APA Title Page and References

This assignment is designed to help you review APA writing guidelines and to begin finding references for the Critical Thinking that is due in Topic 3. This week you are going to start preparing for the assignment you have due in Topic 3. This will allow the instructors to review your research and give feedback you will use to develop the Topic 3 .

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Use the resources found to construct an APA title page and reference section that conform to guidelines found in the Publication Manual of the American Psychological Association. Reference sections should include at least two articles, one e-book, and one electronic source.

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Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 3 , N U M B E R 1 1 – 1 2 , N O V E M B E R – D E C E M B E R 2 0 1 6 ]12

Managing individuals with chronic

disorders of consciousness raises

ethical questions about the

appropriateness of maintaining life-

sustaining treatments and end-of-life

decisions for those who are unable to

make decisions for themselves. For

many years, the positions fostering

the “sanctity” of human life (i.e., life

is inviolable in any case) have led to

maintaining life-sustaining

treatments (including artificial

nutrition and hydration) in patients

with disorders of consciousness,

allowing them to live for as long as

possible. Seldom have positions that

foster “dignity” of human life (i.e.,

everyone has the right to a worthy

death) allowed for the interruption

of life-sustaining treatments in some

patients with disorders of

consciousness. Indeed, most ethical

analyses conclude that the decision

to interrupt life-sustaining therapies,

including artificial nutrition and

hydration, should be guided by

reliable information about how the

patient wants or wanted to be

treated and/or whether the patient

wants or wanted to live in such a

condition. This would be in keeping

with the principles of patient-

centered medicine, and would

conciliate the duty of respecting both

the dignity and sanctity of life and

the right to a worthy death. This

“right to die” has been recognized in

some countries, which have legalized

euthanasia and/or physician-assisted

suicide, but some groups fear that

legalizing end-of-life decisions for

some patients may result in the

inappropriate use of euthanasia, both

voluntary and nonvoluntary forms

(slippery slope argument) in other


This review describes the current

opinions and ethical issues

concerning end-of-life decisions in

patients with disorders of

consciousness, with a focus on the

impact misdiagnoses of disorders of

consciousness may have on end-of-

life decisions, the concept of

“dignity” and “sanctity” of human life

in view of end-of-life decisions, and

the risk of the slippery slope

argument when dealing with

euthanasia and end-of-life decisions.

We argue that the patient’s diagnosis,

prognosis, and wishes should be


Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS

Centro Neurolesi “Bonino-Pulejo” in Messina, Italy; and Dr. Caccamo is from the Department

of Psychology, University of Padua, Padua, Italy.

Innov Clin Neurosci. 2016;13(11–12):12–24

FUNDING: No funding was received for the

preparation of this article.

FINANCIAL DISCLOSURES: The authors have no

conflicts of interest relevant to the content of
this article.

Rocco Salvatore Calabrò, MD, PhD;
E-mail: salbro77@tiscali.it

KEY WORDS: Artificial nutrition and hydration;

euthanasia; minimally conscious state; right to
die; sanctity of life; vegetative state.


The Right to Die in Chronic
Disorders of Consciousness:
Can We Avoid the Slippery
Slope Argument?


Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 3 , N U M B E R 1 1 – 1 2 , N O V E M B E R – D E C E M B E R 2 0 1 6 13

central to determining the most

appropriate therapeutic approach

and end-of-life decisions for that

individual. Each patient’s diagnosis,

prognosis, and wishes should also be

central to legislation that guarantees

the right to die and prevents the

slippery slope argument through the

establishment of evidence-based

criteria and protocol for managing

these patients with disorders of



Consciousness is the condition of

normal wakefulness (opening and

closing eyes, preserved sleep-wake

cycle) and awareness (of the self and

environment) in which an individual

is fully responsive to thoughts and

perceptions, as suggested by his or

her behaviors and speech.


disorder of consciousness (DOC)

results when awareness and/or

wakefulness are compromised

because of severe brain damage.

In recent years, the advances in

diagnostic procedures and intensive

care have increased the number of

patients who survive severe brain

injury and enter a vegetative state

(VS) (also recently named

unresponsive wakefulness


or a minimally

conscious state (MCS). These

entities represent the two main

forms of chronic DOCs.


particular, patients suffering from VS

are unaware of the self and the

environment and cannot show

voluntary, purposeful behaviors

because of severe cortico-thalamo-

cortical connectivity breakdown

that globally impairs sensory-motor

processing and cognition. On the

other hand, patients with MCS show

fluctuant but reproducible signs of

awareness and have a limited

repertoire of purposeful behaviors.

The best management of patients

in VS and MCS requires a correct

diagnosis, an evidence-based

prognosis, and the full consideration

of the medical, ethical, and legal

elements concerning DOC.


particular, patients with DOC need

artificial nutrition and hydration

(ANH) and, often, intensive

treatments. These issues evoke a

thorny ethical problem concerning

the therapeutic decision-making of

such patients (including the

continuation of life-sustaining

therapies) in view of the

uncertainties about their state of

consciousness, prognosis, and

personal wishes, with particular

regard to the end-of-life decisions


In fact, it is worth

remembering that the

implementation of any life-sustaining

treatment, including ANH, should

not be automatic when considering

that every individual should make his

or her own decisions regarding any

kind of therapy, according to the

ethical principles of autonomy and

the right of self-determination and

freedom. If an individual is unable to

make a decision, as in the case of

patients with DOC, a surrogate

should be empowered to ensure the

patient’s best interest and personal

wishes concerning ELDs. Therefore,

the right to lose health, become ill,

refuse treatment, live the end of life

according to one’s personal view of

life, and die should be guaranteed,

which is in keeping with human

dignity and the duty to protect

physical and mental health.

The right to die is further

supported by the following


1. The right to (a worthy) life

implies the right to (a worthy)


2. There is no reason to have a

“dedicated” right to die, given that

dying is a very natural

phenomenon, as is life.

3. Death is a private matter, and

other people have no right to

interfere if there is no harm to

others or the community (a

libertarian argument.

4. It is possible to regulate

euthanasia by proper laws, and

thus avoid the slippery slope

argument (SSA).

3. Euthanasia may avoid illegal acts,

given that euthanasia may happen

anyway (a utilitarian or

consequentialist argument) and

save the extreme despair of

suicide or homicide.

6. Death is not necessarily a bad

thing, owing to the naturalness of

the phenomenon, regardless of

whether it is induced.

7. Euthanasia may satisfy the

criterion that moral rules must be

universalizable, but

universalizability is a necessary

but not a sufficient condition for a

rule to be morally good.

8. Medical resources can be better

managed, and though this is not a

primary reason for the right to

die, it is a useful consequence.

On the other hand, an opposite

view states that life is a unique and

incorruptible gift that, in keeping

with the concept of the sanctity of

human life, must always be

preserved. Hence, each individual

has the moral duty to attend to all

the treatment necessary to preserve

life, with the exception of those

burdensome and/or disproportionate

to the hoped for or expected result

(i.e., life preservation), and to avoid

behaviors that can deliberately

hasten or cause death.

A possible middle ground is

represented by the concept that the

sanctity and the dignity of life are

somehow coincident; consequently,

there is no reason why accepting

euthanasia makes some individuals

worth less than others. Since it is

possible to regulate euthanasia by

proper laws, there is no risk of the


1. Starting an SSA that leads to

involuntary euthanasia, thus

killing people who are thought


2. Less than optimal care for

terminally ill patients (for

economic reasons)

3. Giving too much power to medical

staff in limiting the access to

palliative and optimal care for the

dying, pain relief, saving lives,

using euthanasia as a cost-

effective way to treat the

terminally ill, and limiting the

research for new cures and

treatments for the terminally ill

Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 3 , N U M B E R 1 1 – 1 2 , N O V E M B E R – D E C E M B E R 2 0 1 6 ]14

3. Exposing vulnerable people to

pressure to end their lives (duty

to die) by selfish families or by

medical staff to free up medical

resources or when patients are

abandoned by their families.

At first glance, the problem of

ELDs in patients with DOC may

seem easy to solve. The supporters

of the dignity of human life claim

that since patients with DOC are

unconscious and therefore cannot

fully benefit from their rights, ELDs

should assumed by a third party

(e.g., those with whom the patient is

familiar, medical staff, ethics

committees, or courts).25 These

parties would make the ELDs, taking

into account the best interests of the

patient, his or her wishes, the right

to freedom, and the respect of

human dignity. On the contrary,

those who advocate the sanctity of

life deny any possibility to hasten (by

interrupting life-sustaining

treatments) or cause death (by using

euthanasia and physician-assisted

suicide) (PAS), because they believe

that life preservation is a social and

ethical duty. Moreover, patients with

DOC are in a very frail and

vulnerable condition in which they

cannot express their thoughts on

these issues.13,19–24

Judgements in the Schiavo and

Englaro cases highlight this

controversy. In the Schiavo case,26

the argument was over whether Terri

Schiavo was in a persistent VS,

which had already lasted 15 years. It

began with her collapse in 1990, due

to cardiac arrest, and then her

husband’s initial court attempt to

have her feeding tubes removed in

1998. That was followed by court

battles between the husband and

Schiavo’s parents, who opposed the

removal the feeding tube. Her

feeding tube was removed several

times and then reinserted after more

court orders. It was removed for the

last time in March 2005 after the last

successful court petition by the

husband. Schiavo died 13 days later.

Likewise, Eluana Englaro27

entered a persistent VS in 1992

following a car accident, and

subsequently became the focus of a

court battle between supporters and

opponents of euthanasia. Shortly

after her accident, medical staff

began feeding Englaro with a feeding

tube, but her father “fought to have

her feeding tube removed, saying it

would be a dignified end to his

daughter’s life.” According to

reports, Englaro’s father said that

before the car accident, his daughter

visited a friend who was in a coma

and afterward told him, “If something

like that ever happened to me, you

have to do something. If I can’t be

what I am now, I’d prefer to be left to

die. I don’t want to be resuscitated

and left in a condition like that.” The

authorities refused father’s request,

but the decision was finally reversed

in 2009, after she had spent 17 years

in a persistent VS.

Of note, the United States

Supreme Court has stated that the

irreversibility of a DOC condition and

the clearly defined patient’s wish to

not live under such conditions should

both be clearly demonstrated in

order to withdraw the sustaining

therapies, including ANH.28,29 These

decisions are fully in keeping with

the right of freedom and self-

determination and with the

supporters of the right to life.

However, these are fiercely criticized

and hindered by the sanctity of life


Therefore, we consider whether it

is more ethical to respect human

dignity than to protect the sanctity

of human life at all costs. A correct

approach to this thorny ethical

dilemma requires taking into account

that there is a tangible uncertainty of

DOC diagnosis and prognosis,

consequently making it more difficult

to respect a patient’s rights properly

when making ELDs. Moreover, it is

still debated whether ANH should be

considered a fundamental (i.e.,

always due) or an aggressive therapy

(i.e., useless and bearer of further

suffering).22,24,30–34 Finally, the

motivation sustaining the right to live

with dignity and in respect of human

life sanctity must be analyzed

carefully, given that the access to the

right to die is a SSA. In fact, both the

withdrawal and the maintenance of

ANH may lead to a chain of related

events that may culminate in some

significant and potentially negative

effects on patients with DOC (e.g.,

death or unnecessary and prolonged

suffering). Liberalizing euthanasia

may lead to unnecessary application

in some cases. The strength of each

argument in favor or against ELDs

depends on whether one can

demonstrate a process that leads to a

significant effect. SSAs can be used

as a form of fear mongering in an

attempt to scare the audience, thus

ignoring the possibility of a middle

ground between the dignity and the

sanctity of human life. In this article,

we will review the key concepts of

the positions supporting the dignity

and the sanctity of human life in an

attempt to find a conciliating view to

solve the SSA.



When family members are faced

with an irreversible and hopeless

case of unconsciousness, leaving

their loved one in such a condition

may be unbearable for both the

patient and his or her family

members. The relatives of patients

with DOC live a paradoxical reality.

In fact, they live with a family

member who is both present

(inasmuch as he or she is awake)

and absent (unaware) and alive

(inasmuch as he can open and close

his or her eyes, breathe

independently, and make some

movements) and dead (given that he

or she cannot interact with the

family members or the

environment).35–37 These issues can

foster denial or misunderstanding in

the family members of their current

situation. For example, they may

deny that their loved one is in a VS

because they interpret spastic or

reflexive movements as signs of

improvement,6 thus imagining

chances of recovery that are not

supported by evidence-based

medicine. Given that the family

Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 3 , N U M B E R 1 1 – 1 2 , N O V E M B E R – D E C E M B E R 2 0 1 6 15

members may witness important

responses by the patient that have

not been observed by the clinicians,

the medical staff should attempt to

observe the patient with the family

members and involve them in the

patient evaluation. Assisting family

members in better understanding the

patient’s behaviors and level of

awareness is important and may

strengthen the family members’

relationship with the medical staff.38

Hence, the correct communication

of a proper diagnosis and a reliable

prognosis is essential for the best

management of a patient with DOC.

In fact, inaccurate diagnoses and

prognoses and disclosure of false

diagnostic information to families

may have serious ethical, medical,

and legal consequences regarding

the medical management of the

patient, the well-being of patient’s

family members, and ELDs.39,40 In

fact, an incorrect diagnosis and

prognosis may result in a false

expectancy for recovery by the

family members, the unnecessary

and potentially harmful life-support

prolongation of the patient, financial

and emotional resources being

withheld or withdrawn, resource

misuse and misallocation, and an

inappropriate rehabilitation or long-

term care facility enrollment.13

Nonetheless, identifying residual

awareness in unconscious patients

(thus differentiating VS from MCS)

and establishing a correct prognosis

are extremely challenging, owing to

the inadequate sensitivity of the

clinical and paraclinical approaches

currently available for DOC diagnosis

and prognosis.41–47 Even though the

rate of consciousness recovery varies

from eight percent to 72 percent

(but decreases to 20–30% in patients

persisting in comas longer than 24

hours),47 a severe brain injury may

result persistent unconsciousness for

many years. There have been cases

of emergence from DOC, even after

many years.48 Generally, recovery

from a metabolic or toxic coma is far

more likely than from an anoxic one

where the traumatic brain injury

(TBI) occupies an intermediate

prognostic position. A post-anoxic

coma is a state of unconsciousness

caused by global anoxia of the brain,

most commonly due to cardiac

arrest. The outcome after a post-

anoxic coma lasting more than

several hours is generally, but not

invariably, poor.47

About 40 percent of patients with

VS may be clinically misdiagnosed in

that they may be conscious but are

unable to manifest any signs of

consciousness.49–51 Such a condition

has been recently labeled functional

locked-in syndrome (FLIS),

whereby, using neurophysiological

and functional neuroimaging

approaches, clinicians are able to

record residual brain network

connectivity that is sustaining a

covert awareness.52 A patient with

FLIS is clinically similar to one with

VS, with the exception that the

former is aware of the self and the

environment but is unable to

demonstrate awareness or

communicate.6–9 This may due to the

deterioration of sensory-motor

processes, which support motor

function, rather than the breakdown

of cerebral connectivity.6–12,53,60

The low rate of correct diagnoses

and prognoses may depend on the

variations in scale application,

awareness fluctuation, and subjective

interpretation of clinical findings.

The use of paraclinical tests to

detect residual and covert signs of

awareness may help in better

managing patients with DOC and

consequently supporting their right

to ELDs. Nevertheless, different

paraclinical tests would be necessary

to confirm awareness since single

tests may suffer from the same

methodological bias that clinical

approaches do.39,40,54



The thought of interrupting life-

sustaining treatments, including

ANH, may arise in family members

and caregivers when their loved one

suffers from a long-lasting and

potentially irreversible DOC

condition.34 The idea of hastening

one’s own death may occur when

one’s quality of life is poor or

unbearable (e.g., in the case of

physical pain and/or mental anguish)

and life is considered without dignity

(e.g., feeling there is no chance of

recovery, finding nothing that makes

life worth living, and perceiving life

as a burden to others).55–58 One might

consider that respecting the dignity

of life means respecting the dignity

of death and thus avoiding

unbearable and/or unnecessary

suffering or living in what one might

considered a handicapped and

hopeless condition. As stated by

Marc Augé,59 “To die without dignity

is to die alone, abandoned, in an

inhospitable and anonymous place, in

a non-place. To die without dignity

means to die, suffering needlessly or

to die tied up to a technical gadget

that becomes the sovereign of my

last days. To die without dignity also

means to die in isolation, surrounded

by insensitive people, soulless

specialists, and bureaucrats who

carry out their professional tasks


Many authors22,24,30–34,60–62 criticize

using the interruption of ANH as a

way to hasten death because ANH

suspension inevitably leads to a

lengthy death with the potential for

suffering, and suffering would be

considered an unworthy way to die.

This reasoning suggests that ANH

should be continued in order to avoid

suffering by the patient, even when

that patient is unconscious.61,62

Others argue that ANH is a

standard part of treatment for

patients with DOC, and suggest that

the discontinuation of ANH along

with any other standard treatment

should be permitted when explicitly

requested and that this is in keeping

with the principles of beneficence

and non-maleficence and the

“patient’s best interests” rationale.63–65

However, the rights to freely live

(with obvious due respect for others)

and to make any decision concerning

one’s own personal health are well

established as respecting the

principles of free will and the

personal understanding of the quality

Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 3 , N U M B E R 1 1 – 1 2 , N O V E M B E R – D E C E M B E R 2 0 1 6 ]16

of life and human dignity.66 This

suggests that a human being has an

innate right to be valued and

respected and to receive ethical

treatment. In 1964, the Declaration

of Helsinki56 stated, “It is the duty of

physicians who participate in medical

research to protect the life, health,

dignity, integrity, right to self-

determination, privacy, and

confidentiality of personal

information of research subjects.”

Such issue was further corroborated

by the Council of Europe in 1997 in

the Convention for the Protection

of Human Rights and Dignity of

the Human Being with regard to

the Application of Biology and

Medicine57 and by the United

Nations Educational, Scientific, and

Cultural Organization’s Declaration

on the Human Genome and

Human Rights58 in 1998. Both of

these councils stated that there is an

absolute need for respecting the

human being both as an individual

and as a member of the human

species, for recognizing the

importance of ensuring the dignity of

the human being, and for

safeguarding human dignity and the

fundamental rights and freedoms of

the individual with regard to the

application of biology and medicine.

In keeping with the duties and

rights set forth in the

aforementioned declarations, a

competent individual or an

individual’s surrogate should be free

to make ELDs. We might consider

that ANH contributes to the physical

well-being of the patient and permits

a continuation of life and, possibly,

improvement in the quality of life.

And in cases of long-lasting VS

where the chances of recovery are

slim at best, we might consider that

withholding ANH might cause

physical and/or emotional pain. One

might also consider, however, that

when the burden of life on the

patient outweighs the benefits (e.g.,

in the case of a patient with DOC

who has no chance of amelioration),

the administration of ANH might be

futile treatment. Even the most

conservative positions on life

maintenance, e.g., the Catholic

church, admit that treatments are

not obligatory when considered

harmful.67 Hence, a form of passive

euthanasia might be acceptable when

1) aggressive or unnecessary

therapies in cases of terminal or

hopeless illness only prolong a

painful and suffering life, 2) an

informed request is made by a

sentient patient or, conscientiously,

by that patient’s surrogate(s); and 3)

death is an unintended, although

foreseeable, consequence of therapy

interruption. In this regard, the

unique scope of therapy interruption

must be to avoid the suffering of the

patient and not to provide or hasten

death. Thus, the most conservative

positions will deny any form of

euthanasia but will provide palliative

care, even if this shortens the

patient’s life, thus producing the

unwanted and undesired side effect

of death (passive euthanasia).



The right to die is strongly

criticized by those who claim the

sanctity of human life and argue that

the willingness to die should be

considered unacceptable for moral,

religious, logical, and philosophical

reasons.13,20–24 In fact, it might be

argued that euthanasia and PAS can

be similarly compared to suicide and

homicide, respectively, even when

performed at the explicit request of

the patient or surrogate, given that

they cause death with established

methods and times. As argued by the

most conservatory positions

(including the Catholic Church),13,20–24

this issue is considered by some as

unacceptable because life is an

inviolable gift (by God or nature)

that cannot be removed by self of by

others. The expression sanctity of

life refers to the idea that human life

is sacred and holy, given that A) all

human beings are to be valued,

irrespective of age, sex, race,

religion, social status, or their

potential for achievement; B) human

life is a basic good as opposed to an

instrumental good—a good in itself

rather than a means to an end; and

C) human life is sacred because it is

a gift from God. Therefore, the

deliberate taking of human life

should be prohibited except in self-

defense or the legitimate defense of


In religion and ethics, the

inviolability or sanctity of life is a

principle of implied protection

regarding the aspects of sentient life,

which are said to be holy, sacred, or

otherwise of such a value that they

are not to be violated.13,20–24 Hence, by

merely existing, every human being

lives his or her own life with dignity,

which includes living correctly,

according to moral and ethical

principles. This suggests that one

must die in a natural way, given that

death is a natural phenomenon.

Death might be considered the ‘last

page’ of life, and life must be

experienced with dignity. One’s

death has been decided by the

superior Being, and thus one should

adopt options of preservation,

including the administration of

analgesics and the provision of

adequate human, psychological, and

spiritual support, which may relieve

the sense of solitude and allow

relatives to grieve and be given the

opportunity to humanize death. On

the other hand, the voluntary refusal

of treatment may lengthen the

patient’s period of suffering but will

still result in death as a result of the

disease itself, not by any action or

omission of life-sustaining therapy. In

such cases, death would be natural

and expected.

Some secular positions criticize

the right to euthanasia and PAS from

a logical point of view.28,29 They claim

that it is unreasonable for one person

to determine the death of another

person as there could be a

reasonable chance of healing,

survival, or alternative care. In

addition, they argue that such a

determination should not be made

due to the inherent uncertainty of

the chances for recovery and real

level of awareness in patients with

DOC (e.g., a patient may be in a

state of FLIS, thus unable to

Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 3 , N U M B E R 1 1 – 1 2 , N O V E M B E R – D E C E M B E R 2 0 1 6 17

communicate with those around him

or her but is still aware). Hence,

using this line of thinking, we might

conclude that patients with DOC

should always have the right to live

and to die peacefully and naturally

later rather than have their lives

prematurely ended by removing a

feeding tube, which would lead to

forced starvation.


We might consider in what way

the worthiness of life is defined,

since “worthy” is the pivotal element

of the right to death argument. An

important component of ELDs is

each individual’s perception of what

makes life important, worthy, and

valuable. For example, one individual

might perceive that living with a

disability makes his or her life

unworthy, whereas another

individual with the same disability

may consider his or her life

important and worth living.

Therefore, one might argue that the

dignity of one’s life has to be

determined by oneself, as long as

such determination does not harm

others, including family members.

From this point of view, dignity and

sanctity of life are not conflicting,

and ELDs for patients with DOC

could be based on sufficient evidence

that their condition is irreversible

and hopeless and any ELDs are in

keeping with their wishes. It could be

argued that putting an end to

unnecessary suffering is not an

affront to but rather a strengthening

of the sanctity and dignity of life,

provided this end is freely and

consciously wanted by the either the

patient or his or her surrogate on

behalf of the patient.

A clear and conscious decision to

request the discontinuation of one’s

own life-sustaining therapy, including

ANH, may serve as sufficient legal

justification for such a decision in

most United States courts as long as

the patient is an adult who is capable

of making decisions. But what about

in cases of DOC, in which the

patients lack the capacity to make

decisions, and thus the burden of

decision falls on the patient’s

surrogate or guardian? In the United

States, the Quinlan and Cruzan

cases highlight two important

considerations regarding the ethical

admissibility of ELDs made by a

patient’s guardian or surrogate when

the irreversibility of unconsciousness

has been established: 1) making a

presumptive decision for the patient

in the absence of a living will and 2)

making a decision for the patient

with a living will.68–70 Based on the

principle of substituted judgment, in

some states in the United States, a

surrogate is allowed to refuse life-

sustaining treatment on behalf of the

patient, with or without a living will,

if the patient lacks the capacity to

decide for him- or herself and the

treatment is considered burdensome

and/or unnecessary (i.e., the patient

will never recover, even with

treatment). In these cases,

withholding or interrupting life-

sustaining therapy would be

considered to be in the best interest

of the patient. In other states,

however, a surrogate must provide

evidence of a living will that

satisfactorily communicates the

patient’s desire to have life support

discontinued in the event of

irreversible DOC—before the

surrogate can make such a


The ethical admissibility of ELDs

made by a patient’s guardian or

surrogate becomes thornier when

dealing with cases of MCS, because

these patients may have residual

decision-making capacity and

cognitive ability. There are several

cases in the United States where

ANH was withheld in patients with

MCS (e.g., Conroy, Edna, Martin,

and Wendland cases).71–73 Because

MCS individuals are partially

conscious and are not typically

terminally ill, their legal status is

complex. While consciousness itself

might be a good reason to continue

life-sustaining aids, it may not always

be in the patient’s best interest to

continue living a severely

handicapped life.74,75 Determining

when existence is no longer

subjectively valuable for an individual

with a severely limited capacity to

communicate is a vexing situation.

Assuming that all persons have the

same right to die, MCS surrogates

should remain empowered to act on

behalf of these vulnerable

individuals,76 but also should take

into account the potential that their

loved one with MCS might still have

some cognitive ability.

Altogether, the ethical issues

surrounding ELDs made by someone

other than the patient highlight the

importance of establishing living

wills, which are written, legal

instructions regarding a patient’s

preferences for medical care

(doctors and caregivers) if he or she

is unable to make decisions for him-

or herself because of a terminal

illness, severe brain injury, coma, the

late stages of dementia, or the near-

end of life. By careful planning,

unnecessary suffering of the patient

and burdening the caregiver with

difficult ELDs might be avoided

during times of crisis or grief.

Through the power of attorney, a

person (healthcare agent, proxy,

surrogate, representative, attorney-

in-fact, or patient advocate) is

empowered to make decisions for the

individual who is unable to do so.

Living wills are allowed or legalized

in the United States (e.g., California

Natural Death Act77 and United

States Patient Self Determination

Act78), Germany, France, Canada,

Australia, Denmark, and England,

whereas they are still debated in

Italy.79–81 However, a living will may

present some critical problems. For

example, a patient’s wishes may not

be respected due to the lack of clear

legislation concerning the warranty

of the patient’s right to die. The

medical staff’s rights and duties also

may not be clearly defined, causing

further push back on respecting an

individual’s living wills by raising the

concern about potential criminal

consequences of an omission or

fulfillment of patient’s will.82

Furthermore, the disproportionality

of therapies has not been clearly

defined.83 Some may argue that a

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dying patient has the right to refuse

burdensome medical treatments that

A) have no chance of curing or

improving the patient’s medical

condition(s) and/or B) are

disproportionately painful, intrusive,

risky, or costly when compared to

the expected therapeutic outcome. It

can be argued that every individual

should be free to decide whether to

live in such a condition. But

regarding the living wills of patients

with DOC, it is important to consider

not the value of the life of the person

but rather the value of the treatment

to that person.

To avoid potential problems

regarding the authenticity of living

wills, they should be officially

certified by means of a notary or an

audio-video testimony overseen by a

lawyer or a solicitor. Moreover, a

living will should be checked and

updated continuously to confirm the

desires of its author in terms of ELDs

in general and ELDs specific to DOC,

should this occur. And finally, the

possibility of revising the will of an

incapacitated patient regarding

withdrawal of ANH and other life-

supporting care may need to be

considered, with the help of family

members and friends. Living wills

prepared in such a way will reduce

the chances of misinterpretation of

the document by judges, ethics

committees, and public health



After considering the ethical

dilemma of maintaining a patient’s

dignity while respecting his or her

sanctity of life, the issue of how to

regulate the right to a worthy death

remains. In fact, the lack of a clear

position by those governments that

have not established ad hoc laws on

ELDs has led to the growth of the

phenomenon of indirect euthanasia,

in which pain medication is

administered to the patient to reduce

pain, with the side effect of

quickening the dying process.84 One

might consider that the primary

intention of such treatment is not to

kill the patient but to make the

patient more comfortable, which

might be viewed as morally

acceptable. This type of indirect

euthanasia might be justified using

the “Doctrine of Double Effect,”

which states that if doing something

morally good has a morally bad side

effect, it is ethically correct only

when the bad side effect is not

intended, even if the bad effect was

foreseeable.85 That is to say the good

result must be achieved

independently of the bad one, the

action must be proportional to the

cause, and the patient must be in a

terminal condition.

Without clear euthanasia

legislation, arbitrary nonvoluntary

and even involuntary euthanasia

could potentially occur.85 Euthanasia

must be voluntary to be ethical, but it

is nonvoluntary when it is used in

unconscious individuals or in persons

who are unable to make a meaningful

choice between living and dying and

an appropriate person (a surrogate or

a legal guardian) makes the decision

on their behalf. On the other hand,

nonvoluntary euthanasia can also be

when the person who dies had

chosen life but instead underwent

euthanasia at the request of someone

else (i.e., murder). A conservative

view is that this SSA could lead to an

out of control acceptance of

euthanasia or PAS, even if it is

deemed unacceptable.13,20–24 From a

logical point of view, if the

acceptance of an initial act logically

entails the acceptance of another

(but undesirable) act, it might be

argued that there is no relevant

conceptual difference between the

two acts. And on the other hand, if

the acceptance of an initial act will

lead to a series of similar acts that

are all acceptable, the eventual last

(and unacceptable) event is not

relevant. From an empirical or

psychological point of view, one

could argue that there is instead no

need for a logical connection between

two events; the acceptance of an

event will, in time and through a

process of moral change, lead to the

acceptance of another one.

To avoid an out of control

application of ELD, and to both grant

and regulate the right to die,

governments in the United Kingdom,

Canada, and some states in the

United States have outlined different

protocols for ELDs and euthanasia. A

clear law that limits ambiguity

regarding the representation of

patients with DOCs is still missing in

many countries, including Italy. The

media has brought attention to some

cases that have forced the courts to

decide whether to suspend ANH, but

no clear, consistent legislation with

documented protocol has been

established when considering

euthanasia for patients with


Active euthanasia, in which a

person (physician or not) directly

and deliberately causes the patient’s

death following that patient’s explicit

request (or that of the patient’s

surrogate) through the use of drugs

is legal in a few countries. As of June

2016, euthanasia of this nature is

legal in the Netherlands, Belgium,

Colombia, and Luxembourg.92 PAS

(which refers to cases wherein the

person, who is terminally ill, needs

and asks for the help of medical

professionals in ending his or her

life) is legal in Switzerland, Germany,

Japan, and Canada; it is also legal in

the states of Washington, Oregon,

Vermont, Montana, New Mexico, and

California in the United States.92

The Netherlands has legalized

both euthanasia and PAS but only

after the patient had received every

available type of palliative care. In

2004, the Groningen Protocol93 was

developed establishing the required

criteria each case must meet before

legal child euthanasia may be carried

out, which protects the liability of

the physician. It is worthy to note

that Belgium also allows child

euthanasia when the young patient is

conscious of his or her decision,

understands the meaning of

euthanasia, and suffers from a

terminal illness that causes an

intractable and unbearable pain; the

child’s parents and the medical team

must approve the request.94

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Luxembourg and Uruguay legalized

euthanasia for terminally ill patients,

who have received the approval of

two doctors and a panel of


Switzerland allows PAS for both

adult citizens and foreigners,

whereas PAS is legal in Canada only

for all adult Canadian citizens with a

terminal illness that has progressed

to the point where natural death is

“reasonably foreseeable” (the

Assisted Dying for the Terminally Ill

Bill).96–100 Likewise, Colombia

approved euthanasia for terminally ill

patients with cancer, acquired

immunodeficiency syndrome (AIDS),

kidney or liver failure, and

degenerative diseases (including

Alzheimer’s, Parkinson’s, and

amyotrophic lateral sclerosis) that

cause extreme suffering.101 In

Germany, PAS is legal as long as the

lethal drug is taken without any help,

meaning there is no one guiding or

supporting the patient’s hand.102

Active euthanasia is illegal

throughout most of the United

States, whereas the passive form

(i.e., refusing medical treatment

even if this choice may hasten death)

is legal, with PAS being legal in five

states (Oregon, Washington,

Vermont, California, Montana, and

one county in New Mexico). The

legislation passed in Oregon,

Washington, and California was

based on Oregon’s “Death with

Dignity” Act,103–107 which states that a

“competent adult resident who has

been diagnosed by a physician with a

terminal illness, which will kill the

patient within six months, may

request in writing, from his or her

physician, a prescription for a lethal

dose of medication for the purpose of

ending the patient’s life. The

exercise of the option, under this

law, is voluntary, and the patient

must initiate the request. Any

physician, pharmacist, or healthcare

provider who has moral objections

may refuse to participate.” Two

witnesses, one of whom is not

related to the patient in any way,

must confirm the request. After the

request is made, another physician

must examine the patient’s medical

records and confirm the diagnosis.

The patient must be determined to

be free of a mental condition that

impairs his or her judgment. If the

request is authorized, the patient

must wait at least 15 days and make

a second oral request before the

prescription may be written. The

patient has a right to rescind the

request at any time. The patient

must be referred for a psychological

evaluation if the physician has

concerns about the patient’s ability

to make an informed decision or if he

or she suspects the patient’s request

may be motivated by depression or


Oregon’s Death with Dignity Act

protects doctors from liability

provided the adult patient is

competent and is in compliance with

the statute’s restrictions; at the same

time, this Act also guarantees and

regulates the access to the right to

die. Participation by physicians,

pharmacists, and healthcare

providers is voluntary. The law also

specifies that a patient’s decision to

end his or her life shall not “have an

effect upon a life, health, or accident

insurance or annuity policy.”

According to the Oregon Death with

Dignity Act: Data Summary 2015

Report,106 about 64 percent of the

people in Oregon who filled

prescriptions for lethal medications

died. There were no significant

differences concerning age, gender,

or levels of instruction. The primary

end of life concerns were the loss of

autonomy, the inability to make life

enjoyable, and loss of dignity.

Notably, there was no evidence of

heightened risk for euthanasia in the

elderly, women, the uninsured,

people with low educational status,

the poor, the physically and mentally

disabled, the chronically ill or

unconscious, minors, people with

psychiatric illnesses including

depression, or racial or ethnic

minorities compared with

background populations.108

In Oregon, futile or

disproportionately burdensome

treatments, including ANH, may be

withheld or interrupted under

specified circumstances and only

with the informed consent of the

patient or, as in the case of VS, with

the informed consent of the legal

surrogate.The United States Patient

Self Determination Act does not

address quality of life issues and

does not make a clear distinction

between active and passive

euthanasia when there is clear and

convincing evidence that the

informed consent to euthanasia,

passive or active, has been obtained

from a competent patient or the legal

surrogate of an incompetent patient.

Active euthanasia is explicitly

illegal in Australia, Austria, China,

Denmark, Finland, France, Ireland,

Italy, Latvia, Lithuania, New Zealand,

Norway, the Philippines, Russia,

Spain, Turkey, and the United

Kingdom, though some will allow

access to advanced care directive

options and offer reduced penalties

for those who assist patients in

dying. In Denmark and France, a sort

of “Right to Die with Dignity” act is

under debate.92

Passive euthanasia, as described

earlier, is legal in India, Sweden, and

Ireland. Moreover, passive euthanasia

is tolerated in the United States,

Mexico, Canada, Israel, Argentina,

Hungary, Finland, Thailand (even for

foreign individuals), Portugal (with

the exception of ANH interruption,

which is not allowed), and Germany.

In Japan, there is a law plan for

active euthanasia and PAS. The plan

includes clauses related to an

unbearable and untreatable suffering

(for which the physician must have

ineffectively exhausted all other

measures of pain relief), inevitable

and approaching death, and a written

consent (living wills and family

consent will not suffice).

Interestingly, Japan’s government

instituted “bioethics SWAT teams,”

which are made available to the

families of terminally ill patients in

order to help them, along with the

doctors, come to an informed

decision based on the personal facts

of the case. In Mexico, terminally ill

patients or, if they are unconscious,

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their closest relatives are permitted

to refuse medication or further

medical treatment to extend life in

Mexico City, the central state of

Aguascalientes, and the Western

state of Michoacán.92,108–110

In Italy, active euthanasia is under

the penal law (as being equated to

intentional homicide), as is assisted

suicide. Nevertheless, the extensive

use of pain-relieving drugs, which

could cause premature death (i.e.,

indirect euthanasia), is not

considered a form of euthanasia;

neither is the abstention from

aggressive treatments (i.e., those

therapies that can only prolong a

state without chances of

amelioration). The Italian

government is still in the

developmental stage in regard to

right to die policy, but theirs is

mainly directed at limiting an

individual’s personal autonomy and

the possibility of writing a personal

living will. Indeed, advanced care

directives, which are not yet broadly

recognized in Italy, probably

represent the best way to safeguard

the principle of autonomy.



We believe that all patients with

DOC (i.e., their surrogates) should

be put in the position to freely

choose their own way to end their

lives, in full respect of the personal

and inviolable principles of the

dignity and sanctity of human life. In

our opinion, all patients should be

free to manage their own deaths, or

to empower someone to do it if they

are incapacitated, when they

perceive their quality of life as

severely impaired by physical or

psychological suffering (e.g.,

incontinence, nausea and vomiting,

breathlessness, paralysis, difficulty in

swallowing, depression, fearing a loss

of control or dignity, feeling like a

burden, having a dislike for being

dependent) and when there is no

chance of improvement.

It is urgent that governments

establish safeguards, criteria, and

protocol that protect the right to a

worthy death (in keeping the

patient’s lucid and conscious will and

the personal concepts of dignity and

the sanctity of life), ensure societal

oversight, and prevent euthanasia

and PAS from being abused or

misused (i.e., moving from being a

measure of ‘last resort to one of early

intervention).111 In fact, euthanasia is

progressively moving from terminally

ill people to those who are

chronically ill, and from physical

illness to mental illness or

psychological distress or suffering

(even “tired of living”), and from

conscious to unconscious patients.

This means that the actual laws may

fail to detect and prevent situations

in which people could be subjected

to undue pressure to access or

provide euthanasia and could

circumvent the safeguards that are in


A balanced law should guarantee

and regulate the access to

euthanasia/PAS. Such laws should

require that all patients and their

surrogates are properly educated

regarding the law and their rights

and are capable of making


Hence, ELDs must be voluntary, well

considered, informed, and, above all,

persistent over time. The requesting

person must have provided explicit,

written consent and must be

competent at the time the request

was made. In this regard, some states

require that the voluntariness of the

request has to be confirmed by at

least two witnesses.

A law would avoid non-voluntary

euthanasia in patients with DOC by

confirming the lack of chances of

recovery based on an accurate

clinical assessment corroborated by

advanced paraclinical approaches

and by demonstrating the will of the

patient to not live in such a

condition. In cases with no living will

in place, the best interest of the

patient should be pursued according

to evidence-based medicine and the

opinion of the patient’s surrogate.

The role of the physician is

imperative when making informed

ELDs. Indeed, the so-called

“therapeutic alliance” between the

patient and doctor should be

fundamental in ELD (as well as in

life) and only when this alliance

enforces the patient’s autonomy.

Physicians have a great responsibility

to use their knowledge and skill in

the primary interest of their patients,

and should not only aim to relieve

the burden of sorrow but also strive

to educate and enable patients and

their loved ones to understand,

evaluate, and make their own choices

concerning ELD. Only trained

healthcare clinicians can make

evidence-based diagnoses and

prognoses of DOC conditions, thus

the determination made by the

physician on whether a DOC patient

has any chance to improve is

evidence-based and carefully

considered. The pivotal role the

medical staff plays in ELDs has been

highlighted and regulated in

countries where euthanasia and/or

PAS are legal. Switzerland, however,

allows non-physicians to assist in

suicide. In the Netherlands and

Belgium, a second doctor must see

the patient to confirm the request to

die is valid and the suffering

unbearable, and a network of doctors

is trained to undertake these

consultations. In the United States,

in all five of the states that allow

PAS, it is required that a second

doctor must examine the patient to

confirm the terminal illness before

the request is approved. In Oregon,

Washington, and Vermont, the

patient must also see a mental health

professional when either the

attending or consulting doctor

suspects that the patient may be

suffering from a psychological

disorder (such as depression) that is

impairing his or her judgement. In

addition, ad hoc committees (even if

this is delayed) are used to revise

cases with potential mistakes in the

euthanasia or PAS procedures.

Unfortunately, these committees are

largely underutilized.

Governments and magistrates

must work to establish and

communicate the proper protocol for

ELDs to their citizens in order to

guarantee the rights of patients to a

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peaceful and worthy death and to

limit SSA. Indeed, no additional

requirement relating to the patient’s

experience of the disease or any

minimum level of suffering would

easily extend the application of

euthanasia. On the other hand,

narrowing euthanasia to unbearable

suffering would limit the accessibility

of the right to die for all the other

patients. Likewise, limiting the right

to die from a terminal illness (as in

the United States) could result in the

courts excluding patients with VS

from this right, given that they are

not terminally ill and their prognosis

can only be established with

sufficient confidence using advanced,

non-standard neurophysiological or

neuroimaging approaches. In

addition, the acceptance of solely

passive or indirect euthanasia for

patients in VS would limit their

accessibility to their right to die. In

fact, these patients deserve the same

accessibility to the right to die as

other people and do not deserve a

“worse” euthanasia than the others

(i.e., a slow and agonizing death

because of starvation and


Finally, the people who have the

duty of informing and educating the

public seek to help people cope with

the finiteness of the human

condition, the intrinsic limits of

medicine, and the responsibility to

explore the values surrounding


Hence, there is no reason why any

single moral view of physicians,

magistrates, politicians, or educators

should prevail. A conciliation of the

different currents of thought on

euthanasia may be reached by

placing, at the center, the patient’s

rights to freely manage his or her life

and death while keeping the

principles of dignity and sanctity of

human life intact. ELDs should be

guaranteed in patients with DOCs

when negative prognoses have been

well defined, possibly through the

use of advanced neurophysiological

and functional neuroimaging

techniques, and the desires of the

patients to not live in such

conditions have been clearly

expressed by living wills or by

surrogates. Finally, ad hoc

committees to oversee the proper

access and application of euthanasia

should be instituted and potentiated.


The authors would like to thank

Prof. Anthony Pettignano for his

editing services.


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  • l
  • i>l

    ent Video Games and Violent Crime

    Scott Cunningham,* Benjamin Engelst€atter,† and Michael R. Ward‡

    Video games are an increasingly popular leisure activity. As many best-selling games contain
    hyper-realistic violence, many researchers and policymakers have hypothesized that violent game


    cause violent behaviors. Laboratory experiments have found evidence suggesting that violent
    video games increase aggression. Before drawing policy conclusions about the effect of violent
    games on actual behavior, these experimental studies should be subjected to tests of external
    validity. Our study uses a quasi-experimental methodology to identify the short-run and
    medium-run effects of violent game sales on violent crime using time variation in retail unit sales
    data of the top 30 selling video games and violent criminal offenses from both the Uniform
    Crime Report and the National Incident-Based Reporting System from 2005 to 2011. We find no
    evidence of an increase in crime associated with video games and perhaps a decrease.

    JEL Classification: D08, K14, L86

    1. Introduction

    Violence in video games is a prominent policy concern. The issue has generated six reports to
    the U.S. Congress by the Federal Trade Commission (Federal Trade Commission 2009) and in
    2010 led to a law in California making it a punishable offense for a distributor to sell a banned vio-
    lent video to a minor. This law was later struck down by the U.S. Supreme Court in June 2011
    (Supreme Court 2011). Policymaker concern has been motivated by the connection between vio-
    lent video game imagery and psychological aggression in video game players, particularly adoles-
    cents. While researchers have documented an effect on aggression in the laboratory, some have
    suggested that violent video games are responsible for violent crime such as school shootings
    (Anderson 2004).

    The short-run effect of violent games on aggression has been extensively documented in labo-
    ratory experiments (Anderson, Gentile, and Buckley 2007). These experiments generally conclude
    that media violence is self-reinforcing rather than cathartic. This link has not been found with
    crime data however. Ward (2011) found a negative association between county-level video game
    store growth and the growth in crime rates. In a relevant study, Dahl and DellaVigna (2009) find
    that popular violent movies caused crime to decrease in the evening and weekend hours of a mov-
    ie�s release lasting into the following week, with evidence that violent movies were drawing men
    into theaters and away from alcohol consumption. These two studies suggest the real world rela-
    tionship between violent media and crime may be more complex than the results from laboratory

    * Department of Economics, Baylor University, One Bear Place #98003, Waco, TX 76798-8003, USA;
    E-mail Scott_cunningham@baylor.edu.

    † Darmstadt Business School, Darmstadt University of Applied Sciences, Darmstadt, Germany and Zentrum
    f€ur Europ€aische Wirtschaftsforschung, Mannheim, Germany; E-mail benjamin.engelstaetter@h-da.de.

    ‡ Department of Economics, University of Texas at Arlington, Arlington, Texas 76017, USA and Zentrum f€ur
    Europ€aische Wirtschaftsforschung, Mannheim, Germany; E-mail mikeward@uta.edu; corresponding author.

    Received January 2015; accepted October 2015.

    � 2016 by the Southern Economic Association 1247

    Southern Economic Journal 2016, 82(4), 1247–1265
    DOI: 10.1002/soej.12139

    studies indicate. There is also disagreement within the psychological literature itself about the
    interpretation of laboratory studies of video game violence. For instance, critics have pointed out
    methodological problems such as the use of poor aggression measures and inflated effect size (Fer-
    guson and Kilburn 2008). Also, after correcting for publication bias, studies of media violence
    effects provided little support for the hypothesis that media violence is associated with higher
    aggression (Ferguson and Kilburn 2008).

    We estimate the reduced form effect of intensely violent video games on crime using a strat-
    egy similar to Dahl and DellaVigna (2009). We proxy for video game play using video game sales
    information harvested from VGChartz, an industry source tracking the weekly top 30 best-selling
    video game titles from 2005 to 2011. The violence content for each video game was matched using
    information provided by the Entertainment Software Rating Board (ESRB). Our measures of
    crime are from the Uniform Crime Report (UCR) and the National Incident-Based Reporting
    System (NIBRS). We use both crime data sources separately to create a time series of violent and
    nonviolent crime levels for the periods in question. The UCR data measures crime at the monthly
    level, whereas the NIBRS data measures crime by hour of day. We construct weekly measures of
    crime by aggregating the NIBRS data by week.

    Our main finding is that we fail to find evidence that violent video games increase crime. In
    contrast, we find evidence that violent games cause a modest reduction in crime. Our analysis indi-
    cates that crimes are either invariant to or are decreasing in video game popularity. This is true for
    both nonviolent and intensely violent video games and independent of the crime data used. These
    results suggest that the generalized aggression hypothesis which warns of violent behaviors ema-
    nating from violent media may be negligible or may be mitigated by other factors that decrease
    violence such as intensive time use and catharsis. We estimate the elasticity of crime with respect to
    intensely violent game sales to be small, on an order of 20.02.

    Caution should be used in applying our research design outside our sample frame as it
    exploits only short-run variation in weekly sales which may be different from effects in the long
    run. The decrease in violent outcomes we observe may still be masking possible long-run harm to
    society if gamers develop biased beliefs about eventual danger, or if video game play draws stu-
    dents out of productive schooling. Our approach also may misstate the average elasticity of games
    if behavioral effects from higher quality games diverge from that of lower quality games. Insofar
    as there are negative short-run elasticities and long-run positive elasticities of crime with respect to
    video games, regulation aimed at reducing violent imagery and content in games could have both
    social benefits and social costs.

    2. Background

    From the sensational crime stories of the 19th century (Comstock and Buckley 1883), to the
    garish comic books of the early 20th century (Hadju 2009), to the contemporary debate over vio-
    lent games, Americans have always been concerned about the harmful effects of violent media on
    children. Unlike comic books and pulp “true crime” stories, violence in media, including video
    games, has received substantial attention by psychologists and media specialists. Anderson and
    Bushman (2001) and Anderson, Gentile, and Buckley (2007) discuss hundreds of controlled stud-
    ies on the effects of violence in media, whereas the number of studies on violence in print media is
    smaller in comparison.

    1248 Cunningham, Engelst€atter, and Ward

    Three possible theoretical mechanisms have been proposed for the impact of violent media on
    crime, which we label “aggression,” “catharsis,” and “incapacitation.” The aggression mechanism is
    based on a psychological theory called the “general aggression model” (GAM). GAM posits that
    violent video games increase aggressive tendencies. This model generalizes from social learning
    theory (Bandura 1973), script theory (Huesmann 1998), and semantic priming (Berkowitz and LeP-
    age, 1967; Anderson, Benjamin, and Bartholow 1998) through a process of social learning whereby
    the gamer develops mental scripts to interpret social situations before they occur. This effect creates
    reasoning biases, a tendency to jump to conclusions and may even cause personality disorders
    (Bushman and Anderson 2002). While GAM suggests that aggression increases with repeated expo-
    sure to violent content, most of the evidence for it comes from short-run laboratory experiments.

    The catharsis explanation is that video games act as a release for aggression and frustration
    so that actual expressions of aggression are reduced. While many gamers believe the catharsis
    hypothesis is credible (Olson, Kutner, and Warner 2008; Ferguson et al. 2014), it is not without
    controversy. For instance, most cross-sectional studies fail to find cathartic effects. And while Den-
    zler, F€orster, and Liberman (2008) state rather unequivocally that the “social psychological litera-
    ture lends no support for the catharsis hypothesis,” they also find that aggression can reduce
    further aggression in those cases when it serves to fulfill a goal. A possible physiological mecha-
    nism for catharsis comes from evidence that internet video game playing is associated with dopa-
    mine release that might act to sate the gamer (Koepp et al. 1998; Han et al. 2007). Han et al.
    (2009) study the similarity of the effects of video game playing and methylphenidate (i.e., Ritalin)
    in children with Attention Deficit Hyperactivity Disorder and suggest that internet video game
    playing might be a means of self-medication.

    The incapacitation explanation is based on the economic theory of time use (Becker 1965). Many
    modern video games are time-intensive forms of entertainment involving intricate narratives with com-
    plex plots and characterizations that take dozens, and sometimes several hundreds, of hours to com-
    plete.1 Insofar as video game play draws adolescents from other activities, the time use explanation
    implies a possible short-run decrease in violence if individuals substitute away from riskier outdoor lei-
    sure to indoor leisure, but allows for a possible long-run increase in violence as predicted by GAM.
    The American Time Use Survey (ATUS) indicates that individuals aged 15–19 spent an average 0.85
    hours per weekday playing games and using computers, but only 0.12 hours reading, 0.11 thinking,
    and 0.67 in outdoor recreation, such as sports or exercising. Ward (2015) uses ATUS data to show
    that, when the currently available video games� sales are higher, individuals spend more time gaming
    and less time in class. Stinebrickner and Stinebrickner (2008) find that students randomly assigned a
    roommate in college with avideo game console studied less often, and performed worse in school.

    3. Methodologies

    These three explanations have separate theoretical predictions relating violent video games�
    effects on violence and crime. The tests we develop have the potential of discriminating between

    1 The Web site, How Long to Beat, http://www.howlongtobeat.com, provides user-submitted statistics on completion
    times. The 2011 blockbuster, The Elder Scrolls V: Skyrim, lists completion times between 100 and 330 hours. The 2008
    hit, Grand Theft Auto IV, lists 12 to 162 hours, with the lower bound 12 hours recorded for a “speed trial” effort to
    complete the game as fast as possible.

    Violent Video Games and Violent Crime 1249


    explanations. We use two separate methodologies to determine a causal link between playing vio-
    lent video games and engaging in criminal activities.

    Variation Over Time

    We begin by estimating a standard multivariate regression model of the incidence of various
    crimes as a function of sales of nonviolent and violent video games. Our outcome variables of
    interest, Ct, are the total number of reported criminal incidents in week t across the United States
    that are classified as violent or nonviolent.

    Video game sales are available on a weekly basis, whereas crime statistics are available at the
    monthly (UCR) or daily (NIBRS) level. We, therefore, aggregate crimes into monthly measures
    for the UCR sample and weekly measures for the NIBRS sample. A game purchased in one week
    is often played in subsequent weeks until the user loses interest and moves on to another game.
    Our main explanatory variables are aggregated current and lagged values of weekly sales volumes
    for all games and for violent video games in particular. The actual number of lags, T, is based on
    analysis of actual gaming behavior, which we discuss later.

    We model the supply of criminal offenses, Ct, as:

    ln Ctð Þ5ballln RT


    � �

    1bvln RT


    � �



    All specifications include month-of-year fixed effects for models using UCR-based crime
    variables or week-of-year fixed effects for models using NIBRS-based crime variables to control
    for seasonality. We also include year fixed effects to account for changes in crime and game sales
    that vary at the year level. Thus, our identification comes from variation about the month or
    week�s “typical” sales. We decompose video games into those with violent content, Gv

    t , in addition
    to all games, Gall

    t . In this manner, we hope to identify a marginal effect of GAM from violent
    games versus an incapacitation effect from all games. We can address the issue of game play after
    the date of purchase by including more lags. As we adopt a double logarithm specification, the
    coefficients of interest can be interpreted as elasticities. Equation 1 is estimated using the Newey–
    West (1987) correction for standard errors under the assumption of possible heteroskedastic-
    ity and autocorrelation.

    Correlations between video game play and crime may be due to unobserved determinants of
    crime that are also correlated with the determinants of video game play as well as reverse causality.
    A low opportunity cost of time would affect both video game sales and the relative return to crimi-
    nal activity (Jacob and Lefgren 2003). We account for most of the variation in the opportunity
    cost of time over the year with monthly or weekly dummy variables. Reverse causality may occur
    if higher crime rates cause people to stay indoors and play more video games. Finally, it is also pos-
    sible that game publishers base their release dates on nonseasonal factors that are unobserved by
    the econometrician and that affect both video game demand and criminal activity.

    To purge our results of endogeneity bias, we need an instrument that is highly correlated with
    video game sales but uncorrelated with the unobserved determinants of crime. Weekly sales of
    individual games are highly sensitive to both game quality (Zhu and Zhang 2010) and time on the
    market (Nair 2007). The first instrumental variable is the average age in weeks of the games in the
    current top 30 calculated from the VGChartz data. The second instrument is a measure of their

    1250 Cunningham, Engelst€atter, and Ward

    average quality taken from expert review data collected from the GameSpot Web site.2 GameSpot
    provides news, reviews, previews, downloads and other information for video games. The Game-
    Spot staff reviewed all but a handful of the games in our sample and rated the quality of the titles
    on a scale from 1 to 10 with 10 being the best possible rank. These so-called GameSpot-scores
    assigned to each game are based on evaluations of graphics, sound, gameplay, replay value and
    reviewer�s tilt, or idiosyncratic biases, and are intended to provide an at-a-glance sense of the over-
    all quality of the game.

    Insofar as expert review and game age have no independent association with the unob-
    served determinants of crime, the exclusion restriction should hold. While we can think of no
    obvious reason why either instrumental variable should be correlated with the unobserved
    determinants of criminal behavior, it is possible that such correlation exists. For instance,
    higher rated violent games may increase violence independent of the effect on sales through
    effects on the amount of time the games are played. We interpret our IV strategy primarily as a
    robustness measure.

    Variation in the Marginal Effect in the Cross-Section

    A second test attempts to measure a difference in marginal effects across geographic areas
    representing high video game demand areas. However, only the NIBRS crime data can be disag-
    gregated geographically to the county by week level. The video game sales data are only available
    as a time series. Since video game launches occur simultaneously throughout the United States,
    disaggregated data are not available. Thus, the panel does not introduce any independent variation
    in the video game treatment across geographic areas. However, we expect any effect of video games
    to be amplified in areas of high video game demand. If violent games have a positive (negative)
    effect on crime, the effect should be larger (smaller) in areas where video games are consumed
    more. We proxy video game demand with the fraction of population aged 10–29, who we label as
    the youth. This is the age demographic most associated with video game playing. Our estimating
    equation is given by:

    ln Cit5bvln Gv

    � �
    1bvnln Gnv


    � �
    1bY thY thi1

    ythln Gv


    � �
    3Y thi1bvn

    ythln Gnv

    � �
    3Y thi1bX X1eit


    We test whether the main effect is stronger for high video game demand areas by testing
    whether our estimates of bv

    yth and bnv
    yth differ from zero. As the tests of hypotheses exploit differ-

    ences in marginal effects in the cross-section, they are relatively immune to release date endo-
    geneity concerns. The control variables, X, include year and week-of-year fixed effects.
    A double log specification is retained for consistency with the preceding analysis. To avoid log-
    arithms of zero values of crimes in small levels of geography, we aggregate counties into deciles
    based on their youth fraction. That is, the 10% of the sample population with the smallest
    youth fraction are aggregated together in the first decile, the 10% with the highest youth frac-
    tion are in the tenth decile, and the rest are aggregated into the other eight deciles accordingly.
    Because video game sales data do not vary across deciles, standard errors are clustered on the
    sample week.

    2 http://www.gamespot.com/

    Violent Video Games and Violent Crime 1251


    4. Data

    A fundamental problem we face is obtaining observational data on exposure to violent video
    games. We base our analysis on four different video game data sources to proxy violent video
    game exposure, that is, Gamespot, ESRB, VGChartz, and Raptr. We explain each source in detail
    below. Having introduced our video game data, we follow up with a detailed explanation of our
    two different crime data sets.

    Video Game Data

    Our data on video game sales were obtained from a popular online industry outlet called
    VGChartz.3 VGChartz reports U.S. retail video game unit sales for each week�s top 30 selling
    console-based video games. VGChartz uses avariety of sources to collect data. These include man-
    ufacturer shipments, data from tracking firms, retailer and end user polls, and “statistical trend
    fitting.” VGChartz reports by global region, for example, United States, Japan, Europe, Middle
    East, Africa, and Asia, but disaggregated sales within a region are not available.

    We wrote a PERL script to harvest each week�s top 30 titles in the United States from 2005
    to 2011. The data were then cleaned and restructured to create a panel data set of weekly sales by
    title for the first week of January 2005 to the last week of December 2011. Our raw data set consists
    of 2050 separate titles spanning 364 weeks and across multiple gaming consoles and includes
    weekly unit sales, violent content information, and quality rating information.

    Despite the richness of such high frequency sales data, VGChartz is not exhaustive. It omits
    a portion of all sales in the U.S. video game market as it is a truncated sample of the top 30 titles in
    a week. We believe that this weakness may be mitigated to some degree by the skewed distribution
    of sales. A game�s week of release is almost always its top-selling week. Figures 1 and 2 indicate
    that most games stay in the top 30 for only a few weeks, and game sales decay rapidly with each
    week on the market. Such large turnover in game titles and variation in sales by week provide sub-
    stantial variation for identification.

    Figure 1. Number of Weeks a Game is in the Top 30 Sellers.

    3 http://www.vgchartz.com

    1252 Cunningham, Engelst€atter, and Ward


    Table 1 compares VGChartz data to the Entertainment Software Association (ESA) data.
    While it would appear that VGChartz titles are only one-quarter of all units in 2006, it is worth
    noting that this is in part due to the ESA including sales of non-console-based games such as com-
    puter and smartphone games (ESA Annual Report 2010).4 This fraction rises to about 80% in
    2011, and while this raises some concerns about comparability over time, we expect some of this
    effect to be subsumed into the year dummies.

    We record the violence content of each game using the ESRB�s rating and descriptions of the
    game�s content.5 ESRB is a nonprofit body whose function is to assign each title a technical rating.
    Games considered to be appropriate for all ages are given an E; games appropriate for 10 and
    older are given E10; games appropriate for teens are given a T; games appropriate for a mature
    audience are given an M; and games appropriate for adults are given an A. ESRB also provides a
    detailed description of the content for each title including the style of violence contained in the
    game. Each title was successfully matched with its ESRB rating and content information. Out of
    2050 titles in our sample, 512 are rated Mature and 352 were intensely violent. All intensely violent
    games are rated Mature.

    Figure 3 depicts the logarithm of sales for all games and intensely violent games over time.
    Most of the variation is due to the release of new games each week that are popular initially but
    experience a rapid decay in sales. Although the two lines follow a similar pattern, including a large
    peak around the Christmas gift-purchasing period, sometimes strong sales of a single title will
    cause them to diverge. For instance, the spike in intensely violent game sales in the middle of 2008
    is not mirrored in the more general series. This represents the release of Grand Theft Auto IV, an
    intensely violent and immensely popular game.

    While Figure 1 indicates that consumers tend to buy a game soon after it is released, they
    may play purchased games over longer horizons. We have obtained data from Raptr, a video gam-
    ing social network, on over 100,000 users� gaming sessions.6 These data cover over 10 million

    Figure 2. Average U.S. Video Game Unit Sales by Weeks After Release.

    4 http://www.theesa.com—The reported numbers from ESA also include games for personal computers which amount
    to about 10% of the market each year and are intentionally not included in VGChartz.

    5 http://www.esrb.org
    6 http://raptr.com/

    Violent Video Games and Violent Crime 1253

    Home – 2022-03-03 Release



    sessions for particularly avid gaming enthusiasts. We have aggregated game play sessions by day
    and recorded when a user obtains a new game. Figure 4 records the number of hours played across
    all games around the time a new game is acquired. It is clear that, for this sample, gaming activity
    is highest on the day that a new game is purchased and falls for about three weeks afterward. The
    “scalloped” shape emerges because video games are typically released for more intensive weekend
    play. It also appears that individual video game play time increases just before a new video game
    purchase. This suggests that new game purchases are driven, in part, by a pent up demand for new
    video gaming experiences.

    To explore the link between game sales and game playing, we related our weekly measure of
    video game sales to time use data on playing games. The Bureau of Labor Statistics has adminis-
    tered the ATUS since 2003 by taking a random sample from households that have recently com-
    pleted their participation in the Current Population Survey (CPS). The ATUS records activities of
    a participant for a single day and collects over 1000 diaries per month with some coverage of every
    single day. Each activity is ultimately coded to a three-tier scheme, going from broad top-level cate-
    gory to finer subcategories. For our purposes, the subcategory “playing games” includes the activ-
    ities “playing computer, board, or card games” and so includes activities other than playing video
    games. Basic demographic information on age, sex, race, household income, and household size
    from the CPS is available for every survey respondent.

    Table 1. Comparison of Unit Sales of Video Games (millions) from VGChartz and the ESA

    Year VGChartz Entertainment Software Association Percent (%)

    2005 90.7 227.4 39.9
    2006 63.8 240.1 26.6
    2007 131.6 268.1 49.1
    2008 187.2 298.6 62.7
    2009 181.9 290.1 62.7
    2010 218.4 267.4 81.7
    2011 206.5 245.9 84.0

    Sources: VGChartz from authors� calculations and ESA from http://www.theesa.com/facts/pdfs/esa_ef_2014 .

    Figure 3. Ln Weekly Sales of Video Games.

    1254 Cunningham, Engelst€atter, and Ward


    To confirm that video game sales positively affect the probability of playing video games, we esti-
    mate Probit and Tobit regressions relating a dummy variable for playing games and the amount of
    time playing games to video game sales over the current and preceding weeks as well as controls for
    basic demographics and sets of dummy variables for year, week-of-year, and day-of-week. The details
    are reported in Table A1 and summarized in Figure 5. This figure reports coefficient values and confi-
    dence intervals for various leads and lags of video game sales on the probability of playing a game.
    While leads of video game sales appear to have no effect on game playing, game playing is affected by
    current sales, sales lagged one week, and, perhaps, lagged two weeks. We take this as evidence that
    aggregate video game playing time is correlated with video game sales for up to three weeks.

    In a second step, we examine the difference in video game playing across gender and age
    groups. Therefore, we not only split the ATUS sample into male/female and age above or below 30
    but only focus on gameplay duration. We again use the Tobit estimator in a specification that now
    includes the first three weeks of video game sales (Lag 0, 1, and 2) aggregated as these three weeks
    are the most relevant for gameplay according to the first analysis. We use the same controls as in
    the first estimation. The results are reported in Table A2. Overall, the marginal effects for females

    Figure 4. Time spent Playing Video Games Before and After a New Video Game Purchase.

    Figure 5. The Effect of Video Game Sales on the ATUS Respondents Game Playing.

    Violent Video Games and Violent Crime 1255

    are no different from that from males but the earlier table indicates that males play 40% more. The
    marginal effect for the younger players is larger than older players but the difference is not statisti-
    cally significant. Furthermore, younger respondents play more than older ones. We interpret this
    as, given that a girl or a non-youth plays video games, their gaming behavior is not very different
    from a younger boy.

    Crime Data

    For our measure of crime, we use both the UCR and NIBRS. The UCR program was con-
    ceived in 1929 by the International Association of Chiefs of Police to meet the need for reliable
    uniform crime statistics for the nation. In 1930, the FBI was tasked with collecting, publishing,
    and archiving those statistics. NIBRS on the other hand is a federal data collection program begun
    by the Bureau of Justice Statistics in 1991 for gathering and distributing detailed information on
    criminal incidents from participating jurisdictions and agencies. Participating agencies and states
    submit detailed information about criminal incidents to the NIBRS which are not contained in
    other data sets, such as the UCR. For instance, whereas the UCR contains information on all
    arrests and cleared offenses for the eight Index crimes, NIBRS consists of individual incident
    records for all eight index crimes and the 38 other offenses (Part II offenses) at the calendar date
    and hourly level (Rantala and Edwards 2000).

    Because of the detailed information about the incident, including the precise time and date of
    the incident, economists such as Dahl and DellaVigna (2009), Card and Dahl (2011), Jacob and
    Lefgren (2003), and Jacob, Lefgren, and Moretti (2007) have used NIBRS for event studies. In our
    case, we exploit detailed information about the date of a crime to create weekly counts. The UCR
    are also regularly used in economic analysis of crime by, for example, Evans and Owens (2006),
    Stevenson and Wolfers (2006), or Phillips and Land (2012).

    One potential drawback of NIBRS compared to the UCR, however, is its limited coverage
    as, unlike in the UCR, only a subset of localities participates. Overall, 32 states currently partici-
    pate, and many states with large markets—California, New York, DC—do not participate at all.
    Moreover, not all jurisdictions participate within states over time. In a first step to address selec-
    tion problems, we run our estimations based on both the UCR and the NIBRS sample and com-
    pare the results. Our results are similar regardless of which data source we use. We also address
    possible selection problems by limiting our NIBRS sample to a balanced panel of agencies that
    participated with NIBRS at the start of our sample and continued each year. These agencies are
    located in 1082 separate counties.

    Crime and game sales both follow profound seasonal patterns that could lead to spurious
    correlations. Seasonality in crime is largely due to weather conditions with increases in crimes dur-
    ing warmer months (Jacobs, Lefgren, and Moretti 2007). Game sales are greatly affected by holi-
    day gift-giving at the end of the year. As indicated above, we accommodate these patterns with
    weekly dummy variables, which should capture correlation due to seasonality, and annual dum-
    mies that should capture correlation due to secular trends.

    Final Samples

    We investigate the relationships between violent video game sales and crime. We must drop
    some observations due to holiday seasonality and to construct lags. Our UCR-based data span 84

    1256 Cunningham, Engelst€atter, and Ward

    months in total from 2005 through 2011 but dropping December each year yields a final sample of
    77 observations.

    Our NIBRS-based data span the 364 weeks over the same period but due to dropping nine
    Christmas shopping season weeks and some initial weeks to construct lags, our final sample
    includes only 300 observations. We aggregated the VGChartz weekly observations to the month
    level in the UCR sample. Table 2 reports basic descriptive statistics for all three samples. There are
    two reasons for the large difference in magnitudes across the NIBRS and UCR data sources. The
    first is due to differences in the unit of observation. The UCR data measures crimes at the monthly
    level, whereas NIBRS measures crime at the weekly level. This also explains the differences in
    video game sales across the two samples. The second is due to the many more jurisdictions within
    the United States reporting to UCR than to NIBRS.

    For our panel sample, the same weekly crime information from the NIBRS data was aggre-
    gated for each of 1082 counties along with data beginning in 2005 on the fraction of the popula-
    tion aged 10–29, the primary video game playing age group. From this, counties were aggregated
    into deciles based on this youth fraction to construct a balanced panel spanning 2005 to 2010.

    Our method is most like Dahl and DellaVigna (2009), and therefore, we contrast our study
    with it to illustrate its strengths and weaknesses. Like Dahl and DellaVigna (2009), we do not have
    geographic variation in sales data. Whereas first run movies can be described as nondurables last-
    ing two hours on average, video games have more complex consumption patterns. Unlike feature
    films, video games are more like durable goods played repeatedly after purchase with highly vari-
    able time use by title and individual player. Some families� budget time allowances for video game
    play while others allow unlimited play time. The decision to do so is likely related to the family
    characteristics that are correlated with the determinants of crime, such as family structure and
    income. Furthermore, box office movie sales are available by day whereas video game sales are
    only available at the weekly level.

    Table 2. Summary Statistics

    Variable Mean Std. Dev. Minimum Maximum

    Monthly UCR sample
    All video game sales (1000s) 5542 3842 1308 24,425
    Intensely violent video game sales (1000s) 1203 2058 52 13,889
    All crimes (1000s) 1567 187 1134 2103
    Violent crimes (1000s) 634 73 492 850

    The sample includes 77 monthly observations from 2005 to 2011 that exclude December.
    Weekly NIBRS sample

    All video game sales (1000s) 1192 936 252 9376
    Intensely violent video game sales (1000s) 260.4 696.5 5.4 8264.80
    All crimes (1000s) 47.2 4.7 34.1 55.7
    Violent crimes (1000s) 18.9 1.7 14.6 22.7

    The sample includes 300 weekly observations from 2005 to 2011 that exclude the eight
    Christmas shopping season weeks.

    Weekly by decile NIBRS panel
    All video game sales (1000s) 1138 815 252 7467
    Intensely violent video game sales (1000s) 213.22 522.11 5.41 5715.99
    All crimes (1000s) 4.86 3.96 0.276 15.023
    Violent crimes (1000s) 1.95 1.587 0.116 6.207
    Youth fraction 0.253 0.035 0.197 0.328

    The sample includes 2575 week by decile observations from 2005 to 2010 that exclude the
    eight Christmas shopping season weeks.

    Violent Video Games and Violent Crime 1257

    5. Results

    Variation Over Time

    Our basic OLS regression results of the estimation of Equation 1 are presented in Table 3 for
    the UCR data and Table 4 for the NIBRS data. Each table reports both OLS and 2SLS estimates
    of specifications for three weeks of accumulated sales of video games sales on all crimes.7 These
    specifications also exclude observations that would be affected by the Christmas gift shopping sea-
    son, specifically month 12 in the UCR sample and weeks 47–52 and 1–3 in the NIBRS sample,
    because the time lag between purchase and playing likely differs.

    The first column in each table, reporting the OLS estimates, indicates a small but statistically
    significant decrease in crime when video game sales are higher. The estimates are very similar for
    both crime data samples and indicate that the elasticity is on the order of 20.027 (UCR sample)
    or 20.022 (NIBRS sample). In other words, a doubling of video game sales is associated with a
    2–3% decrease in crime. The estimated effect of violent video game sales is not significantly differ-
    ent from zero. While the negative effect from all games is consistent with incapacitation, the lack
    of a measurable effect from violent games does not provide evidence for either catharsis or GAM.

    Table 3. The Effects of Violent Video Game Sales on Crime—UCR Data


    Crimes Sales Violent Sales Crimes

    Variables First stage First stage Second Stage
    Ln video game sales 20.027** 0.036

    (0.011) (0.034)
    Ln intensely violent

    video game sales
    20.000 20.021*

    (0.004) (0.011)
    Avg. video game quality 0.386 21.772

    (0.357) (1.070)
    Avg. weeks on market 20.058* 20.114

    (0.029) (0.087)
    Avg. violent video game quality 0.068 0.931**

    (0.124) (0.372)
    Avg. violent video game

    weeks on market
    20.089** 20.299**

    (0.029) (0.088)

    Christmas season No No No No
    Year dummies Yes Yes Yes Yes
    Month dummies Yes Yes Yes Yes

    Observations 77 77 77 77
    R-squared 0.981 0.902 0.791 0.967

    Regressions also include year and week-of-year dummy variables. Standard errors in parentheses. First-stage F-statistics
    (4, 56) for the excluded variables are 5.10 and 5.27 which both have p-values less than 0.01. The v2(4) value for the AR
    weak instrument test is 7.78 with a p-value less than 10%.The Sargan statistic for the IVs is 1.612 with a p-Value (v2) of
    **p< 0.01. *p< 0.05. 1p< 0.1.

    7 Estimates were also generated for each of one to six weeks of accumulated video game sales “exposure.” All results are
    qualitatively similar with estimates from more than three weeks becoming less precisely estimated.

    1258 Cunningham, Engelst€atter, and Ward

    The next three columns in Tables 3 and 4 report the first and second stage results for the
    2SLS estimator and once again feature very similar results for each crime data source. There are
    two instrumented variables and four instrumental variables. In the first stage, video game sales fall
    with the average age of all games in the top 30 as well as with the average age of all violent games.
    Sales of violent games are higher with higher quality violent games and lower with the average age
    of violent games. This relationship is slightly different for the NIBRS sample, in which both aver-
    age video game quality and age have negative marginal effects on violent game sales. We present
    standard F-statistics on the excludability of the instruments from the first stage regression. The
    correlations between the instruments and our endogenous variables are strong in the NIBRS data,
    although (F-statistic around 20). In the second stage, the estimated effect of video game sales is
    positive but not significantly different from zero. For violent video games, the estimated effect is
    around 20.02 and significantly different from zero regardless of which crime data source is used.
    In Table 3, we pass the over-identification test based on the Sargan test statistic, but we fail to pass
    the over-identification test in the NIBRS regression. We also test for whether we have a weak
    instrument problem using both the F-test on the excludability of the instruments from the first
    stage, as well as the Anderson–Rubin test. The p-values on the Anderson–Rubin test are both stat-
    istically significant. Thus, while our IV estimation largely supports the main results, it should be
    interpreted with some caution. With that caveat, the negative effect from violent games is consist-
    ent with either incapacitation or catharsis, but does not support GAM.

    Table 4. The Effects of Violent Video Game Sales on Crime—NIBRS Data


    Crimes Sales Violent Sales Crimes

    Variables First stage First stage Second Stage
    Ln video game sales 20.022** 0.007

    (0.007) (0.017)
    Ln intensely violent

    video game sales
    0.000 20.018**

    (0.002) (0.006)
    Avg. video game quality 0.006 20.259**

    (0.024) (0.078)
    Avg. weeks on market 20.013** 20.011**

    (0.002) (0.006)
    Avg. violent video game quality 0.012 0.151**

    (0.009) (0.029)
    Avg. violent video game
    weeks on market

    20.008** 20.040**
    (0.002) (0.006)

    Christmas season No No No No
    Year dummies Yes Yes Yes Yes
    Week dummies Yes Yes Yes Yes

    Observations 300 300 300 300
    R-squared 0.943 0.846 0.682 0.927

    Regressions also include year and week-of-year dummy variables. First-stage F-statistics for the excluded variables are
    21.8 and 20.2 which both have p-values less than 0.01. The v2(4) value for the AR weak instrument test is 31.4 with
    a p-value less than 1%. The Sargan statistic for the IVs is 10.19 with a p-Value (v2) of 0.01.
    Standard errors in parentheses.
    **p< 0.01. *p< 0.05. 1p< 0.1.

    Violent Video Games and Violent Crime 1259

    Differential Marginal Effects

    It is likely that any effect of video games will be localized where gaming demand is higher.
    Ward (2011) exploited this idea by relating changes in various crimes in a county from year to year
    to changes in the number of video game stores. As mentioned before, we do not have cross-
    sectional variation in video game sales. Instead, our strategy focuses on differential gaming pat-
    terns by age. Video game playing is more popular among adolescents and young adults. We use
    this empirical regularity to test whether there is a larger marginal effect of video game sales in
    areas with greater “youth” prevalence as explained in the second part of the methodology section.
    The youth fraction which we measure as the fraction of the population aged 10–29 years has a
    sample mean of 0.261 with a standard deviation of 0.042. We focus our attention on the estimates
    of the interaction terms, bv

    yth and bnv
    yth from Equation 2, to measure a differential marginal effect.

    We estimate Equation 2 using simple OLS including fixed effects for year and week-of-year.
    Results are reported in Table 5. Again, we omit the Christmas gift shopping season, report only
    those variables of interest and for sales aggregated to three weeks. The positive coefficient of the
    uninteracted fraction youth population variable indicates that there is more crime in areas with a
    higher proportion of youth. For ease of interpretation, the youth fraction enters as a deviation
    from the sample mean. This allows us to interpret the uninteracted video game coefficients as
    applying to the average county. Thus, in column 1, for the average county, the video game sales
    variable has no discernable effect on crime. The coefficient for the interaction term with the youth
    population is negative which suggests that, in areas with more video gamers, more popular games
    lead to marginally fewer crimes. This is consistent with a greater incapacitation effect where there
    are more video game players.

    Again, the GAM and catharsis hypotheses relate specifically to violent video games. To
    test this hypothesis, we include violent game sales and its interaction with the youth fraction in

    Table 5. Panel Regression of the Differential Effect of Video Game Sales in High Youth
    Counties—NIBRS Data

    Crimes Crimes

    Ln video game sales 20.0111 20.005
    (0.007) (0.008)

    Ln video game sales 3 youth fraction 24.302** 23.821**
    (0.233) (0.298)

    Ln intensely violent video game sales 20.0041

    Ln intensely violent video game

    sales 3 youth fraction

    Youth fraction 85.199** 80.138**

    (3.176) (3.686)
    Christmas season No No
    Year dummies Yes Yes
    Week dummies Yes Yes

    Observations 2570 2570

    The panel was created by aggregating counties into deciles based on the fraction of the population aged 10–29 years.
    Regressions also include year and week-of-year dummy variables. Standard errors clustered at the week level.
    Robust standard errors in parentheses
    **p< 0.01. *p< 0.05. 1p< 0.1.

    1260 Cunningham, Engelst€atter, and Ward

    column 2. The coefficient for the interaction term for all video games is not only negative but only
    marginally statistically significant. The coefficient for the interaction term for violent video games
    is also negative and statistically different from zero. These results are consistent with either incapa-
    citation or catharsis. They are not consistent with GAM.

    6. Conclusion

    Regulation of the content of video games is usually predicated on the notion that the
    industry generates large and negative social costs through games� effect on aggression. Many
    researchers have argued that these games may also have caused extreme violence, such as
    school shootings, because of the abundance of laboratory evidence linking violent media to
    measured psychological aggression. Yet to date, because the field has not moved beyond sug-
    gestive laboratory studies, we argue their external validity to understanding the impact on
    crime is limited. With the exception of Ward (2011), social scientists have yet to move beyond
    the laboratory to understand whether concerns about game violence�s causal effect on crime
    are warranted.

    Similar to Dahl and DellaVigna (2009) our study suggests the evidence that violent video
    games have substantial social costs is weak. In fact, our study finds that in the weeks following
    popular video game releases, crime rates decrease. More research is needed to determine if violence
    in media may have social benefits by reducing crime. As with the above two studies, we find that
    the short- and medium-run social costs of violent video games may be considerably lower, or even
    nonexistent. The measured effect stemming from intensely violent video games, and not from non-
    violent games, is consistent with catharsis and not with incapacitation. However, this effect is not
    found in all specifications.

    Our results do not completely rule out GAM. Most theories in GAM suggest that long-term
    exposure to violent media increases aggression, whereas our tests measure relatively short-term
    responses to video game violence. It is possible, that a positive GAM effect is large enough in the
    long-run to dominate the negative effect we estimate for violent video games in the shorter-run.
    The case for regulatory intervention depends on whether any or all of these effects apply. Insofar
    as positive and negative effects of violent media are at work simultaneously, the optimal design of
    an intervention that reduces harm from one without raising harm from the other may prove a
    challenge. Weighing possible competing effects on crime is a problem that has been raised by other
    papers in other contexts such as violent movies (Dahl and DellaVigna 2009) and youth gangs
    (Sobel and Osoba 2009). While some early work has been done on the long-term effects of video
    game play, nearly all the laboratory evidence that currently exists has only uncovered very short-
    term effects.8

    Our findings also suggest unique challenges to game regulations. GAM proposes that the
    individuals playing violent video games are developing, accidentally, a biased belief toward people
    wherein they believe they are in danger. It is possible that the decrease in violent outcomes that we
    observe in our study, possibly due to short-run catharsis or incapacitation, is masking the long-
    run harm to society if these violent behaviors are developing within gamers. This suggests that

    8 Anderson (2004) notes the lack of longitudinal studies of effects of violent video games on aggression and calls for
    more studies aimed at investigating the long-term effects. The best evidence we have at present from laboratory studies
    is primarily short-run, making our study more suitable for comparison.

    Violent Video Games and Violent Crime 1261

    regulation aimed at reducing violent imagery and content in games could in the long-run reduce
    the aggression capital stock among gamers, but potentially also cause crime to increase in the
    short-run if the marginal player is currently being drawn out of violent activities. This tradeoff
    may not pass a cost-benefit test.

    A related policy question centers on whether reducing violent content of video games so as to
    diminish GAM related aggression effects also would diminish any time use and cathartic effects.
    Presumably, publishers include content that is violent because there is a market niche that
    demands it. They believe that removing the violence would lower profits because it would reduce
    these gamers� willingness-to-pay. It is not clear how much time use might fall, but lower utility
    from such games would reduce game demand and game play time by some amount. The ability to
    craft a regulation restricting violent content that does not also lower consumer utility seems

    Using our approach, in some specifications, we find a negative relationship between video
    game sales and crime that generates an elasticity of about 20.02. As our research design exploits
    short-run variation in weekly sales, caution should be used in applying it outside our sample
    frame. For instance, if behavioral effects from popular, higher quality games diverge from that of
    popular, lower quality games, then our approach may misstate the average elasticity of games inde-
    pendent of quality. Furthermore, our estimates are exclusively based on short-run variation in
    sales, which may be different from effects in the long-run. For instance, the substitution out of
    schooling to video gameplay as Stinebrickner and Stinebrickner (2008) and Ward (2015) show
    might imply that long-run effects of violent games on crime are positive by reducing human capital
    and wages (Grogger 1998). With this caveat, we use this elasticity to construct a simple counterfac-
    tual for U.S. crimes from 2005 to 2011.

    To provide context for the magnitude of our estimated effects, we consider a simple back-
    of-the-envelope calculation using the numerical growth in video game sales over our sample
    period. From Table 1, video game unit sales as reported by the ESA increased by 8.1%. Assum-
    ing this applies to both violent and nonviolent games, an estimated violent video game-to-
    crime elasticity of approximately 20.02 would predict almost 0.16% fewer violent crimes due
    to violent video game sales. Nationwide, this would translate to almost 36 fewer violent crimes
    committed per week. By comparison, the estimated incapacitation effect from Jacob and Lefg-
    ren (2003) of 13.3% more property crimes due teacher in-service days, would translate into
    about 2300 property crimes for a hypothetical national in-service day.9 Since the video game
    effect occurs year round, this suggests that video games are disrupting, at most, 2000 crimes
    per year.

    This approach can help guide investigators to develop more holistic research designs,
    such as field experimentation and other quasi-experimental methodologies, to determine the
    net social costs of violent games. The main shortcoming of our approach is due to the limita-
    tions of our data on game sales. Unfortunately, the industry does not report cross-sectional
    variation in game sales—only the national weekly sales of the top 30 highest grossing games
    are available.

    9 Our calculation is based on a total of over 1.2 million violent crimes where the calculation of Jacob and Lefgren (2003)
    is based on 6.2 million annual property crimes. Both type of crimes are reported in the FBI�s “Crime in the United
    States,” http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in-the-u.s.-2010/tables/10tbl01.xls.

    1262 Cunningham, Engelst€atter, and Ward


    Table A1. Estimates of Factors Affecting Playing Games from ATUS

    Probit Any Game Playing Tobit Hours Playing Games

    Video game sales
    Four-week lead 20.031 (0.098) 20.074 (0.425)
    Three-week lead 20.161 (0.130) 20.705 (0.555)
    Two-week lead 20.044 (0.130) 20.270 (0.522)
    One-week lead 20.032 (0.155) 20.179 (0.644)
    Current week 0.444*** (0.171) 1.756*** (0.708)
    One-week lag 0.242** (0.120) 1.294*** (0.483)
    Two-week lag 0.072 (0.130) 0.151 (0.530)
    Three-week lag 20.034 (0.126) 20.073 (0.514)
    Four-week lag 20.073 (0.112) 20.056 (0.457)

    High school student 0.007 (0.042) 20.068 (0.179)
    College student 20.078*** (0.030) 20.428*** (0.131)
    Male 0.065*** (0.013) 0.430*** (0.055)
    Black 20.235*** (0.020) 20.994*** (0.089)
    Asian 20.238*** (0.037) 20.977*** (0.162)
    Hispanic 20.409*** (0.021) 21.771*** (0.093)
    Usual work hours 20.004*** (0.000) 20.019*** (0.002)
    Married 20.110*** (0.026) 20.567*** (0.113)
    Unmarried household 20.043* (0.025) 20.188* (0.108)
    Household size 2–3 0.058** (0.027) 0.286** (0.118)
    Household size 41 0.046 (0.030) 0.181 (0.128)
    Age dummies X X
    Income dummies X X
    Day of week dummies X X
    Week of year dummies X X

    Standard errors clustered on the observation week. The sample includes all 87,831 non-Christmas season
    ***p< 0.01. **p< 0.05. *p< 0.10.

    Table A2. Differential Estimates in Minutes of Gaming by Gender and Age from ATUS

    Male Female Age <530 Age >30

    Video game sales sum of Lags 0,1,2 0.670*** 0.752*** 0.993*** 0.645***
    (0.226) (0.177) (0.319) (0.191)

    High school student 0.085 20.267 0.019 20.529
    (0.237) (0.291) (0.194) (1.200)

    College student 20.376* 20.121 20.474*** 20.004
    (0.200) (0.152) (0.172) (0.213)

    Male 2.749*** 20.464***
    (0.122) (0.062)

    Married 20.835*** 20.059 20.430** 20.269***
    (0.138) (0.091) (0.190) (0.094)

    Working 0.036 20.076 0.252 20.354
    (0.229) (0.171) (0.187) (0.234)

    Black 20.602*** 21.128*** 20.372** 21.150***
    (0.139) (0.109) (0.165) (0.099)

    Asian 20.760*** 21.303*** 0.199 21.792***


    Violent Video Games and Violent Crime 1263


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    (0.143) (0.122) (0.161) (0.121)
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    1264 Cunningham, Engelst€atter, and Ward




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    Violent Video Games and Violent Crime 1265





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