Saturday, 17 November 2007

Physician Participation in Capital Punishment

Physician Participation in Capital Punishment
DAVID WAISEL, MD
I
I
f state administration of capital punishment is legal and
ongoing, humane methods of execution should be
sought and applied. In medieval times, the condemned and
their families would bribe the executioner to make death
quick and painless. In the 18th century, Dr Joseph-Ignace
Guillotin proposed amending the French penal code to
require executioners to use what is now known as the
guillotine, believing that to be a more humane method of
execution. In the United States, hanging was the predominant
method of execution until electrocution was introduced
as a more humane method in 1890.1 One of the
subtexts of electrocution was Thomas Edison’s attempts to
promote his direct current electricity by tainting the competing
alternating current electricity through its association
with the electric chair.1 Cyanide gas was introduced in
1924.2 Hanging, electrocution, and chemical asphyxiation
were the primary methods of execution until the introduction
of lethal injection in 1977.2 Lethal injection has been
the predominant form of execution in the 699 executions in
the United States during the past 10 years.3 Recent concerns
about the technical issues surrounding legal execution,
most specifically regarding drug delivery, have
prompted some persons to suggest that physician participation
in capital punishment would minimize these problems.
Opposing the involvement of physicians is the American
Medical Association (AMA), which prohibits physician
participation in legally authorized executions. According
to the AMA’s published position statements,4 “An individual’s
opinion on capital punishment is the personal moral
decision of the individual. 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.” The AMA further stated that physician
participation in capital punishment “distorts the purpose
and role of medicine and its professionals in the preservation
of life. The use of physicians and medical technology
in execution presents a conceptual contradiction for society
and the public. The image of physician as executioner
under circumstances mimicking medical care risks the general
trust of the public.”
The Code of Medical Ethics of the AMA prohibits physicians
from “an action which would directly cause the death of
the condemned [and] an action which would assist, supervise
or contribute to the ability of another individual to directly
cause the death of the condemned.”5 Prohibitions include
nearly all aspects of lethal injection such as “selecting injection
sites; starting intravenous lines as a port for a lethal
injection device; prescribing, preparing, administering, or supervising
injection drugs or their doses or types; inspecting,
testing, or maintaining lethal injection devices; and consulting
with or supervising lethal injection personnel.”5
In this commentary, I argue that poorly done executions
needlessly hurt the condemned and that, in the case of
lethal injections, the problems center not on the specific
drugs chosen but on establishing and maintaining intravenous
access and assessing for anesthetic
depth. I argue that it is honor-
For editorial
able for physicians to minimize the
comment, see
harm to these condemned individu

pages 1043 and
als and that organized medicine has
1047
an obligation to permit physician
participation in legal execution. By participation, I mean to
the extent necessary to ensure a good death. This includes
designing protocols both in general and for specific condemned
persons and participating in the performance of
these protocols, up to and including gaining intravenous
access and giving drugs.
I will not address the policy of capital punishment. Although
numerous issues surround capital punishment (appropriateness,
fairness, and effectiveness as a crime deterrent,
etc), they are beyond the scope of this article. The
purpose of this commentary is to address physician participation
in the ongoing practice of lethal injection.
THE NEED FOR PHYSICIAN PARTICIPATION
Lethal injection is the predominant form of execution in the
United States, in part because it is considered more humane
than hanging, electrocution, and chemical asphyxiation. In
1977, an anesthesiologist suggested a process that appeared
to mimic a typical induction of anesthesia: sodium thiopental
to cause unconsciousness, pancuronium bromide to
From the Department of Anesthesiology, Perioperative and Pain Medicine,
Children’s Hospital Boston, Boston, MA.
The opinions in this commentary are entirely those of the author and do not
reflect the views of his hospital (Children’s Hospital Boston), academic institution
(Harvard Medical School), principal professional society (the American
Society of Anesthesiologists), or any other organization with which he is
affiliated. The author acknowledges that—contrary to his own views—the
American Society of Anesthesiologists “continues to agree with the position of
the American Medical Association on physician involvement in capital punishment”
and wholly repudiates physician participation in capital punishment.
(Available at: www.asahq.org/publicationsAndServices/standards/41.pdf.
Accessibility verified April 26, 2007.)
Individual reprints of this article are not available. Address correspondence to
David Waisel, MD, Department of Anesthesiology, Children's Hospital Boston,
300 Longwood Ave, Boston MA 02115 (david.waisel@childrens.harvard.edu).
© 2007 Mayo Foundation for Medical Education and Research
Mayo Clin Proc. • September 2007;82(9):1073-1080 • www.mayoclinicproceedings.com 1073


PHYSICIAN PARTICIPATION IN CAPITAL PUNISHMENT
paralyze the muscles, and (in the case of lethal injection)
potassium chloride to stop the heart.6
In anesthetic practice, after a drug to induce anesthesia
(like sodium thiopental) is given, anesthesiologists test for
adequate depth of anesthesia, sometimes using a hands-on
assessment like an eyelash reflex (touching the eyelashes to
see if the eyelids flutter). A normal induction dose of 3 to 5
mg/kg of thiopental would be expected to produce unconsciousness
in approximately 30 seconds and peak respiratory
depression in 1 to 1.5 minutes.7 It is not uncommon for
respiratory attempts to return shortly thereafter. Pancuronium
bromide, a paralytic with no anesthetic properties,
is given in a dose of 1 mg/kg and within 4 minutes
produces muscle relaxation to facilitate tracheal intubation.8
San Quentin Operational Procedure No. 770 describes
how a typical lethal execution is to be done9; 2 intravenous
lines are inserted, and saline flows through 1 of the lines.
Individuals other than the condemned person leave the
room. The door is sealed. Through injection ports located
outside the room, 5 g of sodium thiopental (ie, 10 times the
500-mg induction of anesthesia dose for a man weighing
100 kg) is given in “[A] steady even flow…maintained
with only a minimum amount of force applied to the syringe
plunger.” The intravenous line is then flushed with 20
cm3 of normal saline. Two syringes of 50 mg of pancuronium
bromide in 50 cm3 of diluent (ie, a total of 100
mg, 10 times the 10-mg dose given for a man weighing 100
kg) are then “injected with slow, even pressure on the
syringe plunger,” and the intravenous line is flushed with
20 cm3 of normal saline. Two syringes of 50 mEq of
potassium chloride in 50 cm3 of diluent (a total of 100 mEq
of potassium chloride) are then injected.9
If this process is performed correctly, the inmate will be
unconscious before receiving pancuronium bromide and
potassium chloride.7, 10 These massive doses of sodium
thiopental should both stop breathing and cause unconsciousness
in 1 minute.11 In the absence of a hands-on
assessment of anesthetic depth, sustained apnea becomes a
reasonable surrogate for adequate delivery of the massive
doses of sodium thiopental. Sustained apnea guarantees a
sufficient depth of anesthesia.
In contrast, spontaneous ventilation after sodium thiopental
indicates that the desired dose of sodium thiopental
was not delivered. Spontaneous ventilation does not indicate
awareness, but it also does not confirm anesthesia.
The presence of apnea after administration of pancuronium
bromide is not a guarantee that the sodium thiopental
was delivered. A dose that is 3 times a normal intubating
dose of pancuronium (ie, 30 mg instead of 10 mg in a man
weighing 100 kg) will cause muscle relaxation within 1
minute.8 Thus, only a fraction of the pancuronium bromide
needs to be successfully administered to cause apnea. Ap

nea after pancuronium bromide, instead of after sodium
thiopental, does not indicate that the inmate was anesthetized
before the pancuronium bromide. If the inmate was
not anesthetized before the administration of pancuronium
bromide and potassium chloride, the inmate may have the
sensation of paralysis without anesthesia (known as awareness)
and may feel the burning of the highly concentrated
potassium chloride.
One problem with lethal injection is obtaining venous
access, leading to extensive and painful attempts, including
placement of central venous access.12 A more concerning
problem is inadequate medication delivery during the execution.
This can occur from technical errors and procedural
errors (Table 1). For example, in 6 executions since 1999 in
California, the condemned had reactions such as respirations
and tachycardia, which may have been consistent with
awareness or pain.11 The possible patterns of successful and
botched lethal injection are listed in Table 2 and Table 3.
Other problems exist with drug delivery. In 1994 in
Illinois, with use of a machine to inject the sodium thiopental
and pancuronium bromide, the intravenous catheter
clogged, leaving the inmate snorting and his belly “heaving
up and down with the breathing.”14 After the botched execution,
the spokesman for the corrections department
stated, “It looks like the two drugs just don’t mix…they get
tacky and don’t flow when they come together.”18 The same
problem had happened the only previous time the machine
was used 4 years earlier.
In 1995 in Missouri, the arm restraint functioned as a
tourniquet, prolonging the process and bringing into question
the sensations of the condemned person.21 The county
coroner said that the heartbeat stopped several minutes
after the strap was loosened, suggesting that the sodium
thiopental, pancuronium bromide, and potassium chloride
entered the bloodstream at the same time, not giving the
sodium thiopental time to work, and increasing the likelihood
that the condemned person was aware while paralyzed
or felt the burning from the potassium chloride. The
inmate was “gasping, slightly convulsing” 7 minutes after
initiation of the lethal injection.21 The coroner declared that
it was “a little error. It’s not like the guy suffered.”21
In 2006 in Ohio, after a difficult insertion of an intravenous
line, the execution team chose not to insert a second
intravenous line (as apparently called for by prison procedures)
22 and injected the drugs. The inmate appeared to
have fallen asleep, with shallow breathing. But shortly
thereafter, he “raised his head and, frustrated, shook it back
and forth, repeatedly declaring, ‘it don’t work.’”22 The
execution team obtained additional intravenous access,
mistakenly connected the intravenous line to the failed
intravenous catheter, administered the drugs, noticed a reaction
by the inmate, subsequently reconnected the intrave-
Mayo Clin Proc. • September 2007;82(9):1073-1080 • www.mayoclinicproceedings.com

See, e.g., David Waisel, Physician Participation in Capi-
tal Punishment, 82 Mayo Clinic Proceedings 1073, 1078 (2007)

2 comments:

G M Larkin MD said...

Dr Waisel wrote a provocative article on physician assisted murder, but he is accepting a false premise, that capital punishment is an acceptable moral stance, and all else derives from that falsity.

He is correct in stating that there are differences between the Nazi participation in state sanctioned murder and physician assisted murder in the United States, but the similararities are also great.

It is important to separate two separate Nazi programs, although the second developed from the first. The medical dilemma created by incurable painful disease was highlighted by Joseph Goebbles' masterful motion picture "Ich klag An" and brought the question of a "merciful death" to the forefront in Nazi Germany.

The Nazi doctors took a hint at the eugenics practiced in the United States in the 1920s with forced sterilization for the mentally challenged, and went one step further, by advocating the killing of the malformed and mental midgets. Preservation of the "white race" was an American idea, and still remains.

The Nazis extended their "merciful death" program, as we know, and ended up killing millions of healthy Jews, Romani, Poles and others.(The numbers do not matter, but estimates range to about 15 million).

The killing process was medically derived, and administered by physicians-- mainly psychiatrists behind their desks at Tiergartenstrasse-4.

How does this relate to physician participation in executions? Those that are executed are in general not suffering from terminal disease but are for the most part healthy, and suffering perhaps from the chronic diseases of aging. To say that killing them kindly is good for their health is disingenuous; the net result is harm. Killing is the worst pain that a human can suffer. The object of killing is to deprive the inmate of life, and that alone is contrary to medical ethica--PRIMUM NON NOCERE---first of all do no harm.

With "doubling" as Lipton terms it, an easy change for most physicians, the thought of a physician tuning killer is repugnant, and defeats the whole reason for medicine-- to heal-- not only the good guys. It is the end result--Death--that makes all physician intervention unethical.

Add to that my belief that any capital punishment---no matter who the killer might be-- offends, and the reasoning takes a different path. The moral imperative-- thou shalt not kill--- or substitute murder for kill as some Fundamentalists argue-- trumps all its ands and buts; an execution is the most premeditated, deliberate killing there is, and as Camus stated, the cruelest possible murder there is.

The pressures on the Nazi doctors to participate actively in murder was great. Few like Mengele actually enjoyed killing, but few lake Hans Juergen Moench refused, and was able to survive, while Hans LaMotte could not accept the killer role and killed himself .

The legislature backed itself into a corner, with a veritable catch 22; the only ones able to "do the job" are physicians, and they won't---that is unless a new specialty--Thanatology-- is created, for doctors who specialize in killing---either state sponsored or assisted suicide. These folks-- dressed in black scrub suits and halloo'ween masks to disguise their identity, can wear skulls as an insignia on the scrub suit, and would be shunned by other physicians. They would forfeit the right to treat patients, and if the number of executions increase, they can make killing a successful practice, HE WOULD NOT BE A MEDICAL DOCTOR!

The whole discussion is moot---doctors do not kill--they heal. When they can't heal, we alleviate pain, organic or psychological. In this sense, killing does not alleviate pain.

Take away the death penalty, and the discission becomes moot.

G M Larkin MD
Charlotte NC

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A friend of mine was in prison and was killed by the legal injection. Criminals used to suffer more with the ancient methods of penalty, but with this injection is different.