Open Question: Should Physicians Be Involved in Lethal Injection?

In the newest issue of JAMA, two authors affiliated with the AMA offer their opinions on physicians’ role in implementing the death penalty via lethal injection. Hint: they don’t approve of it.

The article says that unlike other methods of execution, lethal injection “has elements of medical practice: insertion of intravenous lines, intravenous injection of medicinal drugs, and monitoring vital signs.” Small wonder then, that 35 of the 38 states that allow the death penalty either require or permit physician participation in executions.

Typically the identity of physicians who participate in executions is held confidential by state authorities. Even if they are made known, licensing boards in death penalty states have trouble taking any action against physicians who participate in executions. Since the boards deal with illegal activities, they can’t crack down on physicians who participate in executions that are legal.

But medical societies have more wiggle room. AMA prohibits involvement of physicians in executions, saying that it goes against the physician’s role as a healer. As the authors put it, “any form of participation in causing death by lethal injection is unethical because it violates the physician’s role, thereby undermining trust….the penal system, not the medical profession, is responsible for finding a way to perform executions.”

Obviously this issue has a certain degree of timeliness, given the Supreme Court’s recent agreement to hear challenges to lethal injection on the grounds that the process often gets so mucked up that it constitutes cruel and unusual punishment. But I think the JAMA piece is right in addressing it as a big-picture best practices question. This is primarily a moral question.

And it’s a tough one, even for physicians who might support capital punishment in the criminal justice system. Just because they believe that murderers should die, it doesn’t follow that they feel criminals do or do not deserve a demise that is as painless as possible. Supporting capital punishment and consenting to having a hand in it are two very different things.

So imagine you’re a doctor and the state has asked you to preside over an execution that will go on with or without a physician present. What’s your medical duty—to try to ensure that things go smoothly and spare the inmate unnecessary pain, or abstain from attending because your presence would mean you were participating in taking a life? Which choice is truer to the physician’s duty to be a healer?

I’m very curious as to what the Health Beat readership—especially our MDs—think about this question. Keep in mind I’m not asking if you support or object to the death penalty as a criminal justice policy (although that’s likely to influence your position); the real question here is one of ethics and medical obligation: where do you think the line should be drawn? Do doctors have a right to refuse participation in procedures that cause harm, even if they’re the law? Or should doctors be doing all they can to make sure that, within the boundaries of the law, harm is minimized?

I’ll start things off: I think the AMA is right, and not just because of its professional imperative to make sure that doctors are trusted. The logic that doctors should feel obligated to make the death penalty as painless as possible makes sense in the short-term, because it reduces the risk of avoidable harm to the executed, but in the moral sense it’s unsustainable. First, we know that our death penalty system is imperfect. A 2000 Columbia University study showed that 65 percent of death penalty cases are overturned on appellate review. Hundreds of convicts have been exonerated by DNA testing. A physician can never be 100 percent sure that he is not putting an innocent person to death—and if you think harming a murderer is medically unethical, harming an innocent is even worse.

Second, I think that it’s hard to say that doctors should heal only within the confines of the law. You can imagine a situation where the law is incredibly unfair, to an extent where it is the doctor’s duty not just as medical expert but as a citizen to resist its implementation. It’s true that the Hippocratic Oath says that doctors shouldn’t violate the morals of their community. But what the heck does that mean in this case—that because the death penalty exists, it represents a community value? Call me cynical, but I don’t think that the trajectory of our laws is a bee-line from the peoples’ hearts to the legislators’ finger tips.

Third, the argument that doctors who don’t participate in the death penalty are allowing unnecessary suffering  when the execution is botched doesn’t hold much weight because there are millions of suffering people not getting treatment from doctors today. In other words, you can’t say doctors are negligent for the care they’re not giving without addressing all of the care they deny, omit, or just never get around to providing for everyone, not just people in death row.

So there you have it. Thoughts?

Comments

[Dr. Marc B Stone]

Why lethal injection?
It's not the quickest and least painful way to put someone to death. A bullet to the brain, when the condemned and the gun are properly aligned and immobilized, is better, quicker and cheaper.

The favored method of execution is a reflection of society's view of itself. Lethal injection is a reflection of the medicalization of society - the way in which health care dominates the economy and health (compared to other values such as liberty, justice, equality, or morality) has become the dominant policy trump card.
When industrialization was the dominant force in society, electrocution was the method of choice. The adoption of lethal injection as the prevailing method of execution is a complement paid to the role of health care in society. The ambivalence that the medical profession feels about lethal injection is connected to a reluctance to admit that it is not the "best" method because doing so would contradict the image of medicine's dominant role.

[charlie]

Does the AMA discourage physicians from participating in Oregon's death with dignity? It seems that if Ann's position of do no harm you should not participate in said program.

[joe blow]

The idea that you need a doctor to administer a lethal injection is ridiculous. All you need is a nurse. They are perfectly capable of starting IVs and pushing the drugs. There is a well defined protocol in place. Push teh drugs, wait 5 mins, check vitals. If there's still a heartbeat or respirations, push another round of drugs, wait 5 more mins, repeat ad infinitum.

The so-called debacles in the administering lethal injection were totally overblown by the media. Its usually improper IV placement which takes a few tries to get the needle into the vein. The media jumps all over that and plays it up like the guy is burning alive in an electric chair or some other nonsense.

The AMA holds no power over doctors performing lethal injections regardless. And any doc who faces repercussions by them has grounds for a defamation lawsuit.

[Ann E Malone]

No.

Kindly remind readers just what precisely does that Hippocratic Oath say?...

It's something about "First, Do No Harm", as I recall.

[Graham]

You should read Atul Gawande's latest book, Better. There's a whole chapter on this debate.

I personally wouldn't be able to participate in the process, but I can at least understand the perspective of the physicians who do, when you understand the alternatives--people not medically trained who can't even tell when an IV is infiltrating the skin (vs in a vein) causing great pain to a person.

[Dr.Rick Lippin]

Niko- your phrase"physicians who might support capital punshment" is an oxymoron.

My opinion-You cannot/should not be a physician if you serve the state in taking a life.

Dr. Rick Lippin
http://medicalcrises.blogspot.com