Lethal injection: a stain on the face of medicine
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7371.1026 (Published 02 November 2002) Cite this as: BMJ 2002;325:1026
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
So far this year the US has judicially murdered ten people; the state
of Texas has killed eight of them. These are all cold-blooded killings
because it has invariably been many years since conviction. American
physicians remain complicit in this barbarism.
The next person to be given a lethal injection is Richard Fox from
Ohio who barring last a last minute reprieve will be killed on 12th
February.
With the following article Jonathan Groner courageously continues to
highlight the cruelty of the American justice system. American physicians
have the power to overturn the death penalty. I wonder if they have the
collective humanity to do so?
"On the morning of February 12, Richard Fox will receive a visit from
a health care professional. This individual will either be a licensed
practical nurse, a paramedic, or a phlebotomy technician (The Ohio
Department of Rehabilitation and Correction will not reveal the
individual's name or exact qualifications). This professional will insert
intravenous (IV) "saline locks" into each of Mr. Fox's arms. Shortly
before 10 am, Mr. Fox will be placed on an "execution bed" -- which looks
like an operating room table -- and most likely strapped down for safety.
The saline locks will be attached to plastic intravenous tubing that looks
identical to the equipment found in any hospital. Then, after a signal
from the warden, the following drugs will be administered intravenously by
hand injection: Thiopental sodium, 2 grams (a drug used for induction of
general anesthesia); pancuronium bromide, 100 milligrams (a potent muscle
relaxant used for major operations); and potassium chloride, 100
milliequivalents (a chemical used to paralyze the heart during bypass
operations). However, in Mr. Fox's case, there will be no ventilator to
support his breathing nor will there be a bypass machine to take over his
circulation. If all goes well, his heartbeat (monitored by a stethoscope)
will cease after a few minutes. A medical doctor will then pronounce the
"patient" dead.
This execution protocol has been performed five times before in Ohio.
The previous victims have included a suicidally depressed man who begged
to be killed, a psychotic man, and a man who may have been innocent. In
each case, the assistance of health care professionals was required to
carry out this medical charade.
Participation in lethal injection is expressly forbidden by national
health professional organizations. The American Nurses Association has
stated that "participation in executions contradicts the fundamental role
of the health care professional as healer and comforter... When the health
care professional serves in an execution under circumstances that mimic
care, the healing purposes of health services and technology become
perverted." The American Medical Association enumerates eight specific
acts that are forbidden, including pronouncing the prisoner dead. Yet,
despite these clear directives, health care professionals, in violation of
the most basic ethical tenets of their profession, continue to
participate.
If you needed an operation (or a transfusion, or chemotherapy), would
you want the nurse or technician who inserted Mr. Fox's intravenous lines
to insert yours? Would you want the physician who listened to Mr. Fox's
heart and lungs before pronouncing him dead to listen to your heart and
lungs? Lethal injection not only defiles those who directly participate,
but taints all health care professionals.
If not for the sake of the mentally ill or the sake of the innocent,
then for the sake of doctors, nurses, paramedics, medical technicians, and
their patients, it is time for the executions to stop."
(source: Jonathan I. Groner MD---Acknowledgements: The information on
Ohio's execution protocol was provided in writing by James S. Haviland,
Warden, and Vincent Lagana, Staff Counsel, Ohio Department of
Rehabilitation and Correction)
Competing interests:
None declared
Competing interests: No competing interests
Editor - Dr Groner's horrific vignette of a recently botched and
hence inhumane execution by lethal injection in the state of Georgia
U.S.A[1] appals as much by the time taken in the 'preliminaries (30 min)
as by the ethics of employing a doctor to insert a central venous line
.The report of the Royal Commission on Capital Punishment (RCCP)[2] may
be of some help to Dr Groner. The Commission was asked by the Prime
Minister of the day to look at methods of execution. Was there a more
humane method than hanging? There was a choice of four methods:
hanging, and in other countries electrocution, lethal gas [cyanide] and
the guillotine. Execution by lethal injection had lapsed since the Nazi
euthanasia programme. Zyklon B (cyanide) killed millions in the
Holocaust.
As to methods of execution, "We shall take as our postulate that the
requisites are humanity, certainty and decency, and those alone….The
requirements of humanity are essentially two. One is that the
preliminaries to the act of execution should be as quick and as simple as
possible, and free from anything that unnecessarily sharpens the
poignancy of the prisoner's apprehension. The other
is that the act of execution should produce immediate unconsciousness
passing quickly into death." The Commission at once rejected the
guillotine as producing a mutilation 'shocking to public opinion in this
country' and rejected also the firing squad, 'which does not possess even
the first requisite of an efficient method, the certainty of causing
immediate death.' 'The figures in our table leave no room for doubt that
in the time taken by the preliminaries, hanging is superior to either of
the other methods (gas, electrocution).'
Lethal injection. (Chairman) What are the objections that you see
to a lethal injection? (Dr Landers) We do not think it would be any more
humane (than hanging), and we think the main objection is its
impracticability.(Chairman) Would you enlarge on that -? - It raises the
question as to who is to do it, and how they are to do it. We cannot
suggest who is to do it… (Dr Landers represented prison medical
officers.)
The British Medical Association (BMA) said: 'If it were practicable,
the intravenous injection of a lethal dose of a narcotic drug would be a
speedy and merciful procedure…But the practical difficulties encountered
in many cases [1] are such as to render the method quite unsuitable for
the purpose of execution'. The Association of Anaesthetists (of Great
Britain and Ireland) AAGBI agreed. There were three reasons why the
method was impracticable. First it was impossible to give an intravenous
injection to anyone with certain physical abnormalities. Secondly it was
never easy to give one except with the co-operation of the subject.
Thirdly, the operation demanded professional skill, which the medical
profession would be unwilling to use for such a purpose.
The BMA was as explicit about the third reason as today's,
American Medical Association (AMA).[1] 'No medical practitioner should
be asked to take part in bringing about the death of a convicted murderer.
The BMA would be strongly opposed to any proposal to introduce, in place
of judicial hanging, a method of execution which would require the
services of a medical practitioner either in carrying out the actual
process of killing or in instructing others in the technique of the
process.' Such absolutist ethics were shared by Dr Frankis Evans,
President of the then Faculty of Anaesthetists of the Royal College of
Surgeons of England.
Perhaps fortunately British doctors were never put to the test. To
intense public disapproval, some years after publication of the
Commission's report [2] Parliament abolished capital punishment. Dr
Groner might take heart from that.
Peter Scott, Retired Consultant Anaesthetist, Bromsgrove.
References
[1] GRONER J. Lethal injection: a stain on the face of medicine.
BMJ, 2002;325:1026-1028 (November 2)
[2] Report f the Royal Commission on Capital Punishment 1949-1953.
London: Her Majesty's Stationery Office, 1953.
Competing interests:
None declared
Competing interests: No competing interests
The following is a news release issued by the International
Secretariat of Amnesty International on 9 December 2002 and very
eloquently describes America’s problem.
USA: Need for reflection on Human Rights Day
"With 2 executions scheduled to take place in the USA on 10 December,
the 54th international Human Rights Day, US politicians should reflect on
their country's selective approach to global standards of justice and
decency," Amnesty International said today, noting that as many as 5 other
men could also be put to death in the USA this week.
"More than half the countries of the world have turned their backs on
judicial killing, recognizing its incompatibility with human dignity, its
failure to have any special deterrent effect, and its capacity for fatal
error", Amnesty International stressed.
"In contrast, the USA, which frequently claims to be the world's most
progressive force for human rights, has put more than 600 men and women to
death in the past decade, many in violation of specific international
standards," the organization added, noting that earlier this year
President Bush promised that "America will always stand firm for the non-
negotiable demands of human dignity" and Secretary of State Colin Powell
asserted that "we will not relax our commitment to advancing the cause of
human rights".
More than 60 people have been executed in the USA this year
alone.They include a mentally ill man, several people whose legal
representation was inadequate, prisoners whose guilt remained in doubt, a
Mexican national denied his consular rights, and a Pakistan national
abducted from Pakistan by US agents ignoring human rights safeguards.
The executions also include the only 3 child offenders (under 18 at
the time of the crime) known to have been put to death anywhere in the
world in 2002. Such executions, of which the USA is virtually the sole
remaining perpetrator, violate international law and have been roundly
condemned by the international community. In October, for example, the
Inter-American Commission on Human Rights noted that the prohibition is a
non-derogable norm which "crosses political and ideological boundaries"
and represents "prevailing standards of decency."
"When any state, let alone a country as powerful as the USA, insists
on its right to adopt a selective approach to international standards, the
integrity of those standards is eroded", Amnesty International continued.
"Why should any other state not then claim for itself the prerogative to
adhere to only those portions of international human rights law which suit
its purposes?"
The USA's attitude to the system of international human rights
protection has continued to cause concern throughout the past year on
areas other than the death penalty:
During 2002, the US has approached governments requesting them to
enter into agreements that they will not surrender US nationals accused of
genocide, crimes against humanity and war crimes to the new International
Criminal Court. In many cases, the US government threatened to withdraw
military assistance from countries that will not agree.
More than 600 detainees held in the US Naval Base in Guantanamo Bay
remain in legal limbo, without access to the courts or lawyers. Some have
been held for almost a year, with no prospect of release or trial. Others
may face military commissions which would flout international standards
for fair trial. Conditions of confinement, in small cells for up to 24
hours a day, with minimal opportunity for exercise, may amount to cruel,
inhuman and degrading treatment and raise serious concern about the well-
being of the detainees.
On 8 November, Amnesty International wrote to the US Government to
express concern about the possible extrajudicial execution of six men in a
car in Yemen, allegedly targeted by a CIA-controlled Predator drone
aircraft.
This time last year, President George Bush proclaimed 10 December as
Human Rights Day in the United States, stressing the importance of the
promotion of human rights around the world and emphasising the USA's
commitment to justice and human dignity.
"A year on, those words are ringing hollow with business as usual for
US executioners, and with the USA's selective approach to international
standards alive and well", Amnesty International said, adding that the USA
should recognize the danger that such an approach poses to global human
rights progress as well as the damage it inflicts on its own reputation
abroad.
The two people who face execution on 10 December are Jerry McCracken
in Oklahoma, and Desmond Carter in North Carolina. Linroy Bottoson could
be executed in Florida today if a judge rules him mentally competent to be
killed.James Collier and Jessie Williams are due to be put to death on 11
December in Texas and Mississippi respectively, and Anthony Johnson and
Jay Neill are scheduled for lethal injection in Alabama and Oklahoma on
Thursday.
Competing interests:
None declared
Competing interests: No competing interests
I am writing to correct a misapprehension of Stephen Hayes, who
posted an earlier comment in response to the article on doctor
participation in U.S. executions, and to offer a brief comment on the
article and some facts related to what he wrote. I am not a doctor, but a
criminal defense lawyer, and I have been an activist against the death
penalty for nearly 10 years, including four years before going to law
school. You may call this bias, but I have befriended people on death
row, people who have been released from death row who were innocent, and
many entirely innocent families or loved ones of those on death row whose
own pain and suffering is intentionally caused by our continued use of the
death penalty. Some of those people are my friends, and it is enraging
that their suffering is caused by the government because of an obviously
broken policy (obviously to anyone who has studied, and unfortunately most
Americans know next to nothing about it), a policy that continues to exist
primarily because of exploitation of the issue by many politicians and
cowardice of many other politicians.
First, to say that most major religions approve of the death penalty
is entirely incorrect, indeed ridiculous. Most religions, at their core,
teach that killing, except in self-defense, is wrong, period (except in
self-defense); to kill after strapping someone down and rendering them
entirely helpless, in front of their family, attorney and other loved
ones, is quite simply torture to all of them. The fact is, almost every
major denomination in the United States, except one or two (Southern
Baptists, and perhaps Mormons) have an official policy statement against
the continued use of the death penalty. This includes Catholicism,
Episcopalians and other Protestant faiths, all forms of Jewish belief, AME
churches, and on and on. Additionally, many smaller faith organizations
have been actively involved in creating or promoting activist
organizations against the death penalty, and spend a great part of their
mission and education on fighting the death penalty (and other forms of
oppression of the poor), including Mennonites, Quakers, the Unitarian
Universalists. For more information on this, and links to the webpages of
such organizations, look at the website for an active North Carolina
organization, People of Faith Against the Death Penalty, www.pfadp.org.
Other educational material and numerous links of interest can be found at
www.cuadp.org.
Second, as to polling, a majority of Americans already support life
without the possibility of parole instead of the death penalty. Polls
that continue to show support for the death penalty are misleading,
because most Americans operate on the incorrect belief or lack of
knowledge that their own states do not have "true" life sentences. In
fact, almost all death penalty states now do have life without possibility
of parole, but most people do not know that and think that without the
death penalty, convicted murderers will all inevitably be released someday
(a few years ago, the District Attorney in Houston, one of the most active
state killing locations -- and he is one of the most active state killers
-- argued in the Texas legislature that Texas should not adopt life-
without-parole as a possible sentence because then it would be harder to
get death sentences!). Polls that take this factor into consideration,
i.e., that ask people their preference between death and LWOP, show that
support for the death penalty then drops below 50%, and a majority support
LWOP.
Third, of course all the people executed were murderers. The
question, though, is whether killing murderers instead of simply
incapacitating them is morally acceptable when modern penal institutions
do make full incapacitation possible. I, like many others, fail to see
any sense in intentionally spreading the pain and suffering caused by
homicides to new innocent survivors -- the young children, mothers,
fathers, brothers, sisters, and other loved ones of those on death row.
This is not an oversight: not only do most states involve doctors in
their chemical suffocation procedures, but they also have explicit legal
provisions allowing usually two family members or other loved ones of the
condemned to be present to witness the execution. The truth is, since
most of those who will endure this suffering are, like those on death row,
overwhelmingly uneducated, poor and disproportionately of minority race or
ethnicity, and therefore powerless, society does not care. If the
deliberately inflicted pain and suffering of executions were being borne
by the upper and middle class, the policy would end overnight.
Finally, what the article does not really discuss is whether the
attempt to be more "humane" is ridiculous as applied to lethal injection.
To say that putting a body to sleep before doing the chemical equivalent
of holding a pillow or plastic sheet tightly over the face makes that
suffocation humane is belied by the actual physical trauma visibly
experienced by many executed bodies (leaving aside the shocking number of
"botched" executions); there is, of course, no way to know, in other
"peaceful looking" cases, how traumatic the suffocation was to the body in
the moments before death. Lethal injection answers the observer's desire
for humane execution; it does not address the trauma experience by the
body, and is likely more traumatic and painful (even if experienced
unconsciously) than many earlier, less "humane" types of killing (one
recently executed inmate in Utah, I believe, chose to be killed by firing
squad, which wasn't illogical given that there is some evidence that such
a death is faster and less painful than lethal injection). I think the
article writer is correct that lethal injection has prolonged the
existence of capital punishment by making those public officials who must
carry it out more comfortable with it, and it is those public officials
who benefit from it politically that are failing to educate the public
about the failures of capital punishment as policy.
Were they less comfortable, they might be more inclined responsibly
to talk about the facts, i.e., that capital punishment serves no general
deterrent purpose, but probably increases the social use of violence as a
way of solving problems; that it costs far more than reliance upon life
sentences entirely because the cost of the initial trial is so much
greater; that it does nothing to reduce harm, but increases pain and
suffering by creating new victims, and delays healing and resolution for
the survivors of the original victims by holding out an illusory promise
of "closure" happening because of seeing somebody killed in their loved
one's name (in addition to the ongoing exploitation of their suffering by
the politicians seeking to uphold the execution in the case); that it
promotes violence and puts public, government officials in the position of
promoting violence, as a way to solve problems; that it is plainly used in
a racially and economically biased way (a black who kills a white person
is about ten times more likely to receive a death sentence than if the
race roles are reversed); that it is almost always used to extinguish
people with serious mental illnesses or borderline intelligence; that it
has been demonstrated to increase risks to police and other law
enforcement; that our criminal justice system has in fact been engineered
in ways that actually make error in capital trial more likely, not less
(for instance, anyone with moral qualms against the death penalty are
stricken from the jury); that it is being administered by a criminal
justice system driven by politics, given that most judges and prosecutors
responsible for the important legal decisions in these cases are elected,
and often run on their records in getting death sentences (yes, even
judicial candidates sometimes brag about the death sentences they have
either overseen at the trial level or upheld at the appellate level); etc.
The list of policy reasons for stopping the death penalty go on and on; in
my state (NC), even though we are in the midst of a severe state budgetary
crisis, politicians won't even discuss the immense savings that getting
rid of the death penalty would bring, because the warped dialogue in this
country on this issue equates support for abolition with being "soft" on
crime, even though there is documentary evidence that abolition would
reduce violent crime rates.
I appreciate that your journal was willing to discuss this issue and
publish it when American medical journals continuously fail to address
this problem.
Thank you.
Aaron Edward Carlos
Competing interests:
I am a criminal defense lawyer, and I have worked as an organizer and activist for years (unpaid, through Amnesty and other organizations) against the death penalty. I do not believe that this is what you mean by competing interest, since I have lost money because of my work on the death penalty (not gained) and since its abolition, which I support, would reduce a large pool and field of available criminal defense work. Moreover, since I am a public defender on a government salary, abolition of the death penalty would not affect my income. However, in the interests of full disclosure, I have let you know my work.
Competing interests: No competing interests
Let me make it clear: I am opposed to the death penalty. But the fact
remains that the death penalty does still exist in this country. I
understand that certain physicians want nothing to do with the executions
that result from this policy. But, on the other hand, one of the duties,
and desires, of a physician is to provide comfort and relieve pain and
suffering. While capital punishment is legal, capital torture is not. I
feel that we have a duty, once someone has been ordered executed, to
ensure that the execution takes place in as "humane" a fashion as
possible. The records are ripe with stories of botched executions. Once we
have made the ignominious decision to end a convict's life, we have a huge
responsibility to bring this event about in as "efficient" a manner as
possible, and that is where the role of the physician comes in.
Enthusiasm for that role is not required, but I just do not see how
physicians can walk away from what is, albeit unfortunately, a dirty job
that somebody has to do.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Dr. Groner's article on the complicity of health practitioners in the
death penalty has
rightly aroused considerable discussion, particularly with regard to
ethics and
regulation by professional bodies.
However, it is the position of PHR-UK that all existing methods of
carrying out the
death penalty violate human rights, because they amount to cruel, inhuman
or
degrading punishment. As such, States that are parties to such UN human
rights
treaties as the International Covenant on Civil and Political Rights or
the
Convention against Torture can be held accountable before some of the most
respected international human rights bodies. China, the United States and
other
death penalty States are parties to such treaties.
PHR-UK is currently working to bring its medical expertise to bare on the
decisions of core human rights treaty monitoring committees.
Anyone
wishing to
help or find out more about how modern methods of execution violate human
rights is welcome to contact the undersigned.
Yours Sincerely,
Dr. Peter Hall,
MBBS, MRCPI, DGM
Chair, Physicians for Human Rights-UK
Competing interests:
None declared
Competing interests: No competing interests
In my posting of 4th November, ‘Rogue nation…etc’, I mentioned the
likely approach of the US Justice Department to the prosecution of the
Beltway snipers – man and boy.
At the helm of this department is Attorney General John Ashcroft, a
man who impresses with his power and stature. An ardent and enthusiastic
supporter of the death penalty this gentleman has been shameless in his
pursuit of capital vengeance for both man and boy in Virginia, a state
second only to Texas in the number of adults and juveniles executed.
Maryland with the most murders on its soil came nowhere in the prosecution
stakes because it is slow to execute and doesn’t kill children. With
political astuteness, characteristic arrogance and a complete contempt for
international law this charming gentleman will achieve his wish. He will
give the people what they want.
The 17-year-old will be tried as an adult, facing the death penalty
in Virginia. Already this youngster is a ‘dead boy walking’ but with a
long hike to the physicians needle. It is quite likely to emerge that he
was controlled by a dominant older man, a man with a deep psychological
hold over his young protégé. Do you sentence a manipulated and abused
child to death? You do in the moral wasteland that is America today.
Competing interests:
None declared
Competing interests: No competing interests
Jonathan I Groner is both wrong and mischievous to liken doctors who
assist with executions to those doctors who helped the Nazis.
A far better analogy is to compare capital punishment with abortion –
both are sensitive issues, which some doctors support and others abhor.
However, all doctors have the right to their own moral judgement on such
matters, and should not be prevented from making their judgements by their
professional body.
A large majority of people in the UK (as in the US) is in favour of
capital punishment (there are no executions in the UK because British
politicians choose to ignore this statistic). This large majority will
include some physicians, who have every right to assist in an execution
according to the rule of law in a democratic society, if they believe that
their actions will ultimately be of benefit to that society.
The assertion that all doctor-patient relationships are somehow
harmed because some doctors assist in executions is fallacious. The
multitude of doctors and patients within a society will encompass widely
varying moral and political opinions. However, an individual patient’s
relationship with a doctor is centred only upon that patient’s medical
condition.
Ian R Cramp
Consultant engineer
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
It was very interesting to read the article of Groner, lethal
injection : a stain on the face of Medicine(1). I was surprised to know
that during 2001, 65 people were executed in the USA by the use of lethal injections which
were given by doctors and nursing staff. Is that the job of the medical
profession?(2)Definitely not. It will change the public image of doctors and nursing staff, their main function being to save lives and
relieve suffering.
References
1.Groner.J.I,Lethal injection:a stain on the face of
Medicine,BMJ,2002;325:1026-1028.
2.Al-Sheikhli,A.K,Is that the job of Medical
profession?,BMJ.com/cgi/eletters/322/7301/1553/a#1534/27th june 2001
Competing interests:
None declared
Competing interests: No competing interests
Monsters Ball
In my posting of 5th November last year (America, eugenics and the
Nazis) I refered to a paranoid schizophrenic called James Colburn who was
to be executed by the state of Texas the following day. Readers may have
wondered what happened to this man.
He is still alive - for the moment.
As is the custom in Texas, the execution was booked for 6pm and a
stay had been routinely denied by the US Supreme Court the day before. At
5.59pm a 'last minute' appeal was accepted by Antonin Scalia one of the
nine esteemed gentlefolk of America's highest court.
This was a welcome but surprising development as Justice Scalia, a
devout catholic is known to be an ardent supporter of the death penalty.
This is the man who a few years ago in a ruling upholding a Texas law
that put a thirty day limit on the raising of new evidence after a death
sentence is handed down wrote: "Americans have no constitutional right to
present evidence of innocence brought forward after conviction." This was
a breathtaking judgement from a man appointed with a life time tenure to
the court that selected the latest Texan incumbent of the White House and
in whose gift such appointments lie.
James Colburn does not claim to be innocent but he is mentally ill
and has been in and out of the prison psychiatric ward during his lengthy
stay on death row. Last week the Supreme Court, without comment, lifted
the stay it granted on the 6th November and cleared the way again for the
execution of James Colburn.
The policy director of the Texas chapter of the National Alliance for
the Mentally Ill was quoted as saying: "the drugs Colburn gets make him
sane enough to be executed. They are developing a synthetic sanity in
order to execute him. Most of us have a problem with that". Not it seems
the Texas judicial authorities, the medical authorities or the US Supreme
Court. God help them!
Competing interests:
None declared
Competing interests: No competing interests