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May 9, 2006

Nature Versus Nurturing the Death Penalty

In a strongly-worded editorial and an accompanying news special report (subscription required), last Thursday’s Nature magazine challenged the humaneness of lethal injections and advocated for continued abstention by the medical community to put an end to the death penalty once and for all.

The special report lays out the issue:
Do no harm. Nearly all US MDs and PhDs recite this three-word oath instinctively when asked why they object to helping with executions. "It violates our ethical oath and erodes public trust," says Priscilla Ray, head of ethics at the American Medical Association (AMA), which prohibits members from participating in executions. Even helping to design a more humane protocol would disregard the AMA code, Ray says. "Formulating a way to kill somebody would violate the spirit of the policy."

As a result of that stance, lethal injections — the dominant method of execution in the United States — are generally carried out by technicians without scientific or medical training, and the protocol does not seem to have been reviewed in 30 years. Typically, prisoners are injected with three drugs in sequence meant to knock out, paralyze and then kill. But many experts are concerned that because of that lack of training, the first drug does not always knock the condemned out properly, leaving him or her paralyzed but excruciatingly conscious as the lungs stop moving, and burning potassium chloride races towards the heart.

The death penalty has quite a bit going against it, from charges of unequal application to different demographics to the sometimes realized nightmare of killing an innocent person. The challenges at hand, though, focus on the suitability of what was supposed to be a more humane alternative to the electric chair: the lethal injection.

One of the most damning indictments of lethal injections as a means of capital punishment came from a 2005 article in The Lancet, which found that 43% of inmates undergoing lethal injection may be conscious when the fatal and excruciatingly painful dose of potassium chloride is delivered, due to insufficient doses of the anesthetic sodium thiopental. The results of the study were considered controversial, though, because they relied solely on postmortem examinations. Regardless, they deserve consideration.

Since I’m writing this from Oxford University, currently at the center of a large animal rights movement, I found the following passage of the Lancet article particularly interesting:
With little public dialogue about protocols for killing human beings, it is pertinent to consider recommendations from animal euthanasia protocols. The American Veterinary Medical Association (AVMA) panel on euthanasia specifically prohibits the use of pentobarbital with a neuromuscular blocking agent to kill animals, and 19 states, including Texas, have expressly or implicitly prohibited the use of neuromuscular blocking agents in animal euthanasia because of the risk of unrecognised consciousness. Furthermore, AVMA specifies that “it is of utmost importance that personnel performing this technique are trained and knowledgeable in anaesthetic techniques, and are competent in assessing anaesthetic depth appropriate for administration of potassium chloride intravenously. Administration of potassium chloride intravenously requires animals to be in a surgical plane of anesthesia characterized by loss of consciousness, loss of reflex muscle response, and loss of response to noxious stimuli”. The absence of training and monitoring, and the remote administration of drugs, coupled with eyewitness reports of muscle responses during execution, suggest that the current practice of lethal injection for execution fails to meet veterinary standards.

(emphasis added)

This is either a dubious victory for the animal rights movement or, more likely, a stunning moral failure on the part of our legal system. The authors of the study draw what seems like the only reasonable conclusion given these circumstances:
Our data suggest that anaesthesia methods in lethal injection in the USA are flawed. Failures in protocol design, implementation, monitoring and review might have led to the unnecessary suffering of at least some of those executed. Because participation of doctors in protocol design or execution is ethically prohibited, adequate anaesthesia cannot be certain. Therefore, to prevent unnecessary cruelty and suffering, cessation and public review of lethal injections is warranted.

In a call for direct medical activism, Thursday’s Nature editorial also calls for physicians to play an active role, through their own inaction, in ending the practice of lethal injection and hopefully dealing the final deathblow to the death penalty in general:
Earlier this year, a California court told state authorities that they must persuade an anaesthetist to oversee an execution, come up with a new protocol for lethal injections — or face a hearing on whether the punishment is inhumane. The last option now looks likely.

If suitably qualified individuals refuse to help prepare a new protocol, the state will face the prospect of continuing to use amateurs to kill people with arbitrary and outmoded technology.

Scientists often abjure political activity, and could in this case argue that they are merely providing a basis from which policy-makers can make decisions. But this decision must be taken by the physicians and scientists themselves. All that is required is a refusal to participate. Men and women of science and medicine should stand shoulder to shoulder on this. Don't advise, don't prescribe, don't inject. Let the death penalty die a natural death.

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