Our ethical obligations to patients are sometimes overridden by the state, but as a profession we’re generally OK with this. Good medical practice doesn’t expect us to protect the confession of a murderer, or disobey the direction of a judge. But what would we do if the state required something of our profession that overrode our ethical judgement? Would we fight, fudge, or fold?
‘Returning violence for violence multiplies violence, adding deeper darkness to a night already devoid of stars. Darkness cannot drive out darkness: only light can do that..’
(Martin Luther King Jr, 1963)
The US is the only G7 country that executes convicted criminals. There are 31 states that execute, and most require the participation of a licensed physician,1 with doctors variably required to cannulate, titrate drugs, and judge effective progress, unconsciousness, and death.
American Medical Association (AMA) guidelines ban physician participation in execution but the AMA does not license doctors.2 Doctors theoretically face being struck off by state medical boards for participating, but none has been. In 2008 the Supreme Court of North Carolina ruled that the state medical board could not revoke participants’ licences. Most states protect them,3 and only a few states are unable to recruit.
THE DEATH OF CLAYTON LOCKETT
Proponents of physician involvement present it as a least-bad option, conferring skill and humanity4,5 to the process, yet a doctor was central to one of the worst ‘botchings’ to date: Clayton Lockett’s 2014 execution in Oklahoma was halted after 33 minutes when he spoke and tried to get off the table. His cannula had been improperly sited despite 16 attempts by the paramedic and doctor, including failed central lines and a femoral artery puncture. The team had run out of drugs and were discussing resuscitation when he died of a heart attack. His lawyer said it looked like torture. The United Nations called it cruel, inhuman, and degrading. The doctor was named in a lawsuit that referred to medical experimentation and drew parallels with Nazi doctors at Nuremberg.6
‘Lethal injection now appears to be the sole method of execution accepted by courts as humane enough to satisfy Eighth Amendment requirements — largely because it medicalizes the process.’ 4
DRUGS, GUNS, AND GAS CHAMBERS
Since 1977, US executions have used a three-drug protocol devised by an Oklahoma doctor: thiopental, pancuronium, and (excruciatingly painful if administered without proper anaesthesia) potassium chloride. Opponents have argued that paralysis risks making painful execution appear painless, but the US Supreme Court declared it constitutional in 2008.7 In 2011, though, the US manufacturer of thiopental determined to stop this use and ceased its production. State attempts to obtain it overseas led to an EU export ban and executioners sought something new.
The answer wasn’t obvious, as execution has no evidence base, and must use drugs neither licensed nor intended for it. Consensus chose midazolam, which is neither anaesthetic nor analgesic, with no evidence-based dose for pain-free unconsciousness (arguably beyond its power). It has since been central to numerous executions so prolonged (and apparently painful) that terrified death row inmates have been asking for the firing squad instead. Joseph Wood’s 2014 execution took nearly 2 hours and 15 injections, 750 mg each of midazolam and hydromorphone (15 times the 50 mg Arizona specified).8
In 2016 drug companies blocked midazolam supplies, and stand ready to block anything else. In April 2017, Arkansas state tried to execute eight people in 10 days, before their last batch expired, but lethal injections have probably had their day. Several states are legislating to reinstate the electric chair. Oklahoma claims to have heard from a company offering gas chamber executions that are both pain-free and mistake-free. Doctors, though, are not off the hook. Utah has returned to the firing squad, but requires a doctor to first place a target over the prisoner’s heart:
‘You are taking a totally defenceless person, planning, premeditating, even rehearsing, then killing him — any sane person other than a psychopath would be dramatically affected by that.’
(Dr Allen Ault, former Commissioner of Corrections, Georgia, US)9
THE MIRAGE OF RESPECTABILITY
Can you really medicalise being shot to death, or does this unwittingly reveal the involvement of doctors as a deliberate mirage, a cynical association of the otherwise unpalatable with medicine’s ethical, humane, in-the-patients’-best-interest aura? If states feel their mandate for capital punishment comes from the people (most US citizens still support it for certain crimes),10 and that opinion is influenced by the belief that the process is humane, then the involvement of doctors must be a significant factor in its continued existence.11
Atul Gawande argues that a society in which the government actively subverts core ethical principles of medical practice is worse off for it.4 He says the US government has proved willing to use medical skills against individuals for its own purposes in various ways, including in Guantanamo Bay. Preserving the integrity of our ethics could not be more important.
Do we care about US medical professional ethics? Is it any of our business? It must surely be our business if, anywhere in the world, states attempt to compromise medical ethics to suit the law.
Fight, fudge, or fold? It’s a question for us all.
- © British Journal of General Practice 2017
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