Rethinking Physician Involvement in Lethal Injection
Why physician involvement in the practice must be reconsidered
Since a moratorium on capital punishment was lifted in 1976, the United States of America has executed over 1,500 death row inmates. The majority of these executions have been carried out using 1, 2 or 3-drug lethal injection protocols. In 2021 alone, 11 prisoners in America were executed this way. So far in 2022, 7 have been executed using the method.
Lethal injection, as a means to carry out state-sanctioned executions, was first proposed nearly 50 years ago by Jay Chapman, Oklahoma's state medical examiner. Following public pressure to abandon the use of electrocution in capital punishment, Chapman's injection protocol spread across the country and capital punishment, through its new association with medicine, became respectable once again.
Following its adoption, the standard lethal injection protocol included the use of three fast acting drugs administered intravenously in the inmate's arm. The first, sodium thiopental, acts as a sedative and relaxes the prisoner. Next, a paralytic agent is administered to inhibit skeletal muscle contraction, paralyzing the inmate. Finally, an injection of potassium chloride is administered to induce cardiac arrest, killing the inmate.
Of these drugs, the most controversial remains the paralytic agent, which effectively serves as a behavioral mask during the execution protocol. The use of this drug has led some medical professionals to refer to the lethal injection process as a sort of theatre: "the curtain goes up, the curtain goes down".
With the employment of a paralyzing agent, onlookers are saved the trouble of witnessing an untidy execution in which inmates may convulse or twitch. But as has been noted elsewhere, the use of the paralytic, from the perspective of the inmate, is bizarre as it offers a more human-seeming execution but allows for the possibility, quite literally in this case, of unbearable pain and suffering. Giving the masking quality of the paralyzing agent, its use in traditional modes of end of life care is generally prohibited.
Controversy related to the procurement of specific drugs used in America’s execution chambers has led to changing protocols from state to state. Some, at times, have relied upon large dose single drug protocols. Haphazard approaches along these lines have led to a number of cruel and unusual executions. These cases have thrust the constitutionality of lethal injection practices into the spotlight repeatedly. Ultimately, high courts in the US have sided against the claim that the protocols are unconstitutional.
A vigorously contested component of the debate around lethal injection has involved the role of the physician in the proceedings. While most professional organizations side against involvement, doctors in America have differing views on this question, some arguing that involvement of skilled professionals mitigates risks that the patient may otherwise face in the hands of untrained or under-trained staff.
As I have argued elsewhere, while interesting, this logic rests on the fundamental assumption that the medical profession’s only recourse is to mitigate harm in cases where the state coerces involvement in carrying out its laws.
This is, of course, ethically and factually awry. Physicians have great impact on societal views and on the laws society ushers in. Refusing involvement would place further pressure on the state given how poorly it handles these proceedings, and may shift public sentiment away from favorable views of the practice.
A patient faced with the certainly of execution may well prefer a physician to be present and involved in the procedure to mitigate the risk of suffering. But physician involvement in lethal injection practices simply distorts and disfigures bioethics norms and standards the profession depends on. The prisoner on the receiving end of physician care in this context could never be said to providing informed consent, given that few otherwise healthy inmates in this position actually want to die.
And those who argue that prisoners are not patients in the context of lethal injection need to ask themselves why doctor involvement is so necessary in that case. Of course it is because they are fulfilling fundamental roles related to their profession. I simply suggest that this extend to professional ethics standards.
This issue is a complex one, there is no doubt. But physician involvement in the practice of lethal injection needs to be rethought, given the power doctors have to influence laws, and given the responsibility they have to uphold ethical principles and the public’s trust.
In the 21st century, there is simply no role for medicine in America’s execution chambers. On this question, the profession can and must do better.
The rest of the civilized world gets this. The rest of civilized medicine gets this. It's now time for American society and medical culture to return to a salient ethic on the question of capital punishment.
Dr Dennis E. Curry is a political commentator and resident physician training in Psychiatry.
*An earlier version of this article first appeared in the Huffington Post Blog in 2016.