Doctor quits prison job over execution

The last few years have seen a flurry of controversies about physician involvement in capital punishment in California, Missouri and elsewhere. Organized medicine groups, including the American Medical Association, have said physicians should not participate in executions because their professional duties lie in preserving lives, not ending them.

But what constitutes participation? The latest test of this ethical standard comes from Washington state.

Just before Thanksgiving, the director of health services for the state's prison system resigned his post prior to the scheduled Dec. 3, 2008, execution of Darold Ray Stenson, who was convicted in 1994 of killing his wife and a business partner.

As the corrections department's top medical officer, Marc F. Stern, MD, MPH, supervised about 700 physicians, pharmacists, nurses and other health professionals. Dr. Stern said that if any of those staffers helped carry out the execution, the actions would put him "in harm's way" ethically because he supervised them, albeit indirectly.

"If I did not recuse myself from the situation, then I would be violating the accepted ethical standards of my profession," Dr. Stern told AMNews. Taking a leave of absence would have been "an end-run around the fact that these people should not be involved."

Dr. Stern asked prison officials to keep him and his medical staff out of the execution process. Later, he learned inadvertently that the prison pharmacy -- which he supervised -- dispensed at least two of the three drugs typically used in the lethal injection process when a question came to his desk about how to enter the nonformulary medications in the computer system.

Dr. Stern asked prison officials to secure the medications from an outside pharmacy so he and his staff would not be involved. When they refused, he said, he tendered his resignation. Washington Dept. of Corrections Assistant Secretary Scott Blonien did not respond to AMNews inquiries. He told The Olympian newspaper that participation in the execution process is voluntary for all prison employees.

Dr. Stern personally opposes capital punishment and says it is an "ineffective deterrent," but said his actions were driven by his professional ethics. He went public in response to a news query from The Olympian.

The AMA first adopted an ethics policy on physician participation in capital punishment in 1980. It was updated in 2000. The policy says that, among other things, physician participation in execution is "an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned."

The National Commission on Correctional Health Care, which accredits about 500 prisons and jails nationwide, has virtually the same language in its standards. The American College of Physicians says the only acceptable role for doctors is to certify the death after the fact. The Society of Correctional Physicians says "correctional health professionals shall not be involved in any aspect of execution of the death penalty."

Several correctional health experts said prison doctors have a special responsibility to steer entirely clear of executions because such participation could affect their medical relationships with other inmate patients.

Supervisory ethics

Medical ethicists disagreed about whether Dr. Stern correctly interpreted his professional obligations.

Steven Miles, MD, is professor of medicine and bioethics at the University of Minnesota Medical School. Dr. Stern, he said, "was right on target. The AMA principle on the medical ethics of this matter is exactly clear. You're not supposed to be involved in any way, shape or form with an execution. Period."

But Robert M. Sade, MD, said the AMA code did not oblige Dr. Stern to quit his post. Dr. Sade is director of the Medical University of South Carolina Institute for Human Values in Health Care.

"The clause that mentions supervision clearly is related to supervision of someone directly involved with the condemned person at the time of the execution," said Dr. Sade, who has written about medical ethics of doctor participation in lethal injection. "It does not apply to distant supervisory roles."

Dr. Sade, a former chair of the AMA Council on Ethical and Judicial Affairs, spoke on his own behalf.

In a statement, AMA Board of Trustees Chair Joseph M. Heyman, MD, said "any conflict resulting from a physician's obligation to assist, supervise or contribute to capital punishment procedures is a professional ethical conflict."

Deborah W. Denno, a law professor at Fordham University in New York who has written extensively on doctors and the death penalty, said Dr. Stern's case should spark re-examination of ethics policies.

Dr. Stern "is taking the broadest interpretation of what his responsibility is," Denno said. "This does raise issues of how unclear this sort of thing can be."