To the Editor: In his discussion of why some physicians participatein executions (March 23 issue),1 Gawande makes contradictoryand thus unpersuasive statements. Although he believes that"some human beings . . . do such evil as to deserve to die,"he still would like "a legal ban on the participation of physicians. . . in executions." His reason, that "the medical assistanceprovided primarily serves the government's purposes," overlooksthe reality that in the United States, "the government" is usand prisoners are executed by "we the people." I do not personallyfavor, nor do I participate in, executions, but until the lawchanges, I believe we owe it to the condemned to ensure thatthey die quickly and painlessly; doing so serves the interestsof both the prisoner and society.
Gawande also says "the government actively subverts core ethicalprinciples of medical practice." How so? Government merely asksphysicians to make an independent decision to help; there isno coercion whatsoever.
Finally, the guidelines of the American Medical Association(AMA) are equally illogical. Their policy that pronouncing deathis unethical but certifying it is ethical seems a rationalizeddistinction without a difference.
Lawrence I. Bonchek, M.D. Lancaster General Hospital Lancaster, PA 17603
References
Gawande A. When law and ethics collide -- why physicians participate in executions. N Engl J Med 2006;354:1221-1229. [Free Full Text]
To the Editor: The AMA forbids physicians to participate inexecutions or to pronounce death — unless someone elsehas pronounced it first. This is analogous to shaking one'shead at a hanging while watching it occur. Accepting capitalpunishment in principle means accepting it in practice, whetherby the hand of a physician or anyone else. If one approves ofcapital punishment in principle (as I do), then one must acceptits practical consequences. If one finds the practice too brutal,one must either reject it in principle or seek to mitigate itsbrutality. If one chooses the latter option, then the participationof physicians seems more humane than delegating the deed toprison wardens, for by condoning the participation of untrainedpeople who could inflict needless suffering that we physiciansmight have prevented, we are just as responsible as if we hadinflicted the suffering ourselves. The AMA position should bechanged either to permit physician participation or to advocatethe abolition of capital punishment. The hypocritical attitudeof "My hands are clean — let the spectacle proceed" onlyleads to needless human suffering.
Bruce E. Ellerin, M.D., J.D. New York University School of Medicine New York, NY 10016 bee2{at}nyu.edu
To the Editor: Gawande refers to the cases of Timothy McVeighand Saddam Hussein to support the view that capital punishmentcan be justified. However, the first concern should be not thenumber of people allegedly murdered by the suspect but the probabilitythat the suspect actually committed the crime. Between 1995and 2005, 741 people were executed in the United States, andthere are at least six well-documented cases of wrongful executions.1
Physicians demand great stringency from a diagnostic process.An obvious reason is that treatment (such as chemotherapy) maycause harm and may even be lethal. In these circumstances, specifictests are applied. A murder trial may be viewed as a diagnosticprocess. If the consequence of the verdict is the death penalty,which has an associated mortality of 100 percent, we do notunderstand why a physician should abandon the strong ethicalstandards in matters of life and death that humanity expectsfrom medicine. In view of the moderate specificity of the justicesystem, we do not believe it is justifiable for a physicianto support capital punishment.
Cornelis Kramers, M.D., Ph.D. Jaap Deinum, M.D., Ph.D. Radboud University Nijmegen Medical Center 6525GA Nijmegen, the Netherlands c.kramers{at}pharmtox.umcn.nl
To the Editor: Lethal injection is not designed to be a humanemethod of execution; it is designed to appear to be a humanemethod of execution. Why else would there be a need for pancuroniumwhen the dose of either thiopental or potassium alone wouldbe lethal? The pancuronium ensures that a person in severe paincannot demonstrate this fact to witnesses.
A humane method of execution is an oxymoron. The deliberatekilling of a human being is always a brutal and violent act.The argument that the death penalty deters murder is so discreditedthat death-penalty supporters do not even bother to make itanymore. Therefore, the only justification for the death penaltyis a desire for vengeance. Death-penalty supporters want tohave their cake and eat it too. They wish to satisfy their bloodlustbut still claim to be humane. By participating in executions,physicians would merely help them to achieve this end.
Robert J. Yaes, M.D., Sc.D. 15 Quantum Place Gaithersburg, MD 20877
To the Editor: The position of the AMA is clear that participationof physicians in executions in any way is unethical, and thisstance has been endorsed by state medical societies, boardsof medical examiners, and all medical organizations that havetaken a position on the subject. What is lamentable is the absenceof disciplinary sanctions against licensees. As Gawande pointsout, physicians who violate this ethical precept almost alwayshide their identity, and states help them do so. I suspect thatmany of the 17 states that require physician participation actuallyhonor that requirement in the breach, since it is getting harderto find willing physicians. For a 2001 execution in New Mexico— the only execution carried out in the state during thepast 45 years — an execution team was imported from Texas,and the names, titles, and qualifications of its members werekept secret. When law and ethics collide, the law should bechanged.
Steven S. Spencer, M.D. 2154 Calle de Sebastian Santa Fe, NM 87505
Dr. Gawande replies: Bonchek does not perceive a conflict betweena physician's core commitment (and oath) to serve the interestsof human beings as individual persons and serving the purposesof the government by assisting in the execution of human beings.He further argues that there is little reason to be concernedabout the use of physicians for governmental purposes, sincewe live in a democracy — the purposes of the governmentare therefore our purposes as a people, he says. These are oddpositions to take. If the government asks us to perform medicalprocedures against a person's wishes and interests, the ethicalproblem ought to be clear — and knowing that the requestis "the people's will" does not erase it. Some persons may commitevils so terrible that they morally forfeit their right to live,but as physicians we nonetheless have a commitment not to useour skills for punishment. That is the conundrum I sought tograpple with. I concluded that society's need for doctors tostay true to the fundamental principles of the profession shouldbe paramount. When the government mandates that a punishmentmust involve physician participation, however, and it providesanonymity, money, and protections against challenges to thephysician's licensure in order to achieve it, it is difficultto see how this is not active subversion of those principles.
The letters from Bonchek and Ellerin also criticize the ethicscode of the AMA that permits a physician to certify death (i.e.,to sign a death certificate) after an execution but not to pronouncedeath. The AMA is capable of defending itself. I will just pointout that the AMA ethics code forbids physicians from attendingan execution in a medical capacity for any purpose — pronouncingdeath, signing a death certificate, or otherwise. It permitsonly signing a death certificate (or performing an autopsy)in a medical setting.1 The act is in this way notably distinctfrom pronunciation of death at an execution.
Atul Gawande, M.D., M.P.H. Harvard School of Public Health Boston, MA 02115
References
Council on Ethical and Judicial Affairs. 1992 Code of medical ethics: current opinions. Chicago: American Medical Association, 1992.
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