Thursday, 15 February 2007

Physicians' Attitudes About Involvement in Lethal Injection for Capital Punishment

Physicians' Attitudes About Involvement in Lethal Injection for Capital Punishment

With regard to the excellent and revealing article by Farber et al,1 we wish to make the following comments.

To the extent that physicians would justify their participation in executions on the basis that capital punishment has a deterrent effect on murder and thus protects life, they should know the current scientific "bottom line" regarding deterrence. There is now widespread agreement among criminologists that the death penalty is not a more effective deterrent to murder than an alternative sanction, namely, long-term imprisonment.2

In the study of Farber et al,1 the number of physicians who believed that the death penalty has a deterrent effect on murder is striking: 46% believed that the death penalty significantly lowers or somewhat lowers the murder rate. The opposite effect of the death penalty has been called brutalization, the proposition that the murder rate goes up after executions. In one explanation of brutalization, individuals receive the message from the state that lethal revenge is correct and proper, and then feel justified in following the example of the state. Only about 1% of responding physicians expressed a belief in brutalization (ie, that the death penalty somewhat raises or significantly raises the murder rate). Forty percent believed that there is no effect (ie, neither deterrence nor brutalization). Notably, Farber et al found that physicians who believed that capital punishment has a deterrent nor effect approved of more physician participation in capital punishment (actions deemed unethical by medical societies) than physicians who believed that capital punishment has no deterrent effect or has a brutalizing effect.

If physicians understood that capital punishment is not a more effective deterrent to murder than long-term imprisonment and does not protect public health by decreasing societal violence, they might have less appetite for participating in executions or otherwise supporting capital punishment. However, it is possible that the expressed belief in deterrence is a surrogate or rationalization for other motives (for example, vengeance or the desire to make a moral statement regarding the sanctity of human life). In this case, physicians' willingness to participate in capital punishment might be little affected by knowledge of the lack of deterrent effect as compared with long-term imprisonment.

Even when physicians hold widely disparate political or scientific views, they may find some common ground in historical matters, especially the history of medicine. It is in this spirit that the following is offered. The idea of brutalization, that capital punishment might increase the level of societal violence, is not new. Dr Benjamin Rush, a physician and signer of the Declaration of Independence, wrote about the brutalization factor as early as 1787 and used a crude statistical analysis to support his hypothesis.3-4 Dr Rush compared the level of murder in Pisa, a city without the death penalty for murder, with that in Rome, a retentionist jurisdiction during the period in question. The much higher incidence of murder in Rome led Rush to conclude that "Even murder itself is propagated by the punishment of death for murder. Of this we have a remarkable proof in Italy."3

Dr Rush considered the demographics of Pisa (Tuscany) and Rome, and concluded that "It is remarkable, the manners, principles, and religion, of the inhabitants of Tuscany and Rome, are exactly the same. The abolition of death alone, as a punishment for murder, produced this difference in the moral character of the two nations."3 Interestingly, Rush concluded that long-term imprisonment was an ultimate solution:

If society can be secured from violence, by confining the murderer, so as to prevent a repetition of his crime, the end of extirpation will be answered. In confinement, he may be reformed—and if this should prove impracticable, he may be restrained for a term of years, that will probably be coeval with his life.3

Although a few modern studies have found a brutalization effect,5-7 when viewed from the perspective of the entire literature, the evidence for brutalization is limited. Criminologists continue to refine their studies by examining more specific subpopulations and circumstances of murder, and additional evidence for brutalization (or deterrence) may emerge. Collectively, however, at the present time it is most prudent scientifically to accept the null hypothesis (ie, no net deterrence or brutalization). Of course, these studies are based on statistical analysis of populations. However, there is another perspective on this issue, and physicians are intimately familiar with this perspective. This is the perspective of the individual patient, the "case." At the same time that physicians understand the necessity and desirability of statistical analyses on populations, they understand that statistics do not predict events regarding an individual patient.

The late Dr Louis Jolyon West8 considered the brutalization effect from the perspective of individual cases. Based on these case studies, he concluded,

I am convinced that there is an even more specific way in which the death penalty breeds murder. It becomes more than a symbol. It becomes a promise, a contract, a covenant between society and certain (by no means rare) warped mentalities who are moved to kill as part of a self-destructive urge. These murders are discovered by the psychiatric examiner to be, consciously or unconsciously, an attempt to commit suicide by committing homicide. It only works if the perpetrator believes he will be executed for his crime.8

Physicians' attitudes about racism, classism, and error in the administration of capital punishment in the United States were not examined in the study by Farber et al. Not only is the death penalty problematic because of the issues of deterrence and brutalization, but very serious concerns have been raised because of race bias, class bias, and errors in its administration. Recent statistics from the Department of Justice9 are consistent with a significant error rate in capital convictions: in 1998, 285 individuals were sent to death row in the United States, but 93 were removed from death row by judicial order (excluding executions). Despite the safeguards in the current system, the threat of executing individuals who are legally or actually innocent is real. How physicians understand or misunderstand these elements of race bias, class bias, and error might provide clues as to why the majority of physicians view their participation in executions as ethically acceptable.

Daniel P. Wirt, MD
Houston, Tex

William C. Bailey, PhD
Cleveland, Ohio

William J. Bowers, PhD
Boston, Mass


1. Farber N, Davis EB, Weiner J, Jordan J, Boyer EG, Ubel PA. Physicians' attitudes about involvement in lethal injection for capital punishment. Arch Intern Med. 2000;160:2912-2916. FREE FULL TEXT
2. Bailey WC, Peterson RD. Capital punishment, homicide, and deterrence: an assessment of the evidence and extension to female homicide. In: Smith MD, Zahn MA, eds. Homicide: A Sourcebook of Social Research. Thousand Oaks, Calif: Sage Publications; 1999:257-276.
3. Rush B. An Enquiry Into the Effects of Public Punishments Upon Criminals and Upon Society: Read in the Society for Promoting Political Enquiries, Convened at the House of his Excellency, Benjamin Franklin, Esquire, in Philadelphia, March 9th, 1787. Philadelphia, Pa: Joseph James; 1787. Available in: Essays: Literary, Moral and Philosophical. Schenectady, NY: Union College Press; 1988:79-94.
4. Rush B. Considerations on the Injustice and Impolicy of Punishing Murder by Death; Extracted From the American Museum; With Additions. Philadelphia, Pa: Mathew Carey; 1792.
5. Bowers WJ. The effect of executions is brutalization, not deterrence. In: Haas KC, Inciardi JA, eds. Challenging Capital Punishment: Legal and Social Science Approaches. Newbury Park, Calif: Sage Publications; 1988:49-89.
6. Cochran JK, Chamlin MB, Seth M. Deterrence or brutalization? an impact assessment of Oklahoma's return to capital punishment. Criminology. 1994;32:107-134. ISI
7. Bailey WC. Deterrence, brutalization, and the death penalty: another examination of Oklahoma's return to capital punishment. Criminology. 1998;36:711-733. ISI
8. West LJ. Psychiatric reflections on the death penalty. Am J Orthopsychiatry. 1975;45:689-700. ISI | PUBMED
9. Snell TL. Capital Punishment 1998. Washington, DC: Bureau of Justice Statistics, Dept of Justice; 1999.

In reply

We are appreciative of the insightful comments by Wirt et al. They point out the large number of respondents to our survey who believed that the death penalty had a significant deterrent effect on the murder rate.1 They also indicate that in order to justify their participation in lethal injections, physicians should know the current scientific evidence involving the death penalty and its effect on the murder rate. While such knowledge is important, we believe that those who condone physician involvement in the death penalty will need to provide a cogent ethical argument for why such participation should be allowed. In our view, as Wirt et al point out, there is no evidence that the death penalty negatively affects the murder rate. In addition, even if capital punishment were a deterrent against violent crime, it still would not justify physician involvement in the process.

In addition, we believe that there may be multiple factors involved in why these physicians condoned the involvement of their colleagues in the death penalty. Physicians have cited the need for a shared public responsibility in conducting lethal injections,2 while others3-4 believe that prisoners suffer less when physicians are involved. It is interesting that Wirt et al raised the issues of racism and classism in attempting to explain why physicians would condone their involvement in lethal injections. We did not investigate the reasoning of physicians in this study. However, in previous work,5 we found that residents' decisions to breach confidentiality in hypothetical cases of self-reported past crime were not affected by the race of the hypothetical patient. It is possible that such biases come into play regarding physicians' attitudes toward involvement in lethal injections. However, we believe more fundamental concerns, such as whether government can ever be involved in medical processes and technology, and physicians' perceived duty to society vs their obligation to their patients, must be explored.

Neil J. Farber, MD
Wilmington, Del

Elizabeth B. Davis, PhD
Washington, DC

Joan Weiner, PhD
Philadelphia, Pa

Janine Jordan, MD

E. Gil Boyer, EdD

Peter A. Ubel, MD
Ann Arbor, Mich


1. Farber NJ, Davis EB, Weiner J, Jordan J, Boyer EG, Ubel PA. Physicians' attitudes about involvement in lethal injection for capital punishment. Arch Intern Med. 2000;160:2912-2916. FREE FULL TEXT
2. Crowley JP, Ingall MA, Kahr FM, Braden W, Hershkowitz M, Rakatansky H. Capital punishment and the physician: the views of 6 Rhode Island physicians. R I Med. 1995;78:215-221. PUBMED
3. Thorburn KM. Physicians and the death penalty. West J Med. 1987;146:638-640. ISI | PUBMED
4. American Medical Association Council on Ethical and Judicial Affairs. Physician participation in capital punishment. JAMA. 1993;270:365-368. FULL TEXT | ISI | PUBMED
5. Farber NJ, Weiner JL, Boyer EG, Robinson EJ. Residents' decisions to breach confidentiality. J Gen Intern Med. 1989;4:31-33. ISI | PUBMED

Arch Intern Med. 2001;161:1353-1354.


Physicians' Attitudes About Involvement in Lethal Injection for Capital Punishment
Neil Farber, Elizabeth B. Davis, Joan Weiner, Janine Jordan, E. Gil Boyer, and Peter A. Ubel
Archives of Internal Medicine. 2000;160:2912-2916.

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