Lethal injections: no healthcare professionals should be involved
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2643 (Published 19 May 2010) Cite this as: BMJ 2010;340:c2643
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Dr Weaver raises the question of 'consent' to death by
lethal injection. There are several strands that need
to be unpicked here.
Clearly the executee has no choice about being executed -
that has been dictated by the courts and statutes of
the country concerned. They may have had a choice about the
method of execution (though this is rare in
practice), so may have 'consented' to the mode of execution.
Such consent would not be invalid, though might
be distinctly constrained by the options available.
The executee could have a choice about whether the execution
was supported by a doctor or not, as Michael
Rivlin suggests. Given the various examples of poor
technique by purely technical staff, I would have thought
this could well be ethically justified.
If we compare the situation with administering anaesthetics
to a patient who is unconscious or semi-conscious,
but suffering severe trauma which needs immediate medical
attention. In ethical terms, here is someone who has
no choice of where they are; if untreated, then they will
die in extreme pain, but 'consent' is not possible.
Why would it be appropriate to intervene for such a person
but not the executee?
This is not about 'consent' as in getting a signed document.
It is about doing the decent thing for another
human being, as the 'critical care specialist' example
shows.
However, there is also the question of the clinician's own
'consent'. There is no reason to expect a clinician
to help kill another person if they do not believe that is
their duty - or that they have sworn not to do so.
It seems only right that they should have the choice in
this. While it may seem improper to argue that they should
also be allowed to choose 'positively' to assist in
providing a painless death to another human, it
seems far worse to deny executees proper care in their
death. I would not see it as being the role of a
profession to deny such support to individuals, though they
would also have no reason to condone (or approve
of) capital punishment. Individually, they can campaign
against capital punishment, but as a profession it is
not for them to seek to dictate this.
This last point also has relevance, I believe, in the
question of assisted suicide. Too often the debate is
about the rights of individuals to choose the timing and
mode of their own death, rather than whether doctors
may or may not choose to help them. Or perhaps I am just
missing that debate?
Competing interests:
None declared
Competing interests: No competing interests
Capital Punishment has become medicalised and much of the world has
followed America’s lead. Even China now uses the lethal injection for
dispatching its capital miscreants.
While I sympathise with Michael Rivlin’s point, I believe he misses
the point on doctors’ opposition to partaking in judicial killing.
Potentially, the American medical profession is a powerful force for
abolishing the death penalty and for leading abolition worldwide - and
that is the important point about opposing doctors’ involvement in
executions.
Hanging was finally abolished in the UK in 1966 and the last two
hangings occurred simultaneously at 8.00 am on 13 August 1964 in Walton
and Strangeways prisons. The skill required to achieve a quick and
painless death by hanging is not on the medical curriculum anywhere in the
world, even in Britain. However, the British medical profession may have
had some minor influence over abolition, principally when it came to the
question of determining sanity or otherwise.
The M'Naghten Rules from 1843 prohibited the execution of prisoners
who were genuinely insane and,
“at the time of the committing of the act, the party accused was
labouring under such a defect of reason, from disease of the mind, as not
to know the nature and quality of the act he was doing; or, if he did know
it, that he did not know he was doing what was wrong.” [1]
In 1884, the Criminal Lunatics Act allowed every condemned prisoner
to be examined by a prison psychiatrist where there were doubts as to
their sanity. Psychiatrists reported secretly to the Home Secretary and
the prisoner was reprieved if not found to be wholly sane, irrespective of
the nature of the crime or their sanity at the time of committing it. Many
of those reprieved this way – and there were many – had either not pleaded
insanity at their trial or had not had their plea accepted by the court.
The British psychiatrist thus had enormous power over life or death and
could give a ‘thumbs up’ – or ‘thumbs down’ – on an individual and highly
subjective whim.
If there were a united will, American doctors could force abolition
by refusing to participate in the whole tawdry circus of judicial murder,
from beginning to end by lethal injection. The argument for doctor
participation simply forces the conclusion that the American profession
does not want, or expect, capital punishment to be abolished, anytime
ever.
[1] The M'Naghten Rules. Wikipedia.
http://en.wikipedia.org/wiki/M'Naghten_Rules
Competing interests:
None declared
Competing interests: No competing interests
Dr Weaver gives some good arguments in opposing the involvement of
physicians in judicial executions. However, I do not find them persuasive.
(For the record, I am firmly opposed to capital punishment.)
For instance, Dr Weaver writes, 'There is no patient; harm is done on
purpose; and there is no consent. So, no healthcare professionals belong
here'. Dr Weaver is right to make the lack of consent a central argument,
but what if the subject does gives consent, or even implores, the
physician to make the death as painess as possible? Might it not be argued
that there is case for the physician to use his skills to make the death
(which is going to happen whether the physician takes part or not) as
painless as possible? After all, as no doubt Dr Weaver would accept, one
of the duties of a doctor is to to help to alleviate pain and minimise
suffering.
I accept that some might suggest that consent would not be valid as
it is not being given voluntarily. But this might not be the case. The
subject might well fill all the criteria for valid informed consent.
Indeed it is arguable that it is rational for the subject to make such a
request. In any case consent is often given by patients when they are in
extreme situations.
Competing interests:
None declared
Competing interests: No competing interests
Dr Weaver presents the standard and accepted view concerning the
involvement of doctors in execution by lethal injection(BMJ
2010;340:c2643). The New England Journal of Medicine published a number of
papers on this subject in January 2008( Curfman et al NEJM 358:403-404,
Gwande et al NEJM.358:448-451).
The Journal also conducted an anonymous electronic survey on whether
of clinicians should take part in executions. The results only known to
participants in the survey was that 24% believed health care professionals
should take part and 15% indicated they would be willing to participate.
The number of respondents was 1800.
This indicates there is a significant minority prepared to act
against the advice and standard view.
Ian McLellan.
iangasmclellan@btinternet.com
Competing interests:
None declared
Competing interests: No competing interests
Onward Christian soldiers ...
The act of capital punishment is barbarous, repugnant and inhumane
and, of course, no healthcare professional should be involved in such a
thing.
As Mike Weaver says, the American Society of Anaethesiologists and
the American Medical Association (AMA) have been opposed to physicians’
involvement in capital punishment for many years. In February this year,
the American Board of Anaethesiology even stated that “anaesthesiologists
may not participate in capital punishment if they wish to be certified.”
On June 15, the state of Texas executed 59 year old David Powell, 32
years after he murdered a police officer. Surely, three decades of
solitary confinement is punishment enough for any man.
Did the AMA protest the matter?
Thomas Whisenhant also spent 32 years on death row before the state
of Alabama executed him by lethal injection on 27 May 2010.
Did the American medical profession protest the cruelty?
On 16 September 2008, the state of Georgia put to death Jack Alderman
after 33 years waiting to be put to death.
Was there protest from the AMA over such cruel treatment of a human
being?
Last Friday, 18 June, at 12.17 am, Ronnie Lee Gardner was pronounced
dead. For reporters outside the execution chamber, the clue to the fact of
execution was the switch to Debussy on the PA system, from the Eagles,
Phil Collins and Supertramp that had gone before.
Ronnie had been executed by a state of Utah firing squad after 25
years on death row.
On Sunday and again Wednesday, the authorities had allowed Gardner
his first “contact” visits in nearly 27 years. After the deadly deed was
done, Tom Patterson, the state director of corrections, was heard to say,
“This has been an onerous responsibility. Done with absolute dignity and
reverence for human life and also reverence for the other lives that have
been lost at the hands of Mr Gardner.” [1]
No doctor, anaesthesiologist or otherwise, was directly involved in
this final act of capital punishment. Will the AMA protest the
extraordinary savagery?
[1] Debussy, four bullets, a dozen balloons: a Utah firing squad does
its job.
David Usborne, The Independent, Saturday, 19 June 2010.
http://www.independent.co.uk/news/world/americas/debussy-four-bullets-a-
dozen-balloons-a-utah-firing-squad-does-its-job-2004758.html
Competing interests:
None declared
Competing interests: No competing interests