Health workers cross line on death

Health workers cross line on death

October 22, 2006
Jennifer McMenamin sun staff
In North Carolina, a physician monitored a condemned inmate's brain waves as the drugs that would bring death were about to be added to the IV.

The doctor was prepared to direct executioners to inject more anesthesia if the prisoner remained conscious.

Doctors in Georgia have gradually taken on larger roles in state executions, starting intravenous lines when nurses could not and, on one occasion, even ordering a second dose of potassium chloride after a prisoner's heart did not stop.

In Maryland, a team of correctional officers, prison officials and hired nursing assistants and paramedics carries out executions. Although a doctor is present, her only role has been to pronounce death.

Across the nation, doctors are crossing a line that has existed for more than 2,000 years in the view of most medical professionals, violating an oath to do no harm to patients by participating in executions.

Even the limited role of declaring that a prisoner has died is prohibited by the American Medical Association and other professional organizations that have taken firm positions against any involvement by doctors and nurses in the administration of capital punishment.

Now, in a case challenging Maryland's lethal injection procedures, lawyers representing state prison officials and ÀôÀ attorneys for death row inmate Vernon L. Evans Jr. are facing off in federal court over whether physicians and highly trained nurses are needed for Maryland's executions.

Even the judge hearing the case has asked whether medical professionals who live by the Hippocratic Oath can be persuaded to help put a man to death.

Indeed, the question of whether physicians could or should participate in executions has become an issue in the long-running national death penalty debate, with opponents arguing that lethal injection procedures as currently carried out in many states by individuals with little or no medical training represent unconstitutionally cruel and unusual punishment.

The presumption has been that doctors don't participate.

But, in death chambers across the country, some have. "I had no qualms," one nurse, who started an IV in an inmate who was about to be put to death in a prison out West, told a surgeon and medical school professor who wrote an article about physician participation in executions for The New England Journal of Medicine.

"If this is to be done correctly, if it is to be done at all, then I am the person to do it." The nurse - like nearly everyone who has taken part in executions, whether in Maryland or elsewhere - remained anonymous.

Of the 15 medical professionals Dr. Atul Gawande located for his article, only five agreed to speak to him, and only one allowed his name to be used.

That physician, Dr. Carlo Musso, compared his role in executions in Georgia to any other "end-of-life issue" that he faces in his practice of medicine, and said a condemned man is "no different from a patient dying of cancer - except his cancer is a court order." "When we have a patient who can no longer survive his illness, we as physicians must ensure he has comfort," Musso, a death penalty opponent, was quoted as saying.

He told Gawande that he had done nothing during the six executions in which he had participated but watch inmates' heart rhythms on a cardiac monitor to determine when the prisoners had died. Attempts to reach him for this article were unsuccessful.

But physicians who participate in executions - even just to pronounce death - do so in violation of many professional medical associations' codes of ethics.

Dr. Arthur Zitrin, a New York psychiatrist and clinical professor who has lodged complaints with medical licensing boards against the few doctors who have been publicly identified as execution participants, explained: "In the event that the condemned inmate is not dead, the obligation of the physician would be to say, 'Get more drugs' or recommend that the execution process continue. ...

The obligation of the physician would be to make a recommendation to kill a person. He's becoming an executioner, really."

Gawande, a Boston surgeon and Harvard Medical School professor who spent more than a year trying to find doctors and nurses who participate in executions for his New England Journal article, said in an interview that some agree to take part out of the belief that their involvement will help ensure that the lethal injection procedures are carried out as painlessly and humanely as possible.

According to Gawande's article, two doctors had become involved at the request of their patients, who happened to work at prisons where executions were performed.

Another of the doctors told his wife about the job right away but could not bring himself to tell his children until they were adults.

And one, after having to give a deposition in a court challenge to a lethal injection, came to work one day to find a sign on his clinic door that read, "The Killer Doctor."

"The four physicians and one nurse all were people like colleagues I have, and had thought through the problem in their own ways," Gawande said.

"What I found was that I respected them and, by and large, they were thoughtful people who were really trying to grapple with a fundamental moral question." I

n Evans' federal case in Baltimore, the testimony of 11 past and current execution team members has offered an unprecedented glimpse into who does what behind the curtains and mirrored glass of Maryland's death chamber when the state carries out the ultimate sanction.

A doctor who participated in the lethal injections of Steven H. Oken in 2003 and Wesley Eugene Baker in December testified that her role was limited to watching the tracings on an EKG machine and notifying prison officials when the condemned men's hearts had stopped.

Other than that doctor - an internist - the execution team member with the most medical training is a certified nursing assistant who earned an associate's degree at a local community college and was taught at the regional medical center where she has worked for nearly a decade how to draw blood, insert catheters and start intravenous lines.

Expert medical witnesses testifying for Evans have characterized the nursing assistant and her execution team colleagues as unqualified and poorly trained for the jobs they carry out on execution nights.

The pair of physicians criticized execution team members' understanding of intravenous systems and of signs that an inmate being put to death might be conscious, and one doctor concluded that some don't even comprehend their individual responsibilities.

Sentenced to death for the 1983 contract killings of two Pikesville motel employees in an attempt to silence witnesses in a federal drug case, Evans, 57, has sued Maryland correctional officials, alleging that the state's lethal injection procedures, as written and carried out, violate the constitutional ban on cruel and unusual punishment.

Lawyers representing the state have argued that an execution is not a medical procedure and should not be held to the same standards. Their expert medical witness testified this month that the troubling scenario raised in Evans' lawsuit - that the convicted killer could be inadequately sedated but unable to signal his distress as painful paralyzing and heart-stopping drugs enter his system - was "medically implausible."

Legal and medical experts who follow the debate over the involvement of medical professionals in state executions say it's difficult to tell how many doctors and nurses are participating and just what their roles are in the death chambers.

Few medical personnel are willing to publicly discuss their roles, and the corrections departments that hire them zealously protect their identities.

What is known has largely emerged from lawsuits filed by death row inmates who, like Evans, have challenged their state's lethal injection protocol.

In Missouri, a federal judge ordered the participation of trained anesthesiologists after the surgeon who oversaw the state's executions for years and who prepared the drugs used in each lethal injection testified in June that dyslexia sometimes caused him to transpose numbers, confuse dosages and refer to drugs by the wrong name.

In California, execution team members testified last month in a federal lawsuit that the execution anteroom, where lethal doses of three drugs are prepared and injected, is packed with people and so dimly lit that one nurse said she passes syringes to an outstretched hand whose owner she cannot see.

"The room is darkened so that people can't identify who's doing what," said Deborah W. Denno, a Fordham University law school professor and a national expert on lethal injections. "There's such an effort to protect confidentiality and diffuse responsibility that people don't even know what everybody else is doing," she added.

Several studies, surveys and research papers document the willingness of doctors and other medical personnel to participate in state executions.

A 2002 study by Denno found that "in general, states allow for substantial physician participation, although the roles are limited, at least officially."

Her research revealed that doctors declare or "pronounce" the death of a condemned inmate in 13 states while that task is left to coroners or a prison warden in six states.

In Connecticut, a doctor must certify that the "executioners are properly trained, including having the ability to properly insert [an] IV."

And in Indiana, a physician must insert the IV for the administration of the lethal chemicals, according to the study.

A survey of randomly selected practicing physicians published in the Annals of Internal Medicine in 2001 found that 41 percent of respondents indicated that they would be willing to participate in an execution and do more than merely certifying another person's pronouncement that the inmate was dead. (Certifying death and giving a condemned inmate a sedative to calm his nerves before an execution are the only roles that the American Medical Association says do not violate the profession's Hippocratic Oath to "do no harm.")

Nineteen percent of the doctors surveyed indicated that they would agree to administer the lethal drugs.

To Dr. Jonathan I. Groner, a surgeon and medical school professor in Ohio who has written about doctors' participation in state executions, nothing could be more troubling.

Drawing a parallel to German doctors who participated in the Nazis' program of euthanizing intellectually and physically disabled people, known as Aktion T4, Groner said, "Most times in history when doctors have forsaken their ethics to help a government program, it has usually worked out badly, not only for the doctors but also for society as well."

U.S. District Judge Benson E. Legg, who is hearing Evans' federal lawsuit, has told the lawyers handling the case that he wonders whether it would even be possible to find a doctor willing to participate in an execution, should he order the state to do so.

And although Evans' lawyers have highlighted execution team members' lack of knowledge or understanding of the overall lethal injection procedure, the judge has wondered aloud whether that isn't intentional "to lessen the burden for the responsibility of killing someone."

Judges in California and Missouri have ordered prison officials there to involve anesthesiologists or similarly qualified medical professionals in administering the anesthesia and making sure the condemned inmate is unconscious when the second and third drugs are injected into an IV, paralyzing the prisoner and stopping his heart.

Both states, however, have struggled to find medical personnel to play those specific roles and are still tied up in litigation to work out the details.

Lawyers for Evans presented four days of testimony in September, and attorneys representing Maryland prison officials wrapped up their case Oct. 12.

No date had been set for Evans' lawyers to present rebuttal testimony and for both sides to offer closing arguments.

jennifer.mcmenamin@baltsun.com

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