The NEW ENGLAND JOURNAL of MEDICINE Perspectivemarch 23, 2006 When Law and Ethics Collide — Why Physicians Participate in Executions Atul Gawande, M.D., M.P.H. n February 14, 2006, a U.S. District Court is- immediately and loudly opposed sued an unprecedented ruling concerning the such physician participation as a O clear violation of medical ethics California execution by lethal injection of murderer codes. “Physicians are healers, not Michael Morales. The ruling ordered that the state executioners,” the ASA’s president told reporters. Nonetheless, in have a physician, specifically an ity that prisoners experienced suf- just two days, prison officials anesthesiologist, personally super- focation from the paralytic, a feel- announced that they had found vise the execution, or else drasti- ing much like being buried alive, two willing anesthesiologists. The cally change the standard proto- and felt intense pain from the court agreed to maintain their col for lethal injections.1 Under potassium bolus. This experience anonymity and to allow them to the protocol, the anesthetic sodi- would be unacceptable under the shield their identities from wit- um thiopental is given at massive Constitution’s Eighth Amendment nesses. Both withdrew the day be- doses that are expected to stop protections against cruel and un- fore the execution, however, after breathing and extinguish con- usual punishment. So the judge the Court of Appeals for the Ninth sciousness within one minute af- ordered the state to have an an- Circuit added a further stipulation ter administration; then the par- esthesiologist present in the death requiring them personally to ad- alytic agent pancuronium is given, chamber to determine when the minister additional medication if followed by a fatal dose of potas- prisoner was unconscious enough the prisoner remained conscious sium chloride. for the second and third injections or was in pain.2 This they would The judge found, however, that to be given — or to perform the not accept. The execution was evidence from execution logs execution with sodium thiopen- then postponed until at least May, showed that six of the last eight tal alone. but the court has continued to prisoners executed in California The California Medical Associ- require that medical profession- had not stopped breathing before ation, the American Medical Asso- als assist with the administration technicians gave the paralytic ciation (AMA), and the American of any lethal injection given to agent, raising a serious possibil- Society of Anesthesiologists (ASA) Morales. n engl j med 354;12 www.nejm.org march 23, 2006 1221 The New England Journal of Medicine Downloaded from nejm.org on October 3, 2016. For personal use only. No other uses without permission. Copyright © 2006 Massachusetts Medical Society. All rights reserved. PERSPECTIVE when law and ethics collide — why physicians participate in executions This turn of events is the cul- other such execution.4 Since 1976, chest. An intravenous line flows mination of a steady evolution in only 2 prisoners have been exe- into his or her arm. Under the methods of execution in the cuted by firing squad, 3 by hang- protocol devised in 1977 by Dr. United States. On July 2, 1976, in ing, and 12 by gas chamber.5 Stanley Deutsch, the chairman of deciding the case of Gregg v. Electrocution, thought to cause anesthesiology at the University Georgia, the Supreme Court legal- a swifter, more acceptable death, of Oklahoma, prisoners are first ized capital punishment after a was used in 74 of the first 100 given 2500 to 5000 mg of sodi- decade-long moratorium on exe- executions after Gregg. But officials um thiopental (5 to 10 times the cutions. Executions resumed six found that the electrical flow fre- recommended maximum), which months later, on January 17, 1977, can produce death all by itself in Utah, with the death by firing by causing complete cessation of squad of Gary Gilmore for the the brain’s electrical activity fol- killing of Ben Bushnell, a Provo lowed by respiratory arrest and motel manager. circulatory collapse. Death, how- Death by firing squad, how- ever, can take up to 15 minutes ever, came to be regarded as too or longer with thiopental alone, bloody and uncontrolled. (Gil- and the prisoner may appear to more’s heart, for example, did not gasp, struggle, or convulse. So 60 stop until two minutes afterward, to 100 mg of the paralytic agent and shooters have sometimes pancuronium (10 times the usual weakened at the trigger, as fa- dose) is injected one minute or so mously happened in 1951 in Utah after the thiopental. Finally, 120 when the five riflemen fired away quently arced, cooking flesh and to 240 meq of potassium is given from the target over Elisio Mares’s sometimes igniting prisoners — to produce rapid cardiac arrest. heart, only to hit his right chest postmortem examinations fre- Officials liked this method. and cause him to bleed slowly to quently had to be delayed for the Because it borrowed from estab- death).3 bodies to cool — and yet some lished anesthesia techniques, it Hanging came to be regard- prisoners still required repeated made execution like familiar med- ed as still more inhumane. Under jolts before they died. In Ala- ical procedures rather than the the best of circumstances, the cer- bama, in 1979, for example, John grisly, backlash-inducing specta- vical spine is broken at C2, the Louis Evans III was still alive after cle it had become. (In Missouri, diaphragm is paralyzed, and the two cycles of 2600 V; the warden executions were even moved to a prisoner suffocates to death, a called Governor George Wallace, prison-hospital procedure room.) minutes-long process. who told him to keep going, and It was less disturbing to witness. Gas chambers proved no bet- only after a third cycle, with wit- The drugs were cheap and rou- ter: asphyxiation from cyanide nesses screaming in the gallery, tinely available. And officials gas, which prevents cells from and almost 20 minutes of suffer- could turn to doctors and nurses using oxygen by inactivating cyto- ing did Evans finally die.3 Only to help with technical difficul- chrome oxidase, took even longer Florida, Virginia, and Alabama per- ties, attest to the painlessness than death by hanging, and the sisted with electrocutions with and trustworthiness of the tech- public revolted at the vision of any frequency, and under threat nique, and lend a more profes- suffocating prisoners fighting for of Supreme Court review, they too sional air to the proceedings. air and then seizing as the hy- abandoned the method. But medicine balked. In 1980, poxia worsened. In Arizona, in Lethal injection now appears when the first execution was 1992, for example, the asphyxia- to be the sole method of execu- planned using Dr. Deutsch’s tech- tion of triple murderer Donald tion accepted by courts as hu- nique, the AMA passed a resolu- Harding took 11 minutes, and mane enough to satisfy Eighth tion against physician participa- the sight was so horrifying that Amendment requirements — tion as a violation of core medical reporters began crying, the attor- large ly because it medicalizes the ethics. It affirmed that ban in de- ney general vomited, and the pris- process. The prisoner is laid su- tail in its 1992 Code of Medical on warden announced he would pine on a hospital gurney. A Ethics. Article 2.06 states, “A phy- resign if forced to conduct an- white bedsheet is drawn to his sician, as a member of a profes- 1222 n engl j med 354;12 www.nejm.org march 23, 2006 The New England Journal of Medicine Downloaded from nejm.org on October 3, 2016. For personal use only. No other uses without permission. Copyright © 2006 Massachusetts Medical Society. All rights reserved. PERSPECTIVE when law and ethics collide — why physicians participate in executions sion dedicated to preserving life the prisoner to show the team the munity and promise anonymity. when there is hope of doing so, best injection site.6 Still, the doc- Nonetheless, several physicians should not be a participant in a tors refused to give advice about have faced such challenges, though legally authorized execution,” al- the injection itself and simply none have lost their licenses as though an individual physician’s watched as the warden prepared yet.7 And despite the promised opinion about capital punishment the chemicals. When he tried to anonymity, several states have remains “the personal moral de- push the syringe, however, it did produced the physicians in court cision of the individual.” It states not work. He had mixed all the to vouch publicly for the legiti- that unacceptable participation drugs together, and they had pre- macy and painlessness of the pro- includes prescribing or adminis- cedure. tering medications as part of the Just by being States have affirmed that phy- execution procedure, monitoring sicians and nurses — including vital signs, rendering technical present, by having those who are prison employees advice, selecting injection sites, — have a right to refuse to par- starting or supervising placement expertise, Dr. A had ticipate in any way in executions. of intravenous lines, or simply be- Yet they have found physicians and ing present as a physician. Pro- opened himself to nurses who are willing to partici- nouncing death is also considered being called on to pate. Who are these people? And unacceptable, because the physi- why do they do it? cian is not permitted to revive take responsibility the prisoner if he or she is found to be alive. Only two actions were for the execution. It is not easy to find answers acceptable: provision at the pris- to these questions. The medical oner’s request of a sedative to cipitated into a clot of white personnel are difficult to identi- calm anxiety beforehand and cer- sludge.