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If convicted murderer Angel Maturino Resendiz, known as the Railroad Killer, is put to death on Tuesday, he will owe his quiet end to medical science. Had doctors not concocted a lethal series of infusions more than 20 years ago, Texas prisoners still would be dying by electrocution.The profession charged with healing has worked to refine the business of killing since French surgeon Joseph Guillotin sought a more civilized execution for the condemned. In the more than 200 years since Dr. Guillotin's name became synonymous with beheading – an "e" was later added to the machine named for him – medical professionals have given guidance in making the death penalty more compassionate, whether by gas chamber, electric chair or, more recently, drugs.
Yet medical ethicists long ago determined this is wrong. Execution, which is hardly in the best interest of the patient, is not the practice of medicine, and doctors are sworn to save lives, not take them. With the latest court challenges to lethal injection – challenges that cite the possibility of significant pain for the immobilized prisoner – the criminal justice system might need medicine's help to keep the death penalty constitutional. Physicians could again find themselves at the nexus of two conflicting values: society's moral and legal obligation to execute without cruelty, and a doctor's sworn obligation to do no harm.
"The basic question is whether medicine has a role in addressing more competent and compassionate ways of executing people," Peter Clark, a medical ethicist at St. Joseph's University in Philadelphia, wrote this spring in the Journal of Law, Medicine and Ethics.
Dr. Clark is a theologian. To him, the answer is clear. "I was appalled that the medical profession was even involved in this," he said in an interview.
Many physicians, though, are more ambivalent. In 2001, a research team described a survey of 1,000 randomly selected doctors from rosters provided by the American Medical Association, the professional society that has unequivocally said involvement in execution is unethical. The doctors were asked whether they would be willing to participate in 10 aspects of lethal injection, eight of which have been deemed wrong for physicians.
To researchers' surprise, 41 percent said they would perform at least one of the actions, which included placing the intravenous lines or supervising the administration of injections.
What about personally giving the final drugs? "I suspected that I'd find that no physician would be willing," said Dr. Neil Farber of Christiana Care Health System in Delaware. Instead, 19 percent said they would.
These doctors usually were not motivated by the belief that they might relieve the suffering of someone who was going to die anyway, Dr. Farber said, though some felt that way. Overwhelmingly, those physicians willing to kill cited their obligations to a state that has said execution is legal and correct.
"They're not seeing it as a conflict," Dr. Farber said. "This is a duty to society."
So it is not that surprising that corrections officials have found physicians willing to participate in capital punishment – some states even require their presence. Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston, recently found four physicians and one nurse who would discuss their reasoning. Dr. Gawande wrote in the New England Journal of Medicine in March that these medical professionals typically didn't make a conscious decision to assume the role of executioner.
"Virtually all of them were brought into the death chamber to pronounce death," he said last week.
Merely being present seems straightforward enough. But executions don't always go smoothly. Technicians can have trouble finding a suitable vein. The dosage of the drug may be inadequate.
"Suddenly all eyes turn to you," Dr. Gawande said.
Their participation was an incremental journey, as in many descents into questionable behavior.
Dr. Gawande supports the death penalty, as do the majority of doctors surveyed. But after talking to those physicians who have witnessed it, he says he began to wonder whether capital punishment is possible without medical supervision.
After 859 lethal injections, it is viewed almost as a rote act. "The trouble is," he said, "there is a large percentage of the time that there is some complication in that regimented approach that requires medical expertise to sort it out."
In 1982, during the first lethal injection in a Texas state prison, two doctors reportedly were on hand only to pronounce death. Yet they were asked advice about the proper injection site, Dr. Gawande said, and the prison official incorrectly mixed the chemicals.
What if a physician finds a heartbeat when it is time to declare a prisoner dead? Offer advice on how to finish him off?
If executions cannot be completed without physicians or nurses, Dr. Gawande believes the death penalty should be abandoned. Tending to the problems of lethal injection is not a doctor's job, he said, and violates public trust. He even would like to see physician involvement legally banned.
"Since the total responsibility for execution rests with the criminal justice system, it's up to the criminal justice system to deal with it," said Dr. Steven Miles of the University of Minnesota Medical School. Dr. Miles has examined the circumstances that lead doctors to have a role in torture and execution.
Corrections officials and the public desire a clinical patina to the administration of the death penalty, he said, largely to make people feel more comfortable. "We're trying to make it sterile," he said. "We're trying to tame execution."
The legal question now is whether it has been tamed enough to meet the requirements set forth in the U.S. Constitution.
Dr. Miles does believe that the current three-drug combination is probably a painful death, masked by an induced paralysis. If prisoners are suffocating, they would have the feeling of being buried alive, he said. If they are improperly anesthetized, the potassium chloride would send a searing pain through the veins as it flowed toward the heart.
As a human being, these scenarios bother him, but as a doctor, he would not offer a solution.
"The question of whether executions should be pain-free is a social policy question," he said, not a medical one.
For that reason, Dr. Arthur Caplan, director of the University of Pennsylvania Center for Bioethics, believes that the profession should excuse itself from the entire debate. If people want flawless executions, he said, then states should create professional executioners.
"The state wants them there," Dr. Caplan said of doctors, "so the state can feel more comfortable."
Dr. Miles puts it this way: If a nation decided to punish adulterers by stoning, it would be wrong for a doctor to give the condemned anesthesia beforehand to lessen the pain. That would send a message of tacit approval and soothe the conscience of those imposing the sentence.
Because a white coat can make capital punishment seem more palatable, some doctors who are involved with executions ultimately find themselves troubled. After the introduction of the guillotine, executions became routine in revolutionary France. Dr. Guillotin grew appalled by his infamy from a killing device. But execution was by then the will of the people, and beyond the influence of medicine.
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