Doctors don't belong on execution teamBy JONATHAN I. GRONER
A PROCEDURE that should have taken less than 15 minutes - administering a death sentence by lethal injection to convicted killer Joseph Clark of Toledo - instead took the State of Ohio almost an hour and a half.
Although the execution team struggled to place an intravenous catheter (commonly called an "IV") in a vein in Clark's arm, it was Clark himself who first noticed that something was terribly wrong. Three to four minutes into his May 2 execution, Clark felt pain in his arm as the lethal drugs collected under his skin instead of flowing into his vein.
Several times he raised his head and said, "It don't work. It don't work." Prison officials then halted the execution and closed the curtains of the death chamber. The execution team inserted needles at multiple locations on Clark's body in attempts to secure a new IV.
During this 40-minute interval witnesses heard "moaning, crying out, and guttural noises," and Clark even requested an oral dose of poison to end his misery. Finally, a suitable vein was found, a new IV was inserted, and Clark was executed again, this time successfully.
Clark's problems were not unique. Despite assertions that lethal injection is as easy as "just going to sleep," many lethal injection executions have gone awry. Several inmates have been subjected to the same "needle torture" as Clark, and a few have reacted violently to the lethal drugs.
Others have faced "technical problems," including an IV inserted backwards in one case, and the IV tubing coming apart in another.
There is at least one case where an inmate was cut in the groin and ankle - and bled profusely - during an attempt by poorly trained technicians to place an IV through a surgical incision, a procedure known as a "cutdown" in medical terms.
The reason for these complications is that lethal injection uses medical procedures without medical professionals.
Furthermore, Clark's troubles were entirely predictable. Any doctor who has encountered intravenous drug abusers knows that former heroin addicts like Clark, who probably gave himself thousands of injections during his life, often have scarring in all their visible veins and may require the skills of a physician (and sometimes a surgeon) for the simple task of starting an IV.
In fact, in an execution in Georgia in 2000, nurses worked for 45 minutes without success to place an IV in a former heroin addict.
Ultimately, a doctor stepped in to place a "central venous line" (a specialized IV inserted into a large vein that drains directly to the heart) in order to carry out the lethal injection.
So why is it wrong to bring physicians into the death chamber?
That question is being debated in many states, including California, Missouri, and North Carolina.
The American Medical Association has long opposed physician participation in capital punishment, stating that a physician shall not perform "an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned."
The AMA also prohibits "monitoring vital signs on site or remotely (including monitoring electrocardiograms)" at an execution.
Furthermore, the AMA specifically addresses lethal injection, forbidding "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."
The AMA's guidelines are derived from a fundamental tenet of medical ethics: physicians, because of their training in the healing arts, wield enormous power over their fellow human beings.
Therefore, physicians have a social contract with society to use their unique knowledge and skills only for good and never to cause harm.
This concept, often cited as "first, do no harm," has long been a cornerstone of medicine, and has directed the medical profession to work for the benefit of society. Even when a single physician violates these ethical rules, the status of the medical profession is degraded.
During the early years of my surgery career, I thought little about the role of physicians in capital punishment.
That changed in 1997, when Arkansas executed three men on the same night.
Reading about the triple lethal injection, where each inmate lay down on a gurney, had IVs placed in each arm and heart monitor leads on his chest, and was then sent off to eternal sleep with large doses of anesthetic drugs, I was struck by how the proceedings seemed eerily similar to a typical day in the operating room.
In fact, with a little research, I found that virtually all the equipment used in lethal injection, from the heart monitor and stretcher all the way down to the alcohol wipes and medical tape, are the same items I used in the hospital. In fact, an "execution protocol" reads like a medical procedure manual.
Lethal injection, I discovered, turned the instruments that I used to save lives into instruments of death.
When I was a surgery resident, I heard a lecture about Robert Jay Lifton, who studied the corruption of physicians in Nazi Germany. Mr. Lifton described how physicians were recruited by the government to kill physically and mentally disabled patients, including the "criminally insane."
In this program, which predated the death camps, the killing facilities were designed on a medical model, and the killing, whether by poison gas, lethal drugs, or other methods, was supervised by doctors. The euthanasia program's chief administrator often stated, "The syringe belongs in the hand of a physician."
Today, at executions in the United States, doctors are increasingly being asked to hold the lethal syringe.
In Connecticut, for example, a "licensed and practicing physician" must certify the qualifications of the person starting the IV and infusing the drugs; in Missouri, a board-certified surgeon places a central venous line into each inmate before execution, and in California, a judge recently asked that two anesthesiologists monitor the inmate during the lethal injection.
Finally, in numerous states, physicians monitor vital signs or electrocardiograms at executions, even though this is also forbidden by the AMA's ethical guidelines.
Thus, Joseph Clark's execution demonstrates the terrible dilemma of lethal injection as medical charade.
On the one hand, this "medicalized" killing procedure, which uses IV tubing, anesthetic drugs, and other medical equipment, becomes torture in the hands of unqualified individuals.
On the other hand, the involvement of medical professionals such as physicians and nurses in executions violates the fundamental ethics of these professions. When medical professionals forsake their ethics, as the Nazi physicians demonstrated, the results for society can be disastrous.
Accounts of Clark's tortuous execution have appeared in newspapers and other media outlets all over the world.
Surely, there will be calls to bring doctors into the death chamber in Lucasville in order to make executions more "humane."
Do Ohioans really want to choose between torturing inmates to death or putting executions in the hands of doctors? This dilemma is inherent in lethal injection, because it puts killing in the hands of healers.
The only way for Ohioans to avoid this untenable choice is to call for a moratorium on executions until capital punishment can be re-examined.
Jonathan I. Groner is a pediatric surgeon and associate professor of surgery at the Ohio State University College of Medicine and Public Health.