No role for physicians in executions: Going against the oath

The recent delay of a legally authorized execution in California has catapulted a question of medical ethics to the center of the controversial subject of capital punishment.

The issue for physicians is not whether they, as individuals, consider the death penalty moral or immoral, just or unjust. It is also not whether Michael Morales, 46, convicted of the 1983 rape and murder of 17-year-old Terry Winchell, deserves this fate.

The matter at hand for medicine is whether dedicated health professionals who take an oath to be healers can ethically have a role in the death chamber. The answer, according to the American Medical Association, is no.

Last month, the Morales case became a flashpoint for debate regarding the use of lethal injection. Two court-appointed anesthesiologists who had agreed initially to attend the execution reconsidered upon learning the details of an order by U.S. District Judge Jeremy Fogel.

Morales' attorneys argued before Fogel that lethal injection constitutes cruel and unusual punishment, citing some recent evidence indicating the mixture can take several minutes to cause death. Fogel responded with an order that would have required the physicians to determine Morales was properly anesthetized while prison officials administered a cocktail of paralytic and heart-stopping drugs.

The AMA immediately took issue with the judge's directive, which the Association said disregarded physicians' ethical obligations. And the Association, along with the California Medical Assn. and the American Society of Anesthesiologists, viewed these two physicians' ultimate decision as the right thing to do.

After all, based on an AMA Council on Ethical and Judicial Affairs opinion issued in 1980 and subsequently updated, there is no gray area. Physicians, as members of a profession dedicated to promoting and sustaining patients' well-being when there is hope of doing so, should not be participants in a legally authorized execution.

Why? Because it would move them beyond their professional responsibility into the distinct and separate sphere of law enforcement, crime and punishment. Crossing this boundary could cast doubt on the sanctity of the doctor-patient relationship.

To guide physicians, then, the AMA has been consistently clear on what activities are not ethical. They include actions that would directly cause the death of the condemned, assist in or supervise the ability of someone else to do so, or automatically cause an execution to be carried out.

Specific examples of what doctors should avoid include prescribing or administering tranquilizers and other psychotropic agents and medications that are part of the execution; monitoring vital signs, including electrocardiograms, on site or remotely; attending or observing an execution as a physician; and rendering technical advice regarding execution.

In regard to lethal injections, it is unacceptable for physicians to start IVs as ports for the device; prescribe, prepare, administer or supervise injection drugs; inspect, test or maintain lethal injection devices; and consult with or supervise lethal injection personnel.

Bottom line: Ethics dictate physicians steer clear of the execution process -- that they stay out of the chamber and are not directly involved in what is happening inside. It is not a statement for or against the death penalty. Instead, it is an affirmation of the importance of applying medical skill and judgment for the purposes of individual health.

Sadly, this recent episode is not likely to be an isolated event.

Only a small number of states bar physician participation or are considering legislation to do so. And, because litigation regarding the constitutionality of execution by lethal injection is expected to heat up in the months ahead, doctors' technical expertise risks being drawn into the discourse.

The death penalty in general -- and lethal injection specifically -- is a complex and charged issue. Ultimately, though, according to the Code of Medical Ethics, there is no question about one aspect of it. Doctors should have no professional role in executions. To do so is simply not ethical.