Originally published on the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics Bill of Health blog.

Suicide is one of today’s most pressing public health issues. It’s the second most common cause of death for those ages 15-34, and claims over 40,000 lives every year. Of those, a staggering 20,000 are the result of firearms. To put that in perspective, there are about 30,000 gun deaths overall in the United States each year, which means that self-inflicted fatalities make up over 60% of total domestic gun deaths. Of the most prevalent means of attempting suicide, firearms are by far the most lethal. Firearm suicide attempts end in death more than 85% of the time, whereas attempts by drug overdose — the most common method — are only fatal 3% of the time.

While suicides by firearm have been on the rise in recent years, there may be an easy way to substantially reduce their incidence. A new study out of the University of Alabama Birmingham by Vars, et al., suggests that allowing individuals at risk of suicide to put themselves on a voluntary “Do-Not-Sell’ list, which would result in a waiting period before they could acquire a firearm, could be effective in preventing suicide attempts. The researchers surveyed 200 patients at both in- and out-patient psychiatric facilities who had disorders associated with anxiety and depression, and found that nearly half of them would put themselves on a list which would preclude them from quickly accessing firearms in the event that they were contemplating suicide. This is particularly notable given that these were all Alabama residents — a state that ranks in the top 10 of Guns and Ammo’s list of the best states for gun owners. In other states with more robust gun control and fewer gun enthusiasts, the Do-Not-Sell rate could very well be higher.

The theory behind the potential efficacy of such a list is that, for many, serious suicidal contemplation is a temporary experience which passes. Research suggests that a majority of those who attempt firearm suicide only contemplate it for less than a day. One study found that almost 50% of those who attempt firearm suicide wait less than 20 minutes between deciding to take their own life and attempting to do so. The majority of those who survive don’t end up dying of self-inflicted injuries. Thus, if a Do-Not-Sell list can prevent potential suicide victims from acquiring firearms immediately, there is a significant chance those suicides will never happen. While there is some evidence to suggest that decreasing access to firearms for those at risk of suicide could lead to increases in other forms of self-harm, the comparatively low success rates of other suicide methods suggest that lives would be saved simply by taking guns out of the short-term equation.

If actual Do-Not-Sell signup rates were to be consistent with what Vars and his colleagues found, the number of lives saved by such a list would be substantial. Vars, et al., found a signup rate of about 46% in the at-risk pool they surveyed. Assuming a similar rate among those who would attempt suicide by firearm nationwide — which, granted, may be a self-selecting pool less likely to register for such a list — a voluntary Do-Not-Sell list would prevent over 9,800 potential suicide victims from obtaining firearms when suicidal thoughts arise. Given that 90% of those who unsuccessfully attempt to commit suicide end up not committing suicide later, allowing people to delay their acquisition of firearms could save nearly 9,000 lives every year. That means 30% of all gun-related deaths that happen in the United States each year would never have the chance to occur.

While the potential efficacy of a Do-Not-Sell list shouldn’t be particularly surprising — people have been self-binding since Odysseus tied himself to the mast of his boat to avoid heeding the sirens call as he passed their island — its potential impact on the number of gun deaths each year is remarkable. Those of us in favor of stronger gun-control laws would likely advocate for a federal mandatory waiting period for all gun purchases, but we shouldn’t let the perfect be the enemy of the good. The voluntary Do-Not-Sell list has shown that it has the potential to substantially decreases the number of needless deaths a year that result from readily accessible firearms, and it likely represents a far less politically polarizing step than further-reaching gun-control measures.

When talking about suicide, it’s easy to get lost in the statistics, but the human cost of even one life lost to suicide is unimaginable. Given the ease with which it could be implemented, if the Do-Not-Sell list could save even one life, I would say it was a no-brainer. But the fact that it could save thousands of lives makes it one of the most promising avenues for reducing suicide and gun-related violence currently available — and makes it too important for policymakers to ignore. Hopefully, as the Do-Not-Sell idea receives increasing attention, states will seriously consider implementing it. For some, it could literally make the difference between life and death.

Originally published on the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics Bill of Health blog.

In July, the Ninth Circuit held that Dignity Health, a faith-based hospital system in the southwest United States, was not exempt from the employee pension requirements of the Employee Retirement Income Security Act (ERISA). The hospital system decided in 1992 that it would consider itself a church for the purposes of ERISA, and therefore would qualify for ERISA’s church exemption and not have to provide fully funded or insured pensions for its employees. As a result of this decision, it underfunded its employees’ pensions to the tune of $1.2 billion.

The Ninth Circuit was the second to make such a ruling after the Seventh Circuit issued a similar decision against Advocate Health Care in March. Many thought these rulings would lead the Supreme Court to leave the issue alone, but that may not be what SCOTUS has in mind. Associate Justice Anthony Kennedy recently granted Dignity reprieve from complying with the Ninth Circuit decision while he and the other justices decide whether to hear the case. Hopefully, this signals that the Court is planning to extend the Ninth Circuit’s decision, ensuring that hospital systems with religious affiliations across the country fulfill their responsibilities to their employees and provide them with the pensions they deserve.

Dignity Health is not a church. While it did have an official relationship with the Catholic Church until 2012, at the end of the day Dignity Health is a medical services juggernaut. It is the fifth-largest hospital system in the country, with 39 acute care hospitals and over 250 ancillary facilities spread across Arizona, Nevada, and California. Its annual revenue is approximately $10.5 billion. It’s so big that in 2012 it was included in an antitrust investigation by the California Attorney General’s Office to assess the impact of hospital consolidation on health care pricing in California.

The arguments in court centered on Dignity’s relationship with the Catholic Church. Dignity argued that because it is a non-profit with a religious affiliation, its pension plans should be regarded as church plans. The plaintiffs countered by arguing that Dignity is a hospital system — not a church — and that it has acquired many non-religious hospitals which perform procedures that go against catholic teachings. Both sides are trying to make sense of an opaque statute. ERISA provides that an organization qualifies for the church plan exemption if it is “associated with a church..[and] shares common religious bonds and convictions,” but it also notes that plans are not church plans if they are for the benefit of employees “who are employed in connection with…unrelated trades or businesses.”

While these arguments make sense from a legal perspective, on a policy level they appear to miss the point. Whether or not Dignity Health has a strong association with the Catholic Church seems irrelevant to whether it should be able to underfund the pensions of its estimated 56,000 employees. The purpose of ERISA is to protect employees, and it’s unclear why a nurse who works for a non-religious hospital is entitled to more protection than a nurse who works for Dignity Health simply because its board shares a set of religious beliefs.

Furthermore, under the provision of ERISA on which Dignity relies, there is no requirement that the organization be a non-profit. Thus, taking Dignity’s argument to the extreme, for-profit companies could avoid complying with ERISA’s pension funding and disclosure requirements by establishing a relationship with a religious organization. In other words, Google could stop adequately funding the pensions of its 57,000 employees — saving billions of dollars — simply by finding religion.

Fortunately, the federal courts that have heard the case have recognized the absurdity of this argument. The U.S. District Court for the District of Northern California noted in its rejection of Dignity’s position that “to maintain a church plan, an organization must not only be associated with the church, but it must have [as] its ‘principle purpose or function . . . the administration or funding of a [benefits] plan or program . . . for the employees of a church.’” Given that Dignity is not a church, the court found that it should have to comply with ERISA like all the other hospital conglomerates that don’t have spiritual proclivities.

It seems as though the courts are getting this one right, but those decisions fail to reach many hospitals and medical centers across the country that continue to underfund pensions for their employees because of religious affiliations. We’re talking hundreds of thousands of doctors, nurses, technicians, orderlies, and other staff members that don’t have ERISA protection for their pensions because the hospitals for which these people work think their religious connections exempt them from fulfilling their obligations as large-scale employers. Hopefully, the Supreme Court’s decision to consider taking this case signals that this practice will soon come to an end.

The church exemption to ERISA exists for good reason. Faith-based organizations without avenues for generating revenue likely can’t fund and insure pensions for their employees in the way multi-national companies can, and they shouldn’t be held to the same standards. But that doesn’t mean a health care conglomerate with over $10 billion in annual revenue should be able to shirk its responsibilities to its employees because it has a spiritual affiliation.  ERISA exists to protect employees, regardless of their employers’ religious leanings, and it’s time for that protection to be afforded to employees of religiously affiliated health care systems.