DEATH PENALTY UNWILLING EXECUTIONERS? Where and why do some doctors still help carry out the death penalty? Sophie Arie reports ethal injection is now the main method of In 2009, death penalty opponent Sister Helen nection to their local prisons. In a rare report, in execution in China and the United States, Prejean, known for her book Dead Man W alking, 2006, Dr Atul Gawande, American surgeon and the two countries that execute the highest began campaigning for medical boards to dis- writer, gathered testimonies from some partici- numbers of people. But the widespread cipline doctors who participate in executions, pating doctors. Dr Carlo Musso, an emergency use of lethal injection—seen as a medical believing this could ultimately make lethal injec- doctor, confirmed that his practice had taken up L and therefore more humane method of execution tion no longer a feasible option for states. But an $18 000 contract (£11 000, €13 000) to pro- than hanging, shooting, or electro cution—has when medical bodies have attempted to strike off vide a medical presence at executions in Georgia. meant that doctors have become more actively or discipline physicians who have participated in He provided cardiac monitoring and determina- involved in carrying out the death penalty than executions, they have been over-ruled by courts tion of death. Other colleagues helped with intra- they were in the past. in the states concerned. venous access. “As I see it this is an end of life The medicalisation of executions has put Some states, such as Georgia and North issue, just as with any other terminal disease. doctors in an extremely difficult position. While C arolina, have won legal protection for doctors It just happens that it involves a legal process in principle assisting in the killing of a person who participate by arguing that they are not instead of a medical process,” said Dr Musso. He (whether legal or not) goes against the ethics of practising medicine, just using their knowledge said he donated part of the proceeds of the work their profession, many decide, for religious or and skills, and therefore cannot be disciplined by to a street children’s shelter. political reasons, that it is better to participate medical bodies. Little is known about the level of training given than not. Medical bodies find themselves caught between to non-medical staff who carry out lethal injec- “With lethal injection, doctors moved into the values of their profession and the values of tions, but there have been numerous reports of centre stage,” says Dr James Welsh, researcher their society. While the American College of Physi- botched executions in which the team has been and adviser at Amnesty International’s UK office. cians is keen to make known its ethical objections, slow to find a vein (often prisoners are overweight “Doctors had to think more about whether that’s it and other bodies are careful not to enter into the or are drug users), excessive doses of drugs have what they went into medicine to do.” political debate. Only the International Council of been used, or individuals have had adverse Nurses in the United States formally opposes the re actions and suffered for up to half an hour Doctors’ involvement in the United States death penalty itself. before finally dying. In America, some 34 states currently allow “The US bodies have focused on the ethical Since 2006 a wave of court cases has exposed the death penalty and over 80% of those use debate. But there is still something of a silence shocking practices that led to protracted pain for lethal injection. All except Kentucky state either about the death penalty itself,” says Dr Welsh. the convict. One case, that of Michael Morales require or permit doctors’ participation in execu- “At the moment it’s a game of ping pong between in California, in 2007, in which two anaesthet- tions (www.deathpenaltyinfo.org/documents/ social values and medical issues,” he says. ists refused at the last minute to participate, FactSheet.pdf). State authorities go to some highlighted the fact that non-medical execution lengths to protect the identity of medical staff, Are doctors willing? staff were often failing to anaesthetise prison- who can be involved in different ways, from In some cases, doctors have refused to cooperate ers correctly at the beginning of the three-drug anaesthetising, injecting, and finding veins, to when asked by a state, but one of the few sur- lethal injection procedure. This meant that pris- pronouncing and certifying death. Usually their veys asking physicians for their opinion on the oners remained conscious but unable to signal participation is kept anonymous and they are issue suggested that many strongly support the their pain when the lethal muscle paralysing often paid in cash. death penalty and the involvement of doctors in drug pancurionium bromide was injected. Judge Professional bodies such as the American executions. A survey published in 2000 by the J eremy Fogel ruled that the risk of this happen- Medical Association and the American College of Archives of Internal Medicine ing made the whole procedure Physicians have taken a common position since (2000;160:2912-6) found that “The medicalisation unconstitutional. He also later the early 1980s, when lethal injections were first only 20% of over 500 physicians of executions has found that the state’s execution used in the United States, against the involvement objected to any kind of involve- teams “almost uniformly have of doctors in carrying out the death penalty. “A ment of medical professionals put doctors in an no knowledge of the nature or physician, as a member of a profession dedicated in executions. Some supported extremely difficult properties of the drugs that are to preserving life when there is hope of doing so, doctors carrying out lethal injec- position” used or the risks or potential should not be a participant in a legally authorised tions themselves and most sup- problems associated with the execution,” say the AMA guidelines. ported medical staff support for a non-medical procedure.” The case gave new impetus to those The AMA formally bans its 240 000 members execution team. who argue that lethal injection goes against the from participating, including even pronouncing Reasons for the doctors’ willingness to partici- American constitution and forced several states death, because the doctor would not be allowed pate range from religious and political beliefs to to revise their protocols. But it also strengthened to revive the prisoner if he or she was found to be the idea that it is important to try to minimise the the argument that medical professionals should still alive. It only acknowledges that a doctor can suffering of convicts right up to their time of death. be present at executions to ensure they are not provide sedatives at the request of the prisoner Many participating doctors are prison doctors botched. “Physician participation in execu- before the execution and certify death afterwards. or are in practices that develop some kind of con- tions, though looked upon with disdain, is more 1286 BMJ | 11 JUNE 2011 | VOLUME 342 DEATH PENALTY JORGEUZON/AFP/GETTY IMAGES The execution by lethal injection of Manuel Martinez Coronado in Guatemala City on 10 February, 1998, carried out by doctors and broadcast live on television pr evalent—and perhaps more necessary—than Little is known about where China obtains the Japan, which executes prisoners by hanging, is many would like to believe,” wrote Deborah drugs it uses for lethal injections. It is thought to strikingly oblique about its use of the death pen- Denno, professor at Fordham Law School, in a use a similar cocktail to that used in the United alty. In a report in January this year, the Council 2007 paper entitled: The lethal injection quan- States, involving a barbiturate anaesthetic, of Europe criticised the “atrocious practice” in dary: how medicine has dismantled the death sodium thiopental, followed by muscle para- Japan of “executions carried out under a shroud penalty (source: http://standdown.typepad.com/ lysing pancuronium bromide and finally potas- of secrecy and taking the death row inmates Denno-FordhamLawReview-Oct07.pdf). sium chloride, which causes cardiac arrest. and their families by surprise.”In 2008 Japan Several states in the United States have currently executed 15 people, the highest number since In China had to postpone executions because supplies of 1975 (www.reprieve.org.uk/2010_03_29ray_of_ Much less is known about the situation in China, sodium thiopental have dried up, amid increas- hope_deathpenalty). which is the world’s number one executioner. ing objections by drug companies and interna- Between 5000 and 10 000 people are thought to tional legislation against the misuse of the drug Worldwide trends be executed every year, says Phelim Kine, a US for executions. The only US producer of the drug, Globally though, the use of the death penalty is based China researcher for Human Rights Watch. Hospira, stopped manufacturing it this January. on the decline. In the United States, the numbers And since 2009, China has switched almost of death sentences dropped steadily over the wholesale from execution by a shot in the head to Executions elsewhere seven years up to 2009, when 106 sentences lethal injection. “Trained medical staff” carry out Iran and Saudi Arabia, the other two countries were recorded (source: US Death Penalty Infor- intravenous injections, according to state media, with the highest numbers of executions, use older mation Centre). New Mexico, New Jersey, and and forensic doctors pronounce the death and methods such as stoning, beheading, and hang- New York State have recently abolished the death generate a computerised report.