In the execution chamber: Do doctors have a place -- at all?

Years ago, prisoners condemned to death received a blindfold and a cigarette before they faced the firing squad. Today, they receive a dab of antiseptic on their arm before having a catheter inserted in preparation to receive a lethal three-drug cocktail.

First performed in 1982, lethal injection is the main method of execution in 37 of the 38 states with the death penalty. Of the 191 executions performed in the United States since 2001, 189 have been lethal injections. Now, a loose coalition of medical ethicists and death penalty opponents, increasingly concerned about the "medicalization" of executions, is making an uncoordinated but multipronged attack on the procedure.

Although it has not been directly involved in these efforts, the American Medical Association has a prominent role in this debate because of the long-standing opposition to physician involvement in executions written in the Association's Code of Medical Ethics. "The code is clear: The physician cannot play any role in an execution -- passive or active," said Michael Goldrich, MD, chair of the AMA Council on Ethical and Judicial Affairs.

First issued in 1980, the AMA policy does not take a stand on capital punishment itself but calls for keeping physicians out of the process. Lethal injection prohibitions apply to prescribing or administering tranquilizers as part of the execution; monitoring vital signs; rendering technical advice; selecting injection sites; starting intravenous lines; prescribing, preparing, administering or supervising the injection of drugs or their doses; inspecting, testing or maintaining lethal injection devices; and consulting or supervising lethal injection personnel.

Involving state medical boards

Although AMA opposition to physician involvement in executions is long-standing policy, a 2001 survey on physicians' willingness to participate in lethal injections showed that only 3% of doctors were aware of the policy. A year earlier, a similar survey reported that 43% of physicians said they approved of doctors administering the injection.

Arthur Zitrin, MD, is very familiar with this portion of the ethics code. Dr. Zitrin, an 86-year-old retired New York University psychiatrist and self-described death penalty abolitionist, is initiating one of the more controversial attacks on lethal injection. He is identifying physicians who participate in executions in hopes of getting their licenses revoked.

"My effort, and it's been a quixotic effort in some respects, is to identify doctors who participate in executions and work to have charges filed against them for violating medical ethics," Dr. Zitrin said. "It's very hard to identify these doctors. They're paid in cash and the department of corrections won't release their names."

A complaint initiated by Dr. Zitrin and dated Sept. 20 was sent to the Georgia Composite State Board of Medical Examiners seeking an investigation and "appropriate sanctions" against Jackson-based internist Hothur V. Sanjeeva Rao, MD, for his participation in executions.

Dr. Rao told AMNews that he merely monitored lethal injections, and he quit doing that almost six months ago. "There was just too much harassment, and I didn't want to be involved in these things," he said. "I don't have any problems with prisoners who have killed people and don't have any regrets receiving the death sentence, but I don't want to be involved."

Monitoring executions violates AMA policy, but the more serious charge is that, on Nov. 6, 2001, Dr. Rao inserted a catheter into a prisoner's right subclavian vein after a nurse couldn't find a suitable vein in the prisoner's right arm, hand, leg or foot. The complaint states that Dr. Rao's actions violate the Hippocratic Oath and the AMA Code of Ethics. The complaint also notes that in March 1994, the AMA, the American College of Physicians and others issued a statement calling for state licensure boards to treat participation in executions as grounds for disciplinary action.

Jim McNatt, MD, medical director for the Georgia board, would not comment on the case specifically but said that this type of complaint was not unique.

"The board gets put into political [arguments] all the time in several areas, and we have to look at the facts in each one," he said.

Dr. McNatt said complaints also are filed against doctors who perform abortions but that neither performing abortions nor participating in executions is illegal in Georgia.

Differing opinions

Dr. Zitrin's actions have drawn both support and opposition.

"I think Dr. Zitrin is on to something," said Michael Franzblau, MD, a retired San Rafael, Calif.-based dermatologist and active capital punishment opponent who helped remove physicians from his state's execution chamber. "Unless we take a very firm stand to our colleagues and say this is acceptable and this isn't, bad things are going to happen."

New Haven, Conn.-based attorney Kenneth F. Baum, MD, disagrees. "Reasonable people can disagree on the death penalty, and reasonable people can disagree whether physicians should participate," he said. "But it's another thing for one physician to say 'My opinion is right' and to hunt down physicians who are participating in executions and take their licenses away."

One of the other signers to Dr. Zitrin's complaint is Jonathan I. Groner, MD, a surgeon at Columbus Children's Hospital in Ohio. Dr. Groner has spoken and written extensively on the subject and has submitted resolutions to the Ohio State Medical Assn. and the AMA calling for a moratorium on lethal injections.

"The big movement has been to get the AMA to come up with a more powerful statement because the current policies are not widely disseminated," he said. "The party line [that] states offer is that lethal injection is a 'medical procedure.' It's killing someone, for crying out loud."

Dr. Groner, who also opposes physician-assisted suicide, said his opposition to capital punishment developed after three events that profoundly influenced him: a grand rounds program on Robert J. Lifton's The Nazi Doctors; the Arkansas execution of Ricky Ray Rector, who was so mentally impaired from a self-inflicted gunshot wound that he saved his dessert from his last meal so he could eat it after execution; and his own participation as a witness in a murder trial in which he felt the defendent received inadequate representation from a court-appointed attorney.

Taking the issue to court

Columbia University anesthesiologist Mark J.S. Heath, MD, has chosen the courts as his arena for opposing the death penalty. He has assisted in challenges to the constitutionality of lethal injection in some 20 different states, including testifying as an expert witness on the subject in Georgia, Louisiana, Tennessee and Virginia and testifying before the Nebraska and Pennsylvania legislatures.

Although this battle is going on nationwide, Dr. Heath said it is not a coordinated effort and is mostly carried out by public defenders seeking to protect their clients from lethal injections. It was Gwinnett County public defender Matthew Rubenstein who subpoenaed Dr. Rao to testify about his role in Georgia executions.

Dr. Heath argues that the only purpose of the second drug in the lethal injection mix, pancuronium, is to make the execution more "esthetically pleasing" by relaxing muscles to prevent involuntary movement.

Sodium thiopental is the first drug administered and renders the prisoner unconscious. The third drug, which causes the prisoner's death, is potassium chloride.

"If insufficient thiopental is delivered to the patient's circulation, pancuronium will cause the execution to be deeply inhumane, because the inmate will die by asphyxiation and will experience the agony of an intravenous injection of concentrated potassium," Dr. Heath said.

Because of the pancuronium, however, observers cannot tell if the condemned is conscious or not when the potassium chloride takes effect.

Dr. Heath said these legal challenges have led to some states "tweaking" their lethal injection procedures. North Carolina amended its lethal injection protocols last month so that condemned prisoners will receive duplicate injections containing not less than 1500 mg each of sodium pentothal to ensure that they are unconscious when the potassium chloride is administered.

Dr. Baum notes that the very fact that things can go wrong during a lethal injection is reason for having physicians present if the prisoner requests it.

"Nobody is sentenced to a botched execution," he said. "Once you say it's all right to categorically deny comfort care to someone in their final hours, you step onto an enormous slippery slope. You provide a lot of fuel for people to start perverting what are the appropriate ethical [boundaries] for medical practice."

He compared condemned prisoners to the terminally ill and, although he opposes the death penalty, Dr. Baum argued that by not being present at executions, physicians are -- in effect -- abandoning dying patients.

CEJA's Dr. Goldrich disagreed and said participating in an execution falls outside of the realm of patient care -- even if that patient is a prisoner condemned to death.

"The obligation for the physician to a prisoner who is a patient is to provide competent and compassionate care," Dr. Goldrich said.

"Medicine really has no role in addressing more competent or compassionate ways to execute people."