Physicians’ Willingness To Participate in the Process of Lethal Injection for Capital Punishment

Physicians’ Willingness To Participate in the Process of Lethal
Injection for Capital Punishment
Neil J. Farber, MD; Brian M. Aboff, MD; Joan Weiner, PhD; Elizabeth B. Davis, PhD; E. Gil Boyer, EdD; and Peter A. Ubel, MD
Background: It has been found that physicians condone colleague
involvement in capital punishment. Physicians’ own willingness
to participate has not been explored.
Objective: To examine physicians’ willingness to be involved in
cases of capital punishment.
Design: Survey exploring physicians’ willingness to participate in
10 aspects of capital punishment by lethal injection, 8 of which
are disallowed by the American Medical Association.
Setting: United States.
Participants: 1000 randomly selected practicing physicians.
Measurements: Questions assessing willingness to be involved
in and attitudes toward capital punishment.
Results: 41% of respondents indicated that they would perform
at least one action disallowed by the American Medical Association;
25% would perform five or more disallowed actions. Perceived
duty to society (P< 0.001), approval of the death penalty
(P< 0.001), and approval of assisted suicide (P5 0.015) correlated
with increased willingness to perform disallowed actions.
Only 3% of respondents knew of any guidelines on this issue.
Conclusions: Despite medical society policies, many physicians
would be willing to be involved in the execution of adults. The
medical profession needs to be better informed about the ethical
issues involved in physician participation in capital punishment.
Ann Intern Med. 2001;135:884-888. www.annals.org
For author affiliations, current addresses, and contributions, see end of text.
See editorial comment on pp 922-924.
Occasionally, physicians’ personal values conflict
with their perceived societal duties. One example
is the case of lethal injection for the purpose of capital
punishment (1). Some states require that such lethal
injections be performed by physicians (2, 3). At the
same time, leading medical societies have concluded that
physicians should avoid participating in capital punishment
(4, 5).
Physicians’ attitudes toward involvement in capital
punishment may depend on how they balance their responsibilities
to individuals against their duties to society
(6). Other factors may include a desire to provide a
more painless death for the prisoner or concern over the
competency of other health care personnel (7). In a previous
survey (8), we found that a majority of physicians
condoned involvement of their fellow physicians in capital
punishment. For the current study, we conducted
another survey to ascertain physicians’ attitudes about
their own involvement in capital punishment, as well as
factors associated with these attitudes.
METHODS
We conducted a cross-sectional mailed survey of
1000 randomly selected practicing physicians in the
United States, identified through the American Medical
Association (AMA) master file, the most thorough listing
of physicians available. Students, residents, and nonpracticing
physicians were excluded. The sample was
otherwise not stratified. The institutional review board
of Christiana Health Care System approved the study.
Each physician received an anonymous questionnaire
and a $5 incentive. A second questionnaire was
mailed to all nonrespondents. All responses received before
1 June 1999 were included in the analysis. The
questionnaire asked respondents how willing they would
be to personally participate in different aspects of capital
punishment. Responses were based on a 4-point Likerttype
scale. The tested aspects included eight actions disallowed
by the AMA and two actions that the AMA
permits (see Appendix, available at www.annals.org) (9).
Attitudes about the death penalty and assisted suicide, as
well as physicians’ opinions on different aspects of physician
involvement in capital punishment, were assessed
by using Likert-type scales (Appendix). These attitudinal
questions were developed from a survey of the literature
(1, 10–14), as well from a qualitative assessment of
comments from our first survey (8), and were pretested
for face and content validity.
Two of the authors manually entered data for analysis.
Thirty percent of the sample was cross-checked,
and no errors were detected. The number of disallowed
Brief Communication
884 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 www.annals.org
Table. Characteristics and Attitudes of 413 Physicians Who Responded to a Survey Assessing Involvement in Lethal
Injection for Capital Punishment*
Characteristic Value Characteristic Value
Demographic
Mean age 6 SD, y 50 6 11
Sex, n (%)
Male 314 (76)
Female 92 (22)
Marital status, n (%)
Married 344 (83)
Divorced 22 (5)
Single 32 (8)
Widowed 4 (1)
Ethnicity, n (%)
African American 20 (5)
White 302 (73)
Asian 60 (14)
Hispanic 7 (2)
Religion, n (%)
Protestant 139 (34)
Catholic 101 (24)
Jewish 74 (18)
Islamic 5 (1)
Atheist 15 (4)
Other† 69 (17)
Religiosity, n (%)
Very religious 103 (25)
Somewhat religious 209 (51)
Not very religious 58 (14)
Not at all religious 35 (8)
Ever a victim of violence or related to a victim of
violence, n (%)
Yes 101 (24)
No 306 (74)
Professional
Specialty, n (%)
Internal medicine 101 (24)
Surgery 85 (21)
Family practice 65 (16)
Pediatrics 46 (11)
Psychiatry 33 (8)
Anesthesia 29 (7)
Obstetrics–gynecology 23 (6)
Emergency medicine 12 (3)
Physical medicine and rehabilitation 5 (1)
Practice type, n (%)‡
Private practice 267 (65)
Academic medicine 67 (16)
Health maintenance organization 30 (7)
Veterans Affairs 6 (1)
Other 71 (17)
Practice locale, n (%)
Urban 172 (42)
Suburban 155 (37)
Rural 74 (18)
Mean proportion of time spent seeing patients 6 SD, % 84 6 22
Mean proportion of practice devoted to primary care
6 SD, % 45 6 45
Current AMA member, n (%)
Yes 147 (36)
No 260 (63)
* Not all respondents answered every question. Some values do not add up to 100% because of rounding and nonresponses. AMA 5 American Medical Association.
† Includes Hindu and Buddhist.
‡ Respondents were asked to check all categories that applied. Values add up to more than 100% because of multiple choices.
Ever an AMA member, n (%)
Yes 299 (72)
No 108 (26)
Geographic location of practice, n (%)
Northeast 95 (23)
South 127 (31)
Midwest 94 (23)
West 85 (21)
Practice in state with death penalty, n (%)
Yes 349 (84)
No 52 (13)
Attitude toward death penalty, n (%)
Oppose under all circumstances 93 (23)
Oppose or favor depending on circumstances 232 (56)
Favor under all circumstances 79 (19)
Effect of death penalty on the murder rate, n (%)
Somewhat or significantly lowers the murder rate 184 (45)
Does not affect or increases the murder rate 219 (53)
Favor physician-assisted suicide, n (%)
Yes 146 (35)
No 140 (34)
Unsure 118 (29)
Statements about capital punishment
Physicians should not develop a patient–physician
relationship with a prisoner who is about to be
executed.
Agree, n (%) 222 (54)
Disagree, n (%) 174 (42)
A physician acts primarily as a member of society rather
than as a medical professional when performing an
execution of a prisoner via lethal injection
Agree, n (%) 227 (55)
Disagree, n (%) 171 (41)
Some nurse practitioners or other ancillary personnel are
as capable in performing the procedures of capital
punishment as are qualified physicians
Agree, n (%) 320 (77)
Disagree, n (%) 76 (18)
One of the reasons physicians should be involved in
capital punishment is their duty to society
Agree, n (%) 90 (22)
Disagree, n (%) 312 (75)
Lethal injection for capital punishment uses technology
but does not involve medical care
Agree, n (%) 262 (63)
Disagree, n (%) 141 (34)
Patients suffer less when physicians perform an execution
via lethal injection than when any other groups, such
as nurse practitioners or prison personnel, perform
them
Agree, n (%) 63 (15)
Disagree, n (%) 331 (80)
Brief Communication Physicians and Capital Punishment
www.annals.org 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 885
actions that the respondents were definitely willing to
perform or were somewhat willing to perform was calculated
as a separate variable. Associations between attitudinal
and sociodemographic variables and the number
of disallowed actions that respondents were willing to
perform were analyzed by using chi-square tests or the
Kendall tau correlation, as appropriate. Binomial regression
analysis was used to determine which associated
variables were significant.
Role of the Funding Sources
The funding sources had no role in the collection,
analysis, or interpretation of the data or in the decision
to submit the paper for publication.
RESULTS
Of 1000 questionnaires, 25 were returned undelivered,
11 were sent to physicians who had retired from
practice, and 2 were sent to physicians who had died. Of
the 962 physicians who received surveys, 413 (43%)
returned them. Respondents’ demographic and professional
characteristics and attitudes toward the death
penalty and assisted suicide are shown in the Table.
The percentage of respondents agreeing to perform
the disallowed actions varied from 19% for administering
the lethal drugs to 36% for determining death (Figure).
Twenty-five percent of respondents were willing to
perform five or more of the disallowed actions, while
14% were willing to perform all eight disallowed actions.
Forty-one percent of respondents were willing to
perform at least one disallowed action, and 59% were
willing to perform none of the disallowed actions. Of
interest, 11 physicians were unwilling to give tranquilizers
the night before the execution yet were willing to
perform five or more of the disallowed actions.
Physicians who were in favor of the death penalty
were willing to perform more disallowed actions than
physicians who were opposed to capital punishment
(P , 0.001). Physicians who believed that capital punishment
reduced the murder rate were willing to perform
more disallowed actions than physicians who believed
that capital punishment did not affect or actually
increased the murder rate (P , 0.001). Physicians who
approved of assisted suicide were willing to perform
more disallowed actions than physicians who opposed
assisted suicide or were not sure what was appropriate
(P 5 0.015).
Most of the statements on capital punishment,
when respondents agreed with them, were associated
with an increased number of disallowed actions that respondents
were willing to perform. Only the belief that
lethal injection involves only technological skill, not patient
care, and the belief that nurse practitioners are as
capable as physicians in conducting lethal injections
were not associated with an increased willingness to perform
disallowed actions.
Most of the demographic characteristics had no significant
association with the number of disallowed actions
deemed acceptable. However, physicians who were
ever members of the AMA were more willing to perform
disallowed actions (P , 0.01). All significant attitudinal
and demographic variables were entered into a binomial
regression model. Past or present membership in the
AMA (P , 0.05), belief that duty to society is a reason
for physician involvement in capital punishment
(P , 0.001), and belief that physicians should not develop
a patient–physician relationship with prisoners
about to be executed (P , 0.05), along with attitudes
toward the death penalty (P , 0.001) and toward assisted
suicide (P 5 0.05), had a significant effect on the
Figure. Percentage of physicians surveyed ( n5 413)
who were willing to perform actions involving capital
punishment by lethal injection that are allowed and
disallowed by the American Medical Association.
White bars indicate disallowed actions; shaded bars indicate allowed actions.
IV 5 intravenous.
Brief Communication Physicians and Capital Punishment
886 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 www.annals.org
number of disallowed actions that respondents would be
willing to perform (R2 5 0.574).
DISCUSSION
This study demonstrates that physicians are willing
to be involved in lethal injections for capital punishment
even though such involvement is contrary to the best
interests of the prisoner, is in violation of the Hippocratic
Oath (15), and is prohibited by most medical
societies (4, 5).
Similar to our previous study (8), we found that
physicians who supported the death penalty and were in
favor of assisted suicide were willing to perform more of
the disallowed actions. While physicians have argued
that involvement in capital punishment affords a more
rapid and humane death for convicts (4, 6, 16), in this
study, the only aspect of the lethal injection process
associated with respondents’ willingness to perform the
disallowed procedures was perceived duty to society.
Pellegrino (12) has pointed out that in situations involving
capital punishment, physicians face competing values:
the requirement to fulfill legally or socially prescribed
roles (as an agent of society as a whole) and a
responsibility to the patient (as a member of the medical
profession). In our survey, some physicians felt that duty
to society outweighed their concerns about the mandate
to do no harm to the individual. While for some physicians
the social role of acting as a punitive agent for the
state is unacceptable (17), for others their societal responsibility
is paramount and cannot be delegated (13).
Some of the physicians in our study may have made
specific value choices because they lacked education
about the ethical issues involved. Only 3% of the respondents
knew of any guidelines on this subject, yet
AMA membership was associated with a willingness to
perform more AMA-disallowed actions. Greater effort
will need to be made to ensure that all physicians are
aware of the ethical concerns regarding physician participation
in capital punishment.
This study has several limitations. First, given the
response rate of 43%, nonrespondent bias is likely.
However, the age, sex, and specialty distribution of our
survey respondents was similar to that of physicians in
practice in the United States in 1996 (18). Moreover,
even if all of the nonrespondents had reported avoiding
involvement in all of the disallowed actions of capital
punishment, there would still have been 11% of respondents
willing to perform five or more disallowed actions
and 18% willing to perform at least one. Regardless of
the small size of these numbers, the fact that some physicians
would be willing to perform actions involving
lethal injections is of concern. Second, we do not know
whether any of the respondents were involved in cases of
capital punishment. If so, some bias would be introduced
into the study. Third, and more important, we do
not know whether surveyed physicians would actually
perform the actions as stated in their responses.
Some physicians are willing to participate in cases of
capital punishment despite prohibitions by several medical
associations. While support of the death penalty and
support of assisted suicide are associated with a greater
willingness to participate, physicians may be basing
some of their reasoning on their perceived duty to society
rather than their responsibility to the prisoner. This
issue needs to be discussed at a societal level. Furthermore,
increased effort must be made to educate physicians
about the ethical concerns involved in participation
in capital punishment.
From Christiana Health Care System, Wilmington, Delaware; and
Drexel University, St. Joseph’s University, and University of Pennsylvania,
Philadelphia, Pennsylvania.
Grant Support: By the Osler Fund, Department of Medicine, Christiana
Care Health System. Dr. Ubel is a recipient of a Career Development
Award in health services research from the Department of Veterans Affairs
and is a Robert Wood Johnson Generalist Physician Faculty
Scholar.
Requests for Single Reprints: Neil J. Farber, MD, Department of
Medicine, Christiana Care Health System, 501 West 14th Street, Wilmington,
DE 19899; e-mail, nfarber@christianacare.org.
Current Author Addresses: Drs. Farber and Aboff: Department of
Medicine, Christiana Care Health System, 501 West 14th Street, Wilmington,
DE 19899.
Dr. Weiner: Management Department, Drexel University, Philadelphia,
PA 19104.
Dr. Davis: Administrative Sciences, George Washington University,
2136 Pennsylvania Avenue, 301, Washington, DC 20052.
Dr. Boyer: Department of Management and Information Systems,
Mandeville Hall, St. Joseph’s University, 5600 City Avenue, Philadelphia,
PA 19131.
Dr. Ubel: Ann Arbor Veterans Affairs and University of Michigan, 300
North Ingalls, Room 7C27, Campus Box 0429, Ann Arbor, MI 48109-
0429.
Brief Communication Physicians and Capital Punishment
www.annals.org 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 887
Author Contributions: Conception and design: N.J. Farber, B.M.
Aboff, J. Weiner, E.G. Boyer, P.A. Ubel.
Analysis and interpretation of the data: N.J. Farber, J. Weiner, E.B.
Davis, E.G. Boyer, P.A. Ubel.
Drafting of the article: N.J. Farber.
Critical revision of the article for important intellectual content: N.J.
Farber, J. Weiner, E.B. Davis, E.G. Boyer, P.A. Ubel.
Final approval of the article: N.J. Farber, B.M. Aboff, J. Weiner, E.B.
Davis, E.G. Boyer, P.A. Ubel.
Provision of study materials or patients: N.J. Farber.
Obtaining of funding: N.J. Farber.
Collection and assembly of data: N.J. Farber.
References
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© 2001 American College of Physicians–American Society of Internal
Medicine
Brief Communication Physicians and Capital Punishment
888 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 www.annals.org
Appendix. Survey Instrument
CAPITAL PUNISHMENT RESEARCH GROUP
We are interested in what you would allow your role to be in various aspects of state-mandated lethal injection for capital
punishment of violent crimes. Your participation in this survey is voluntary; however, should you choose to participate, we ask
that you complete all of the questions as fully and as completely as possible.
Please be assured that your responses will remain absolutely confidential, and you will not be identified on this survey
instrument. Although not sufficient to reimburse you for your time, please accept the $5.00 bill as a token of our appreciation.
Neil J. Farber, M.D. Brian M. Aboff, M.D. Peter A. Ubel, M.D.
1. We will present you with a number of ways in which you could potentially be involved in state-mandated lethal injection.
In each example, indicate whether you would perform that particular procedure if asked to do so by a state prison official.
Please assume that you are still in your current job or practice, that you have the time available to perform the procedure
in question, that the prisoner has been correctly convicted of a violent crime for which the death penalty will be
administered, and that you will be compensated by the state for your time (check one answer for each procedure).
In this setting, you would be. . .
definitely
willing to
perform
probably
willing to
perform
probably not
willing to
perform
definitely not
willing to
perform
A. Start intravenous lines as a port for the lethal injection. e e e e
B. Monitor the subject’s vital signs during the execution. e e e e
C. Prescribe a tranquilizer the day before the execution to help
the individual sleep. e e e e
D. Select injection sites for the lethal injection. e e e e
E. Administer lethal drugs as part of the execution. e e e e
F. Examine and determine the point at which the individual died. e e e e
G. Inspect or maintain lethal injection devices. e e e e
H. Supervise lethal injection personnel. e e e e
I. Sign the death certificate after the lethal injection. e e e e
J. Order drugs used in lethal injections for the prison to stock in
its pharmacy. e e e e
2. We will ask you about your opinions regarding physician involvement in the process of lethal injection for capital
punishment. Please indicate whether you agree or disagree with each statement (check one answer for each statement):
strongly
agree
agree disagree strongly
disagree
A. Physicians should not develop a patient–physician relationship
with a prisoner who is about to be executed. e e e e
B. A physician acts primarily as a member of society rather than
as a medical professional when performing an execution of a
prisoner via lethal injection. e e e e
C. Some nurse practitioners or other ancillary personnel are as
capable in performing the procedures of capital punishment as
are qualified physicians. e e e e
D. One of the reasons physicians should be involved in capital
punishment is their duty to society. e e e e
E. Lethal injection for capital punishment uses technology but
does not involve medical care. e e e e
F. Patients suffer less when physicians perform an execution via
lethal injection than when any other group, such as nurse
practitioners or prison personnel, performs them. e e e e
Continued on following page
Brief Communication Physicians and Capital Punishment
www.annals.org 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 889
3. How do you personally feel about the death penalty for persons convicted of first degree murder?
e oppose it under all
circumstances
e oppose/favor it depending
on the circumstances
e favor it under all
circumstances
4. What do you believe the death penalty does to the murder rate?
e significantly
lowers it
e somewhat
lowers it
e no effect e somewhat
raises it
e significantly
raises it
5. When a patient has an illness that cannot be cured, do you think that physicians should be allowed by law to end the
patient’s life if the patient and his or her family request it?
e Yes e No e Unsure
6. Have you or someone you were close to ever been a victim of a violent crime?
e Yes e No
We also need some information about yourself:
7. Age
8. Sex (check one): e Male e Female
9. Marital Status (check one answer):
e Married e Divorced e Single
e Widowed e Other
10. Race (check one answer):
e African-American e White e Hispanic
e Asian e Other
11. Religion (check one answer):
e Protestant e Catholic e Jewish
e Muslim e Atheist e Other
12. How religious (spiritual) do you feel you are (check one
answer)?
e very religious (spiritual)
e somewhat religious (spiritual)
e very little religious (spiritual)
e not at all religious (spiritual)
13. Do you know of any published guidelines on the issue of
physician involvement in capital punishment (check one
answer)?
e Yes e No
If yes, what are they?
14. Year graduated from medical school
15. How would you characterize the locale in which you
practice (check one answer)?
e Urban e Suburban e Rural
16. How would you characterize your type of practice
(check all that apply)?
e Private practice
e HMO practice
e Academic faculty
e VA
e Other
17. What percent of your professional time is spent seeing
patients? %
18. What is your medical specialty/subspecialty?
19. What percent of your practice is devoted to primary
care? %
20. In what state do you practice?
21. Are you currently a member of the American Medical
Association (check one)?
e Yes e No
22. Have you ever been a member of the American Medical
Association (check one)?
e Yes e No
THANK YOU FOR YOUR ASSISTANCE.
Brief Communication Physicians and Capital Punishment
890 20 November 2001 Annals of Internal Medicine Volume 135 • Number 10 www.annals.org