooperJK,PiemmeTE.Useof laboralorylests

and pharmaceulical

s:

varialionamongphysicians andeffectof

COSI

audilon

subsequent u

-

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1558

THE

NEW ENGLAND JOURNAL

OF MEDICINE

June 12 ,

1986

The county population is predominantly urban (92 percent) and

white (88.4 percent), with smaller black (4.4 percent) and Asian

(4.3 percent) minorities. All violent deaths in King

Count

y are

investigated by the office of the medical examiner.

We systematically reviewed the medical examiner's case files to

identify every firearm-related death

that

occurred in the county

between January 1,1978, and December 31 , '1983. In addition to

general

demographic

information, we

obtained

specific

data

regard

ing the

manner

of death , the scene

of

the incident, the

circum

stances, the relat ionship of the suspect to the victim, the type

of

firearm involved,

and

the blood alcohol level of the victim at the

time of autopsy .

When

records were incomplete ,

corroborating

in

format io n was

obtained

from police case file s and direct interviews

with the original investigating officers .

Gun shot deaths involving the intentional shooting of one person

by another were considered homicides . Self-protection homicides

were considered "justifiable" if they involved the killing of a felon

during the commission of a crime; they were considered "self

defense" if that was the determinalion of the investigating police

department and the King County prosecutor's office." All homi

cides res ulting in criminal charges and a ll unso lved homi

ci

des were

con

si

rlered criminal homici

de

s.

Th e circ

umstance

s of all homicides were also noted. Homicides

commi tted in association with an other felony (e.g. , robbery) were

identified as "felony homicides ." Homicides co

mmitted during an

a rgument or fight were considered "altercation homicides." Those

committed in the absence of eit her set of circumstances were

termed " primary homicides. "

Dea ths from self-inflicted gunshot wounds were considered

suicides if they were officially certified as such by one of us

(D.

T. R

.), who is the medical examiner. Unintentional self-infli cted

gunshot wounds were classified as accidental. Although the medi

cal examiner's office considers deaths involving the unintentional

shoo ting of one person by another as homicide, we classified

the se dea ths as accidental for our analysis . Deaths in which there

was uncertainty about the circumstances or motive were identi

fied as

undetermined.

"

RESULTS

Over

the six-year interval, the medical

examiner's

office investigated 743

deaths

from firearms (9.75

deaths

per 100,000 person-years) .

This

total repre

sented

22.7 percent of all violent deaths

occurring

in

King County

during this period, excluding traffic

deaths. Firearms

were involved in 45

percent

of all

homicides and 49 percent of all suicides in King

County - proportions lower

than

the

national

aver

ages of 61 and 57

percent

, res

pe

ctively.

12 , 13

Guns ac

counted for less than I

percent

of

accidental

deaths

and 5.7 percent

of deaths

in which the

circumstances

were

undetermined

(

Table

I).

Of the

743

deaths

from firearms noted during this

six-

year

period, 473 (63 .7 percent)

occurred

inside a

Table 1. Violent Deaths in King County, Washington, 1978-1983.*

M II ER

TOTAL

OF

DEATH

DE4.THS FlREARM DEATHS

'U

M

ER

% OF TOTAL

Suicide

1,049

469 45 .0

Homicidet 521

256 49 .0

Acc idenlal

1.58 1 II

0.7

Un

determined

122

7 5.7

TOlal

3.273 743

22.7

O ala

on

tra

ffic

dea

lh

s

are not in

cluded.

tC

aiegory

inc:ludcs uniOlenlionaJ homicides

Table

2

Relationship of Victim to Resident in Nonsuicidal Deaths

Involving a Firearm Kept in the Home .

RELATIONSHIP

No.

%

RELATIVE RISK

Stranger 2

1.0

Friend or acquaintance

24

37

12

.0

Nonresident relative

3 5

1.5

Resident 36 55

18 .0

Relalive 17

Spouse

9

14

Roommate

6

9

Self

7

Other 3

4

ased on lhe number

of

homicides involving strangers.

house or dwelling,

and

398 (53.6 percent)

occurred

in

the

home

where the firearm involved was kept. Of

the se 398 firearm

deaths,

333 (83.7 percen

t)

were sui

cides, 50 (12.6 percen t) were homicides, and

12

(3

percent

) were

accidental gunshot

.deaths. The precise

manner

of death was

undetermined

in three addition

al cases involving self-inflicted gunshot

wounds

.

In

265 of the 333 cases of suicide (80

percent

), the

victim was male . A blood

ethanol

test was positive in

86 of 245

suicide

victims tested (35 percen t) and

showed a blood

ethanol

level

of

100

mg

per deciliter or

more

in 60 of the 245 (24,5

percent).

Sixty-eight per-

cent

of the suicides involved handguns . In eight cases,

the medical

examiner's

case files specifically noted

that the

victim

had acquired

the firearm within two

days of

c

ommitting

suicide.

The victim was

male

in 30 of the 50 homicide

deaths (60

percent

). A blood ethanol test was positive

in

27

of 47 homicide victims tested (57

percent

) and

showed

a blood

ethanol

level

of

100

mg

per

deciliter or

more

in 10 of the victims (21

per

ce

nt

). Handguns were

involved in 34 of these

deaths

(68 percent),

Forty-two

homicides (84 percent) occurred

during

altercations in the home,

including

seven that were

later

determined

to

have

been

committed

in self

defense. Two additional homicides involv1ng the shoot

ing

of

burglars by residen ts were considered legally

j

ustifiable ." Forty-one homicides (82 percent) re

sulted in criminal

charges against

a resident of the

house or apartment in which the shooting occurred.

Four of

the 12 acciden tal

deaths

involved self

inflicted gunshot wounds. All

12

victims were male. A

blood

ethanol

test in the victims was positive in only

two cases. Eleven

of

these accidental

deaths

involved

handguns.

Excluding firearm-related suicides, 65 deaths oc

curred

in the house

where

the firearm involved was

kept (T a ble

2)

,

In

two of these cases, the victim was a

stranger to the persons living in the house, whereas in

24 cases (

37

percent),

the

victim was

an acquaintance

or friend. Thirty-six gunshot victims (55 percen t) were

residen ts of the house in which the shooting occurred,

including

29 who were victims

of

homicide. Resi

d t nts were most often shot by a relative or famil y

member

(11 cases), their

spou

se

(9

cases), a room

mate (6

cas( :s),

or themselves (7 cast':s) (Table

Vol. 314

Guns

the

deat

often as

of firea

involved

times

m

IJle

3).

F

in

a se

tal

gun

firearm

We f

dea ths

almost

ty occu

these

in

firearm

protect

Less

sidered

homici

defens

still les

cides i

these h

apartm

Ove

study

ker ha

to

rea

bl e.

14

ticula

violen

We

death

autho

timat

the r

uncle

volve

ity

of

simp

suici

easy

inten

rate

Table

I

'B

a

7/25/2019 Kellerman - 1986 - Protection or Peril - An Analysis of Firearm-Related Deaths in the Home

3/4

15

un

e 12 , 1986

Nonsuicidal

Death

S

1.0

120

15

18.0

)

OCCurred in

was kept

Of

were sui

es, and J

2

(3

. The precise

addition_

wounds.

percen t), the

positive

in

ercent)

and

d ccili ter Or

per

eight

cases

call y noted

within two

homicide

wa

s positive

and

deciliter

or

s were

) .

during

tha

t were

in self

shoot

red legally

re

of the

occurred.

sel f

in only

invol

ve

d

oc

was

a

in

) were

occurred,

Resi

or family

a room

2).

Vol.314 No. 24

FIREARtvl-RELATED

DEATHS

Guns

kept in

King

County homes were involved in

the

deaths

of

friends

or

acq uaintances

12

times as

often as in those of strangers. Even after the exclusion

of firearm-related suicides, guns kept

at

home were

involved in the

death of

a

member of

the

household

18

times more often

than

in the death of a stranger (Ta

ble 3).

For

every time a

gun

in

the home

was involved

in

a

self-protection homicide,

we noted 1 3 acciden

tal

gunshot

deaths, 4.6 criminal homicides; and 37

firearm-related suicides (

Table

3).

DISCUSSION

We found the home to be a

common location

for

deaths related to firearms . During our

study

period,

almost two thirds of the g

unshot deaths

in

King Coun

ty occurred inside a

house or

other dwelling. Over

half

these incidents occurred in the residence in which the

firearm involved was kept. Few involved acts of self

protection .

Less

than 2 percent of homicides nationally are

con

sidered legally

justifiable.

11

,

13

Although justifiable

homicides do not include homicides committed in self

defense, the

combined total of

both in our

study

was

still less than one

fourth

the number

of

criminal

homi

cides involving a gun kept in the home . A majority of

these

homicide victims were residents

of

the house or

apartment

in

which the

shooting occurred .

Over 80 percent of the homicides noted during

our

study

occurred

during arguments

or

altercations. Ba

ker has observed that in cases of assault, people tend

to reach for the most lethal weapon readily availa

ble.

14

Easy access to

firearms

may therefore be

par

ticularly dangerous in households prone to domestic

violence.

We found the

most common

form of firearm-related

death

in

the home t be suicide. Although previous

authors

have

correlated regional

suicide rates

with es

timates of

firearm

density,15,16 the precise nature of

the

relation between gun availability

and

suicide

is

unclear.

I

,1 7 The choice of a

gun

for

suicide

may in

volve a combination

of

impulse and the close proxim

ity of a firearm.

Conversely, the

choice of a

gun

may

simply

reflect the seriousness of a person's intent. f

suicides involving firearms are more a product of the

easy

availability of

weapons

than

of

the strength of

inte

nt

, limiting access to firearms will decrease the

rate of suicide. f the opposite is true, suicidal persons

Table 3. Classification of 398 Gunshot Deaths Involving a Firearm

Kept in the Home.

RELATI

V

CLA SS IFlCATI ON

No

.

R I iK*

Self-proteclion homicide 9

2 .3

1.0

Justifiable homicide

2 0.5

Self-defense homic ide 1.8

Unintentional deaths

12

3.0

1.3

Criminal homicide

41

10.3 4 .6

Suicide 333 83.7 37 .0

UnJen

own 0.8 0.3

ased

on

Ih

e number

or

elf prolcclion homicides .

KELLERMANN

AND

REAY

will only work harder to acquire a gun or kill them

selves by

other

means . For

example, although

th

elimination of toxic coal gas from domestic gas

sup

plies in

Great Britain

resulted in a

decrease

in success

ful

suicide attempts, 18

a

similar

measure in Australi

was associated with increasing rates of suicide b

other methods.

19

A recent

study

of 30 survivors of attempts to com

mit suicide with firearms suggests that many of them

acted on

impulse.

o

Whether

this

observation applie

to nonsurvivors as well is unknown. The recent

acqui

sition of a

firearm was

noted in only eight of our cases

and

we do not know

how

long before death any suicid

vi

ctim

planned

his

or her attempt. However,

given th

high case-fatality rate

associated with suicide attempt

involving firearms , it seems likely that easy access t

guns

increases

the

probability that an impulsive

sui

cide attempt will

end

in death.

21

Detectable concentrations of

ethanol

were found i

the

blood

of

a

substantial

proportion of

the victim

tested. This suggests that ethanol may be an inde

25

pendent risk factor for gunshot

death.

22

- Althoug

this

hypothesis

is

compatible

with

the known behav

ior

al and physiologic effect of

ethanol, the strength o

this association remains to be defined.

25

There are

many

reasons that people own guns . Un

fortunately,

our

case

files

rarely

identified

why

th

firearm involved

had been

kept in the home: We

can

not determine,

th

7/25/2019 Kellerman - 1986 - Protection or Peril - An Analysis of Firearm-Related Deaths in the Home

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1560

T H E NEW ENGLAND J O U R N A L O F ME DI C I NE

June 12,

1986

The home

can be a

dangerous

place.

We

noted 43

suicides, criminal homicides, or accidental gunshot

deaths

involving a

gun

kept in the home for every case

of homicide for self-protection.

In

the light of these

findings, it may reasonably be asked whether keeping

firearms ill the home increases a family's protection or

places

it in

greater

danger. Given

the

unique status

of

firearms

in American

society

and the national toll of

gunshot deaths , it is

imperative

that we

answer

this

question.

' ' 'Ie a re indebted to William Appkg a te, M.D. ,James P . LoGerfo,

M . D ., M . P .H .,

and

Noel Weiss , M .D ., for

their

review of this

manu sc ript; to Pat Luckman

,

Robin McColley

,

and Sara Clark

for

th e

ir

efforts in

its

preparation; and,

most

important, to the law

enforce

ment agencies of King

Count) '

for their

c

ooperat ion and

a

ssistance.

REFERENCES

I . Wri ght

lD

, Rossi P, Daly K, Weber-Burdin E. Weapons . crime. and vio

lence in America : a literature review

and

research agenda. Washington.

D.

C.

: Government Printing Office, 1981.

2. Wrig ht

JD,

Ros

si

P. Weapon

s. crime

.

and

violence

in

America: executive

summa!), . Washington, D.

C.

: Government Printing Of lice. 1981.

3. Wright JD . Public opinion and gun control : a comparison of results from two

recent national surveys. Ann

Am

Acad Pol

Soc

Sci 1981 ; 455:24-39 .

4 .

An analysi s of public anitudes towards handgun conlIo!. Cambridge. Mass :

Cambridgc

Repons,

1978.

5. Attitudes of the American electorate toward gun contro!. Santa Anna. Calif. :

Decision Making InSlitute, 1978.

6.

Newton

GD,

Zimring FE. Firearms and violence

in

American life: task

force. repon on firearms. Washington. D.C. : Government Priming Office,

1969.

7 . Davis JA Generd! social sur'\,eys .

1972-1978

: cumulative codebook.

Chicago : National Opinion Research Ccnter . Universit y of Chicago, 197H :

172

8.

Ale xander GR . Massey RM. Gibbs T, Alle kruse JM . Firearm-related fatali

ties: an epidemiologic assessment of violent death . Am J Public Health

19H5; 75: 165-8 .

9 . Yeager M , Alviani

JD. Loving

N.

How

well does that handgun

prOlec

. and your family" Techmcal repon no . 2. United States Co t YOU

Mayors . Washington,

D.C.,

1976. n erence

of

10.. Bureau of

Census

. 1980. census

of

population, Washington. Washinot

D.C .: Government Prmtmg Office, 1981.

0

on.

II. Uniform

crime reponing

handbook. Washington, D C : Federal

Bureau

InvesttgattOn,

Umted States Depanment of

Justice, 1984 . of

12

. Centers for Disease Contro!. Suicide surveillance. 1970.-1980.. April 1985

13.

Cnme

III

the

Umted

States 1983:

Umform

Cnme

Reports for

the U .

States. Washington, D.C.: Federal Bureau of Investigation, United S ~ : ~

Depanment of Justice, 1984. '"

14

. Baker SP. Without guns , do people kill people" Am J Public Health 198-.

75 :587-8. ) .

15

.

Cook

PJ .

The

effect of gun availability

on

robbery and robbery murde

cross-section study of

50.

cities . In: Hearings before the S U b c o m m t e r o ~

Cnme of the Commlllee on the JUdiCiary, Hou se of Representat ives.

Wash.

ington, D .

C.

:

Government

Printing Office , 1978 .

16

.

Markush

RE, Bartolucci AA. Firearms and suicide in the United States.

Am

J Public Health 1984; 74: 123-7.

17. Westermeyer J. Firearms, legislation. and suicide prevention. Am 1 Public

Health 1984; 74: 10.8 .

18. Brown lH. Suicide

in

Britain: more ""empts , fewer deaths, lessons for

public policy . Arch Gen Psychiatry 1979; 36: 1119-24.

19. Burvill PW . Changing patterns of suicide in AUSlIalia, 1910- 1977. Ac ,

Psychiatr Scand

1980.;

62 :258-68 .

20. . Peterson LG , Peterson M, O'Shanick

GJ,

Swann A. S e l f

i n ~ i c t e d

gunshot

wound s:

lethality of

method

versus intent.

Am

J PsychialIy 1985;

142

:

228-

31.

21

.

Baker SP,

O Neill

B. Karpf

RS .

The

injury fact book . Lexington,

Mass.

:

Lexington Hooks . 1984

.

22

.

Tinklenberg JR . Alcohol and violence. In : Bourne PG

,

Fox R. cds. Alcohol

ism : progress in research and lIeatment.

New

York: Academic Press ,

1973: 195-210..

23 . Alcohol and violent d ea th - E ri e County , New York, 1973-1983. MMWR

1984; 33:226-7.

24. Hedeboe J, Charles AV, Nielson J , et al. Interpersonal violencc: patterns

in

a Danish community. Am J Public Helilth 1985 ; 75:6513.

25. Goodman RA, Mercy lA, Loya F, et al . Alcohol use and inte rpersonal

violence: alcohol detected in homicide victims . Am J Public Heallh

1986

;

76 : 144-9.

26 . Drooz RB . Handguns and hokum: a methodological problem . JAMA

1977

;

238 :43 -5.

27 . Reay D, Tapp J . Annual Repon 1980.: Division of the King County Medi-

cal

Examiner, Dcpartment of

Public

Health

. Seallle: King County ,

1981.

ME

ACQU

IS

AN

AS

JAMS F

T

HE in

is

c

l

here

have

and trea tm

peets of i

the

relali v

ding in t

r

genital sh

known to

transmi ss

doeumen

ated with

InJune

herpes to P

rieneco fre q

contr olled

times

dail

.

days only,

th

e a

bilit

y

and viru ;

signs of inf

the

e x { e r n

ren ces)

for

During

"ho had

"eek

end -o

evalua tion

ine Pat icn

herpes fo r

cours e o n

before th r

sy mpt

o ms

penile ilC

a penil e I

s

mall

) m

O

\Vas

Cul t

u

proto

co

l

IV

e

aIs

On the leI

bl

ood

' '

ointme nt

has b

t tn

From th

l

iooallnS1

Bcthl:

sda.

Bldg

10

,

Suppor