Breach of Trust: Physician Participation in Executions in the United States

Medical Responses to Physician Participation in Executions

The advent of lethal injections has prompted the medical community in the United States to clarify its position on physician involvement in executions, and to solidify its opposition to physician participation. By 1980, four states had passed lethal injection statutes. The same year, a landmark article in the New England Journal of Medicine detailed the history of medical participation in executions and ethical considerations. The authors concluded that lethal injection, by requiring medical knowledge and skills, was "a corruption and exploitation of the healing profession's role in society."19 Later that year, the AMA Council on Ethical and Judicial Affairs issued a report that prohibited the participation of physicians in executions. The Council wrote: "An individual's opinion on capital punishment is the personal moral decision of the individual. A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution. A physician may make a determination or certification of death as currently provided by law in any situation."20 Other medical organizations followed suit. In 1981, the World Medical Association (WMA) stated that it was unethical for physicians to participate in executions, except to certify death.21 In a press release, the Secretary General of the WMA said: "Acting as an executioner is not the practice of medicine and physician services are not required to carry out capital punishment even if the methodology utilizes pharmacologic agents or equipment that might otherwise be used in the practice of medicine."22 Similar pronouncements were made by the American College of Physicians in 1984, and the American Public Health Association (APHA) in 1985.23 The APHA resolution applied to other health professionals as well, stating that "health personnel, as members of a profession dedicated to preserving life when there is hope of doing so, should not be required or expected to assist in legally authorized executions."24 Other health professional organizations also took notice of participation in executions. The American Nurses Association in 1983 declared that participation was a breach of the ethical tradition of nursing.25

The Walker execution in Illinois in 1990, and the shield of anonymity around the participating physicians, catalyzed further action on the issue by organized medicine. In 1991, the ACP sponsored a resolution to the AMA requesting that the Council on Ethical and Judicial Affairs develop a guideline clearly defining physician participation in executions. The following year, the Council reaffirmed its 1980 position, and clarified the AMA prohibition on participation.

The Council report clarified the distinction between determining and certifying death. "Determining death includes monitoring the condition of the condemned during the execution and determining the point at which the individual has actually died. Certifying death includes confirming that the individual is deadafter another person has pronounced or determined that the individual is dead."26 The Council defined participation to include:

prescribing or administering tranquilizers and other psychotropic agents and medications that are part of the execution procedure;

monitoring vital signs on site or remotely (including monitoring electrocardiograms);

attending or observing an execution as a physician;

rendering of technical advice regarding execution.

And in the case of lethal injection, the guidelines specify that physician participation includes:

selecting injection sites;

starting intravenous lines as a port for a lethal injection device;

prescribing, preparing, administering, or supervising injection drugs or their doses or types;

inspecting, testing, or maintaining lethal injection devices;

consulting with or supervising lethal injection personnel.

The guidelines also specified actions that do not constitute physician participation in executions:

testifying as to the competence to stand trial, testifying as to relevant medical evidence during trial, or testifying as to medical aspects of aggravating or mitigating circumstances during the penalty phase of a capital case;

certifying death, provided that the condemned has been declared dead by another person;

witnessing an execution in a totally nonprofessional capacity;

witnessing an execution at the specific voluntary request of the condemned person, provided that the physician observes the execution in a non-physician capacity and takes no action that would constitute physician participation in an execution;

relieving the acute suffering of a condemned person while awaiting execution, including providing tranquilizers at the specific voluntary request of the condemned person to help relieve pain or anxiety in anticipation of the execution. The Council chose not to issue guidelines on psychiatric involvement in executions, including evaluation of an inmate's competence to be executed, and treatment to restore an inmate's competence to be executed. The Council decided to consult further with the American Psychiatric Association before issuing such guidelines. It is expected that the Council will consider the issue in 1994. In Chapter 5 of this report, we explore the ethics of psychiatric participation and suggest reasonable guidelines.

The Council guidelines are clear about which medical activities constitute physician participation in executions. In the next chapter, we highlight the conflicts between these ethical guidelines and the role prescribed for physicians in state law and correctional department regulations about executions.

19 Curran WJ, Casscells W. The ethics of medical participation in capital punishment. New England Journal of Medicine 1980;302:226-230.

20 Opinion 2.06 of the Council on Ethical and Judicial Affairs of the American Medical Association: Capital Punishment. In: 1992 Code of Ethics: Annotated Current Opinions. Chicago, IL: American Medical Association, 1992.

21 World Medical Association, Resolution on physician participation in capital punishment, September 1981.

22 Ibid.

23 American College of Physicians Ethics Manual. Annals of Internal Medicine 1984; 101:263-74. American Public Health Association. Position Paper 8521: Participation of Health Professionals in Capital Punishment. In: APHA Public Policy Statements 1948-present, cumulative. Washington, DC: APHA, 1993.

24 American Public Health Association. Position Paper 8521: Participation of Health Professionals in Capital Punishment. In: APHA Public Policy Statements 1948-present, cumulative. Washington, DC: APHA, 1993.

25 American Nurses Association. Code for Nurses with Interpretive Statements. Kansas City: ANA, 1983.

26 Council on Ethical and Judicial Affairs. Physician participation in capital punishment. Journal of the American Medical Association 1993;270:365-368.