Is separation of medicine and state the answer?

By: Stuart Reeves
Posted: 9/17/07

A number of things make for strange bedfellows, perhaps none more so than government and medicine.

In the last seven years, it seems every time we open a newspaper we see this "Honeymooners"-esque relationship playing out whether it concerns the particulars of stem cell research, the rights of comatose patients, or women's right to choose. More recently however, the headlines have more to do with ethical dilemmas that occur when these crazy kids cozy up just a bit too close to each other.

We have heard about psychologists developing interrogation techniques for Guantanamo Bay detainees and doctors forcing feeding tubes into the same detainees that are carrying out hunger strikes in protest to their detention.

Both of these scenarios are currently receiving plenty of scrutiny by members of the medical community, public opinion and the media, but they are certainly not without their own champions from the political world and even those in the medical community that find these practices perfectly valid.

These scenes are a world away to most people, but there is yet another secluded area where these two, government and medicine, are sneaking off to pitch woo. Moreover, this place is on our own soil.

In the 37 states that utilize lethal injection to carry out capital punishment, many, including Florida, Missouri, Texas and North Carolina require the presence of a physician to at least pronounce the time of death of the condemned. Some require the doctor to administer the three drug cocktail, consisting of an anesthetic, a paralytic, and then a fatal does of potassium chloride. Some only ask that the doctor locate a suitable location for the injection and prepare the site.

The American Medical Association (AMA) has recently made a hard ruling that any of these activities violates their code of ethics, citing that medicine is first and foremost a life preserving practice and participation in executions brazenly violates the mandate that a doctor, "above all, do no harm."

The AMA further charged, any physician(s) that participate in any capacity will face revocation of their membership in the association and could also face license challenges in the states where they practice.

To protect doctors from these complications, Florida, for example, has gone as far as to make participating physicians don full moon suits with dark visors so no witness can identify and report them to their state's medical board.

Most states feel that the presence of a physician legitimizes the execution process and further protects it from any 8th Amendment challenges against cruel and unusual punishment.

It should not take much imagination to see that if the AMA got their way and no physicians were present to administer the drugs properly, the black hood and needle would be handed to Bob the Prison Guard and the prisoner would surmise that the prospect of dying will be the least of his concerns.

So, why, if it is ethically questionable and socially controversial, would any doctor choose to participate in capital punishment?

According to a 2006 article in the New England Journal of Medicine by Dr. Atul Gawande, M.D., M.P.H., some do it out of a sense of civic duty.

These physicians feel that a jury of the condemned's peers, through deliberation and the legal process, concluded that the individual was too dangerous to be allowed to live and must be removed.

Society has asked these physicians, as the persons most qualified to do so, to carry out the sentence.

Others, according to Gawande, participate regardless of their own stance on capital punishment and adopt the outlook that if we have capital punishment and if it is to be carried out, it should at least be done in the most humane way possible. They see the participation of fully trained doctors as the only method that insures it happens that way.

So, there you have it. State governments need doctors to carry out executions and are willing to protect their identities to do so.

The AMA says the whole affair violates the standards of ethical behavior for the medical profession.

Though a domestic example, it adds to the growing list of conflicts that seem to emerge when medicine chooses to waltz with government, be it federal or state.

Clearly a comprehensive separation of medicine and state just is not realistic.

We have to rely on a body of some authority to regulate the education and licensing requirements of doctors, otherwise any snake oil salesman with a stethoscope could set up shop.

Further, we need to rely on the government oversight to some extent to ask if certain research projects and their methods are beneficial to society and can be conducted in an ethical manner.

Could a graded separation be possible?

Perhaps, but regardless of such a separation's prospect for success, what we have seen with recent postures of both the American Psychological Association and the American Medical Association is that some legislative construct is going to be necessary to preserve the autonomy of medical practice and prevent it from becoming a convenient instrument of the state.