Justin Loke
5th year medical student
University of Oxford
justin.loke@green.ox.ac.uk

“Dr. A remembered [him saying], almost to comfort him, “No, they can never get the vein.” The doctor decided to place a central line. It was like placing one “for any other patient,” he said.”(1)

These words may be familiar to many students who have had to turn to their seniors when they reached that embarrassing point when they have failed to place a line or managed to take blood.  Chillingly, this is one of the most common reasons why doctors have been asked to participate in executions.  Lethal injection comprises 97% of the executions in the US since 2000 because other methods of executions are too cruel, and it is increasingly the method used by mobile execution vans in China, which leads nations in numbers of executions.  Medics have been involved with the prescription of the lethal cocktails, putting in of lines, pronunciation of death and some are involved in removal of their organs as well.  Deaths by lethal injection are sold by its proponents as a clean and fail safe method of execution.  There is increasing evidence that it is not.  Angel Diaz was recently executed in Florida.  At post mortem it was found he had 30cm long chemical burns in both antecubital fossae, which suggested that his cannulae were misplaced which would explain why it took him 34 minutes and two sets of injections to die (2).  

 Whilst in California, the execution of Robert Lee Massie might have been accomplished with him still being awake when the final injection of potassium chloride was delivered.  Zimmers and colleagues (3) recently looked at a number of execution details released by states such as California and found that this was not the only case where the inmates were potentially aware and potentially they could have died from asphyxiation from the pancuronium bromide. 

These anecdotes are of no surprise when the execution teams appear totally incompetent.  Executioners in Missouri have admitted to having no written protocol and to halving the amount of anaesthesia.  Whilst in Alabama, executioners have attempted to cannulate the non existent “external carotid vein” (2).  This accumulation of evidence has resulted in Californian Judge Jeremy Fogel, in December 2006, ruling that the lethal injection was in contravention of the 8^th Constitutional Amendment which forbids “cruel and unusual punishments”.  California and other states have now requested the help of medics to “fix” their situation.

Unsurprisingly, the authorities have tried to find ways of legitimising the system by the involvement of medics, for example the Missouri Judge Fernando Gaitan Jr ordered that executions could only continue with board certified anaesthetists administering the anaesthetics.  This would not be the first time doctors have been involved and in fact, the current lethal injection protocol was devised by the anaesthetist, Dr Stanley Deutsch, at the University of Oklahoma who advised that a combination of barbiturates and muscle relaxant should be used in the lethal injection to simulate an anaesthetic procedure. (4)

What motivates these doctors to take part?  Dr Carlos Musso is a doctor who specialised in Emergency care and subsequently became involved in medical care in his local prison.  He started “out of curiosity” (5) and began to empathise with the specific needs of those requiring medical care there, “substance abuse and non compliance is high.”  The American Medical Association (AMA)  are opposed to the participation of physicians in the execution process and are only allowed to give pre-execution anxiolytics at the prisoners’ request or to confirm the death of a prisoner after someone else has made the initial confirmation.  Although Dr Musso knew of this, and despite his personal conviction against the death penalty, he agreed to participate.  When asked why, his answer was emphatic, for him this was simply an “end of life issue” and that “my duty to care for a patient in a humane way and to address the pain and suffering at death far outweighs any other of my personal ethical or moral choices as a physician.” 

Although participation by physicians is forbidden by the AMA, in a recent survey only 3% (6) knew that guidelines exists on the issue  and that one in four surveyed would be willing to do at least five of the eight prohibited actions that occur during an execution.  Dr Lawrence Egbert (7), visiting professor of anaesthesiology at John Hopkins University, said that he “did a survey of Johns Hopkins University senior medical students…4% of students are willing to do this work….” 

Such statistics are damming of the AMA in its failure to educate its members of the importance of ethics at the grass root level and to appreciate the professionalism required of a doctor.  Corinna Moore (8), a medical student at John Hopkins said that “It would be hard to argue that physicians who administer lethal injections are not doing harm, even if they believe in the principal of capital punishment.”

But representative of the ambiguous views of many I spoke to, then said, “I’m not sure how I feel about a medical association banning physicians from administering the injection when the government and many physicians themselves believe capital punishment is justified.” But the majority of students reflected Corinna’s view that “I really just wish capital punishment itself could be stopped.” This issue was not discussed during their medical student course at all.  One doctor had said that if he had known of the guidelines he would not have participated. A couple of doctors have had fruitless attempts to de-license them and many states promise anonymity to protect them.

At the first state execution in Texas, initially, the doctor only agreed to pronounce the death of the prisoner, but was eventually persuaded to show the executioner the best injection site.  Doctors in these situations have become no less than executioners, and have twisted the skills they developed to heal, damaging the hard won confidence of patients.  One doctor who has been involved said; “If the doctors are removed, I don’t think [lethal injections] could be competently done.”(1) 

Many American states have reached this conclusion and doctors there have to decide whether they are willing to legitimise the process by being present.  Perhaps they should remember the words of John Donne, “Any man’s death diminishes me, because I am involved in mankind”.

(1) Gawande A. When law and ethics collide-why physicians participate in executions. N Engl J Med 2006; 23: 1221-29
(2) Koniaris LG, Sheldon JP and Zimmers TA The Lancet; 2007; 369 352-.353 
3) Zimmers TA, Sheldon J, Lubarsky DA, López-Muñoz F, Waterman L, et al., Lethal Injection for Execution: Chemical Asphyxiation?,  PLoS Medicine Vol. 4, No. 4, e156 doi:10.1371/journal.pmed.0040156
(4) Groner JI. Lethal injection: a stain on the face of medicine. BMJ 2002; 325: 1026-28
(5) Supplement to Gawande A. When Law and Ethics Collide - Why Physicians Participate in Executions. N Engl J Med 2006;354(12):1221-9.
(6)Farber NJ, Aboff BM,Weiner J, Davis EB, Boyer EG, Ubel PA. Physicians’ willingness to participate in the process of lethal injection for capital punishment. Ann Intern Med 2001;135:884­8.
(7)Personal Communication, Dr Lawrence Egbert, 12^th June 2007
(8)Personal Communication, Corinna Moore, 13^th June 2007

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