El Paso AND Dayton. Less than 24 hours apart. Nowhere else on earth are mass murders occurring at the rate they are in the U.S. What is different about our country compared to others that have vanishingly low rates of gun violence, such as Japan?

Some politicians are trying to blame the shootings on violent video games, instead of our almost universal access to guns in this country, including weapons of war. Indeed, older literature suggested a link between violent video games and aggression. However, a 2019 longitudinal study, “Aggressive Video Games are Not a Risk Factor for Future Aggression in Youth: A Longitudinal Study,” with better methodology than the older studies, failed to show a link.

There is a strong relationship however, including a ton of research studies that show a strong association between gun deaths and easy access to guns.  In other words, it is not the video games, America, IT IS THE GUNS.

The same old story all over again

I first wrote this common-sense gun control story after the Parkland High School mass murders on February 14, 2018. It was published in The Hill and got the usual barrage of angry comments from lovers of the Second Amendment. That was 18 months ago. Think about that, Parkland was only 18 months ago. Since that time we have had close to one mass shooting per day every day since then. And now El Paso AND Dayton.

The story below is what I wrote for the Hill. Sadly, it is still relevant today because we have done NOTHING, ABSOLUTELY NOTHING to stop these horrific and predictably repetitive mass murders.

My story is particularly relevant now because pro-gun folks are once again deflecting the blame for our unique proclivity towards mass murder by gun. Couldn’t possibly be the extraordinarily easy access to guns? It must be easy access to violent video games, right? Maybe throw in some mental health issues and even, according to one state representative, gay marriage and our acceptance of people with sexual identities other than heterosexual.

When it comes to gun control, we’ve been asking the wrong question

As the title of my original story indicates, I believe when it comes to our approach to common-sense gun laws, we have been asking the wrong question about who should have guns.

Asking who should be restricted from gun ownership is not the right question, we should be asking who has demonstrated, via a standardized protocol, that they have earned the right to have one.

We are already using standardized protocols when we implement mandatory background checks to determine who should not have guns, but the screening, often poorly implemented, is based on categories of people (mentally ill, felons, domestic abusers) we think shouldn’t have guns. 

Related story: The Founders and the Sanctity of Gun Ownership

What I am proposing is we develop stringent and transparent tests of fitness to own a gun and then we apply those tests equally to everyone – first to get a gun and then repeated over time in order to keep the gun. This is not pie in the sky. Japan, a country with one of the lowest rates of gun deaths in the world has been doing this for years. They have proven that it works there. It can work here too.

Here is my op-ed from The Hill:

“Every time the gun control debate is reignited after another mass shooting, the conversation quickly focuses on who should be restricted from purchasing guns, almost always with the suggestion that the solution to our mass shooter problem hinges on preventing people with mental illness from acquiring access to guns. But asking who should be restricted from gun ownership is not the right question. Its answer will not make a single dent in our dismal standing as the country with the highest number of gunshot deaths in the developed world.

It can’t because we have demonstrated over and over that it is impossible to enforce such restrictions dependably.

Unstable people, including mass shooters, such as Nikolas Cruz and others, have obtained their firearms legally because, at the time they bought them, they did not meet the criteria to be denied gun ownership based on their mental health status.

Dr. Amy Barnhorst, the vice chairwoman of community psychiatry at the University of California Davis, explains the challenges:

The mental health system doesn’t identify most of these people because they don’t come in to get care. And even if they do, laws designed to preserve the civil liberties of people with mental illness place limits on what treatments can be imposed against a person’s will.

She points out that posting threatening statements on social media or scaring your classmates is usually not enough to hospitalize someone against their will.

Nor, do we (or should we) require that this type of information be reported to the National Instant Criminal Background Check System (NICS).

Reframing the approach to gun ownership

I believe it’s time to reframe the approach to gun ownership from opt-out (everyone who wants a gun can get one unless we can prove they should not have one) to opt-in (everyone who wants a gun must demonstrate, on an ongoing basis, that they are capable and willing to responsibly manage gun ownership).

For those of you who would argue that this is a violation of our Second Amendment right, I ask how is this different from what we do now?

We have already determined that it is legal to restrict certain categories of people from owning a gun (e.g., felons, domestic abusers) in the interest of public safety.

Why not go one step further and proactively determine who should be able to have a gun just like we decide who should be able to drive a car, practice medicine, or cut our hair?

Getting a gun in Japan

There is a successful model for this approach. Japan, a country with one of the lowest rates of firearm-related deaths in the developed world, has implemented a comprehensive system for evaluating prospective gun owners with an eye to public safety. This is what you have to do to get a gun in Japan:

  1. Attend an all-day class organized by the police and then pass a written test
  2. Apply for training at a licensed shooting range a process that requires a certificate of residency, a photo ID, and a list of past jobs and addresses
  3. Pass mental health and drug tests administered in a hospital test and present the certificate to the police.
  4. Pass an in-person interview with a police officer who may ask questions such as “Why do you want a gun?” “What do you do for a living?” “Do any of your relatives have mental health issues?”
  5. Pass a rigorous background check for any criminal record, association with criminal or extremist groups, evidence of instability or domestic strife.
  6. Attend a training session at a licensed shooting range that includes both a gun safety class and test as well as shooting instruction and a competency exam
  7. Obtain the approval of the police who make an unannounced visit to your home and workplace to ask employees and neighbors about your behavior, including such questions as “Do you ever hear screaming voices from their apartment?”

Once approved for a temporary license to have a gun, the applicant can visit a gun shop to select a gun. But you can only buy shotguns and air rifles, not handguns. And you cannot take the gun you selected home until the official license is issued.

The gun owner must then provide police with documentation on the specific location of the gun and ammunition in their home, each of which must be locked and stored separately. You have to have the police inspect the gun once per year and to re-take the class and exam every three years.

Too much, you say? Why should gun owners have to subject themselves to this type of scrutiny? If you take the time to read about the issue, the answer is clear.

It’s because it keeps guns out of the hands of bad guys — even gangsters in Japan don’t have guns — as well as irresponsible,  the mentally ill, unstable teens, domestic abusers, and a whole host of other people who most of us would agree should never have a gun.

Why should we do it? Because it works and what we are currently doing does not.”


Related stories:

There is No Better Time to Commit to Reducing Gun Violence

Kristof Asks the Right Questions About the Newtown Slaughter


This story was initially published in November 2018. Sadly it has been updated to reflect the most recent mass murders – El Paso and Dayton.

Patricia Salber MD, MBA (@docweighsin)

Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. Founded in 2005 as a single-author blog, it has evolved into a multiauthored, multi-media health news site with a global audience. She has been honored by LinkedIn as one of ten Top Voices in Healthcare in both 2017 and 2018.

Dr. Salber attended the University of California San Francisco for medical school, internal medicine residency, and endocrine fellowship. She also completed a Pew Fellowship in Health Policy at the affiliated Institute for Health Policy Studies. She earned an MBA with a health focus at the University of California Irvine.

She joined Kaiser Permanente (KP)where she practiced emergency medicine as a board-certified internist and emergency physician before moving into administration. She served as the first Physician Director for National Accounts at the Permanente Federation. She also served as the lead on a dedicated Kaiser Permanente-General Motors team to help GM with its managed care strategy. After leaving KP, she worked as a physician executive including serving as EVP and Chief Medical Officer at Universal American.

She has served as a consultant or advisor to a wide variety of organizations including digital start-ups such as CliniOps, My Safety Nest, Doctor Base. She currently consults with Duty First Consulting as well as Faegre, Drinker, Biddle and Reath, LLP.

Pat serves on the Board of Trustees of MedShare, a global humanitarian organization. She is also Chair of MedShare's Western Regional Council.


  1. Dr. Salber, thank you for reposting this. Your recommendations make even more sense today than they did a year and a half ago. Unfortunately, it appears as though the NRA, weakened though it may be, still retains the power to shut down sensible gun control measures at the federal level and in most states. News reports indicate Wayne LaPierre is still calling Trump to give him his marching orders.
    The fundamental problem lies in my field, not yours–as you know, I’m a lawyer. Sadly, in District of Columbia v. Heller, a case I call the Plessy v. Ferguson of 2d Amendment law, the Supreme Court for the first time recognized an individual right to own firearms, divorced from service in a state militia. While the Court’s opinion gives lip service to reasonable regulation, the NRA and its servants in the federal and most state legislatures don’t find any regulation to be reasonable. So we are where we are, and despite the usual groundswell of support for regulation, we are likely to stay there for the foreseeable future.
    There is really only thing we can do. We need to vote for candidates who will regulate guns, at the federal and state level. We also need to be certain those candidates understand that they need to appoint or confirm judges who understand that Heller is bad law, and needs to be overturned. Only then will Congress have the tools to end the slaughter. Lastly, we need to vote for candidates who will take private money out of politics, so our representatives are not beholden to the NRA and gun manufacturers.

    • Hi Mitch. I agree with all of your points. People have to understand that the appointment of qualified, fair and impartial judges is one of the most important “perks” of the party in power. While we were diverted with all of Trumps endless stream of antics and bad behavior, the Republicans were filling judge seats with young ideologues who will have their positions for decades.

      BTW, I saw a headline yesterday saying some folks were considering repealing the 2nd amendment. Have you heard that? Thoughts?

  2. Totally agree with Dr. Salber’s argument, except one: We absolutely SHOULD report threatening postings on social media to the National Instant Criminal Background Check System ( NICBS). How many anecdotal examples do we need to make it abundantly clear that among the multitude of verbal bullies lurk many would be actual killers? We do it with potential Islamist terrorists and we don’t get all riled up about their first amendment rights. Why are we so protective of white potential mass Killers’ first amendment rights? Is there some not-so-subtle racist attitude here?
    At the risk of angering First Amendment zealots, I would add to the criteria of gun-ownership denial (mental illness, felons, and domestic abusers) holding extreme right-wing ideologies, such as white supremacy. And when extreme leftists start resorting to violence -I would add them to the list as well. It is time (actually past due) that we value the lives of ALL the people over the perceived rights of the few potential killers among us.

  3. Dr Salber’s recommendations continue to make sense. We must continue to push forward on sensible approaches and safeguards until we achieve success on behalf of the People. As I recall Dr Salber was one of the earliest from the medical profession to advocate common sense approaches to stem gun violence many years ago. Remembering that reminds me we must strive for a national law given the results of this past Tuesday’s election.


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