LETHAL INJECTION: THE MEDICAL CHARADE

Ethics & Medicine, Summer 2004 by Groner, Jonathan I

How in God's name can there be a showing of cruel and unusual punishment by the insertion of a medically accepted device to inject a fluid into the body?

-Daniel J. Porter, District Attorney, State of Georgia v. Michael Wayne Nance

Introduction

Lethal injection-the intravenous administration of a tranquilizer, a muscle relaxant, and cardioplegic agent for the purpose of judicial execution-is the standard method of capital punishment in the United States. Since 2001, lethal injection has been used in 189 of 191 (99%) executions1 and is the chief method of execution in 37 of the 38 states that have the death penalty, as well as for the federal government and military.2

The American Medical Association's (AMA) opinion on capital punishment is found in section E-2.06 of its Code of Medical Ethics.3 The AMA states that "A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution."3 Participation is defined to include "monitoring vital signs on site or remotely (including monitoring electrocardiograms); attending or observing an execution as a physician; and rendering of technical advice regarding execution." Because pronouncing death requires a physician to monitor an inmate's vital signs, either via electrocardiogram or stethoscope, it is, therefore, forbidden by the code.4 Certifying death, which does not require monitoring but does require the physician to sign a death certificate, is allowed in the AMA guidelines.4

Opinion 2.06 also makes specific reference to lethal injection, and forbids the following: "selecting injection sites; starting intravenous lines as a port for a lethal injection device; prescribing, preparing, administering, or supervising injection drugs or their doses or types; inspecting, testing, or maintaining lethal injection devices; and consulting with or supervising lethal injection personnel."3

According to its position papers, the American Osteopathic Association (AOA), which represents osteopathic physicians in the United States, "deems it an unethical act for any osteopathic physician to deliver or be required to deliver a lethal injection for the purpose of execution in capital crimes."5

The American Nurses Association (ANA) also forbids its members from participating in lethal injection, and, in 1996, joined the AMA in calling upon "all health care professional societies to ensure that their members know and understand that participation in an execution is a serious violation of ethical standards."6

In a 1994 book entitled "Breach of Trust," the American College of Physicians, along with several human rights groups, warned that the system of capital punishment was increasingly using "the medical profession's evaluative skills and therapeutic techniques to...legitimate the act of killing."7 However, since this book was published, over 500 lethal injections have taken place. The participants in these executions, along with their qualifications, are often hidden from public view. In 2002, the constitutionality of lethal injection was challenged in the case of State of Georgia v. Michael Wayne Nance, and execution participants were subpoenaed to testify under oath. The hearings provided a detailed description of six lethal injection executions. The purpose of the present study is to compare the actions of medical professionals in those executions against the AMA's ethical code.

Methods

The transcript of State of Georgia v. Michael Wayne Nance is a public record of the testimony and evidence presented between April 30 and May 1, 2002, in the Superior Court, Gwinnett County, Georgia, USA. The files consist of 381 pages of testimony and 509 pages of exhibits, including "death watch" logs, last meal requests, pharmacy records, professional licenses of the participants, and the routine paperwork associated with executions at the Georgia Diagnostics and Classification Center (GDC) in Jackson, Georgia, USA. The transcript was reviewed in order to compare the conduct and actions of the physicians and nurses during lethal injection executions to Opinion 2.06 of the AMA's Code of Ethics. The ANA has not specifically delineated "disallowed" actions; however, because the AMA and ANA share a mutual position on participation in lethal injection, the same standard was used for evaluating the conduct of the nurses present at the executions.

Results

Health care to inmates at GDC is provided by Georgia Correctional Health Care (GCHC), a division of the Medical College of Georgia. The medical professionals who participate in executions performed at GDC are employees of GCHC, with the exceptions of Timothy Harden Jr., MD, who was hired before GCHC was awarded the contract for prison health care and was employed directly by the prison, and Sanjeeva Rao, MD, a "contract physician" who was paid specifically for his expertise in vascular access.

The physicians performed seven of the eleven activities that are forbidden by the AMA's ethical code (Table 1), and the nurses performed five of the eleven prohibited actions (Table 2). In two cases, the testimony about the role of the physicians was particularly noteworthy. In the execution of Ronald Spivey (executed January 24, 2002), a physician (the testimony does not make clear which specific doctor was present) ordered a second dose of intravenous potassium chloride after the first round of drugs failed to result in cessation of cardiac electrical activity. In the execution of Jose Martinez High (November 6, 2001), the nurses were unable to find veins for intravenous lines despite multiple attempts. Therefore, Dr. Rao, a board certified critical care physician, performed a right subclavian vein catheterization in order to carry out the execution.