   |  | | The role of physicians in lethal injection |
By Mike Magee, MD
Currently some 3350 US citizens are living on Death Row awaiting execution.1 They have each been there an average of just over 12 years since sentencing. As they languish, legal battles continue over the constitutionality of both the death penalty and the means of execution. The death penalty itself is currently allowed in 38 states. Since 1976, lethal injection has been the method of choice for execution 83% of the time. Today it is the preferred method in all states allowing execution.2
The most widely used method of lethal injection involves three injections occurring in sequence.3 The first, sodium thiopental, is intended to induce a state of deep unconsciousness and freedom from pain. The second, pancuronium bromide, paralyzes the body's muscles. The third, potassium chloride, stops the heart from beating, and leads to death. While this approach to halting life, most would agree, is considerably more humane then other techniques such as death by hanging or electrocution, it is not without controversy. Legal challenges have revealed that the type, amount, and delivery of the drugs, as well as their effectiveness in doing what they are intended to do, varies from state to state, as does the supervision, speed and success of the procedure.4
In some cases it is claimed that the inmate may appear unconscious, but experiences severe pain and is unable to express this because the muscles are paralyzed, preventing movement or communication. If some of this may be sounding eerily familiar, it is because it closely reflects story lines of recent news reports, TV dramas and movies of real life mishaps in our nation’s operating rooms. This should come as no surprise since the technique for lethal injection and two of the three drugs utilized have been part of the armamentarium of modern anesthesia for decades. When administered properly, the unconscious patient experiences pain free surgery. Administered improperly, the results are the polar opposite, and the only one who knows this is the powerless and suffering patient.5
The similarities between instruments and techniques designed to care for patients and kill condemned prisoners creates profound ethical discomfort among most physicians. While medicalization of the death penalty may be thought of as a means to prevent needless pain and suffering associated with the death penalty, the price is a corruption of the historical values and established tenets of the profession of medicine. The physician's obligation, embedded from the first days of training, is to help, not hurt patients. For more than three decades, the American Medical Association (AMA) has specifically prohibited physician involvement in executions.6,7 Doctors can not measure the chemicals, insert intravenous lines, inject drugs, monitor sedation, medically intervene, or even be the primary declarer of death in executed prisoners. These restrictions have been affirmed and reaffirmed by the AMA, which is not empowered to remove a physician's license if he or she disobeys, but is prepared and has recently revoked the AMA membership of a California physician who participated in an execution.6
As members of the AMA's Council on Ethical and Judicial Affairs recently wrote, "The specific role of the physician in society ...is preventing and healing illness and relieving suffering. The core requirement for that role is trust in the profession which is advanced and preserved by ethical principles. Any form of participation in causing death by lethal injection is unethical because it violates the physician's role thereby undermining trust. Courts and legislatures should not ask physicians to violate ethical standards to solve problems raised by legal challenges."6
What challenges? Well there are many, in both state and federal courts, claiming lethal injections are inadequately supervised, and poorly performed. As the Death Penalty Information System describes, "Those raising lethal injection challenges (both those executed and those stayed) are generally claiming that the drugs used in the executions cause extreme and unnecessary pain, and that the combination of chemicals masks the pain being experienced by the inmate from the sight of those administering the death penalty. The appeals assert that this is a violation of the Eighth Amendment's ban on cruel and unusual punishments. Initial rulings from federal District Courts in California and Missouri have held the procedures in those states to be unconstitutional because they lack sufficient safeguards and oversight to ensure the orderly application of lethal injection."8
The array of challenges and conflicting judgments have created enough confusion to cause the U.S. Court of Appeals in 2006 in the case of Alley v. Little to issue this dissenting opinion: "We are currently operating under a system wherein condemned inmates are bringing nearly identical challenges to the lethal injection procedure. In some instances, stays are granted while in others they are not and defendants are executed, with no principle distinction to justify such a result."8 The Supreme Court is currently hearing a case from Kentucky challenging lethal injection, poorly administered, as "cruel and unusual punishment." Initial hearings and comments by the Justices reflect conflict and sharply varying opinions on the question.9
The clear solution is to standardize and further medicalize the procedure, bringing physicians and modern anesthesia into the death chamber. No way, says the AMA. In their words: "The penal system, not the medical profession, is responsible for finding a way to perform executions.”6
References:
1. Death Penalty Information Center. Death Row Inmates by State and Size of Death Row by Year. 2008.
2. Death Penalty Information Center. Facts About the Dealth Penalty. 2008.
3. Denno DW. When legislatures delegate death:the troubling paradoxes behind state uses of electrocution and lethal injectionand what it says about us. Ohio S L J. 2002;63: 63-260.
4. Brown v. Beck, N. 5:06-CT-3078-H (ND NC April 7, 2006)
5. Offical Movie Homepage: Awake. 2007.
6. Black, L. Sade, RM, Lethal Injection and Physicians: Sate Law vs. Medical Ethics. JAMA, December 19, 2007; Vol. 298, No. 23, 2779-2781.
7. American Medical Association. Ethical Opinion E-2.06: Capital Punishment. In: Code of Medical Ethics of the American Medical Association. 2006-2007 ed. Chicago,IL: American Medical Association 2006;19-20.
8. Death Penalty Information Center. LETHAL INJECTION: National Moratorium on Executions Emerges After Supreme Court Grants Review. 2008.
9. Totenberg, N. Supreme Court Takes Up Lethal Injection. NPR News. 2008.
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