When doctors become agents of the state

When doctors become agents of the state

Last week highlighted three very different examples of doctors becoming entangled in political issues. Not many would argue against the sentencing of Lothar Kipke, the former East German Swimming Association medical director, who gave female teenage swimmers anabolic steroids without their or their parents' knowledge. Although he claimed not to have known the full extent of damage caused by these drugs, he had undoubtedly acted on behalf of the state, whose interest was in bolstering the regime by winning international sporting competitions. However, physicians' duty to society may, some critics would argue, necessitate evasive actions on behalf of the state without consideration of the welfare of the individual—an argument often used in public-health medicine, and also by advocates of doctors' participation in capital punishment.

Last week, two men were executed in Virginia, USA. They had both committed murders when they were only 17 years old—Douglas Christopher Thomas, now aged 26, and Steve Edward Roach, 23, brought the numbers executed in the USA since 1976 to 604. In all but one of the 38 US states where the death penalty is legal, a physician is expected to attend executions. In 28 states, a doctor is legally required to participate. And yet the American Medical Association decrees that: “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.”

Can doctors who are involved in executions honestly say that they honour the goals of medicine as reinterpreted by the US Hastings Center of bioethics in 1996: to save and extend life; to promote, maintain, and restore health; and to ameliorate and relieve suffering? Or have they diminished their professional integrity in their quest to satisfy the prevailing political consensus about the death penalty? If laws that challenge professional ethics are passed within a non-democratic state, it is easy to condemn doctors acting as instruments of that state. But should we not extend this argument to all countries where the patient's wellbeing is not at the centre of concern? Andrew Sikora and Alan Fleischman, from the Albert Einstein College of Medicine, New York, recently challenged the professional organisations of medicine “to impose sanctions on members who participate in capital punishment, while these organizations work to support legislation prohibiting physician involvement in execution” (J Urban Health 1999; 78: 400–408).

In last week's third example, the role of doctors was the least clear-cut. The UK's Home Secretary Jack Straw (see p 297) made the surprise announcement that after reading a medical report from four UK clinicians, he was “minded to take the view that no purpose would be served by continuing the present extradition procedures” against General Augusto Pinochet. This political decision was based on the results of a medical assessment that had taken place on Jan 5. As yet the medical report has not been released to either the public or to the Spanish judge, Baltasar Garzon, who spearheaded the extradition proceedings.

Although the four experts were chosen on advice from the Chief Medical Officer—they have outstanding national and international reputations and have no competing interests in the case—the lack of transparency in making this decision has led the Spanish government and several human-rights organisations, such as Amnesty International and the Medical Foundation for the Care of Victims of Torture, to mount legal challenges. Should doctors—however independent, expert, and well-meaning—collaborate in decision-making that has obvious political implications? Without complete transparency, even independent-minded physicians who assist the judicial process of democratic nations can find their opinions manipulated for political purposes.

The Lancet, Volume 355, Number 9200, 22 January 2000