Correspondence
Participation of Physicians in Capital Punishment
N Engl J Med 1994; 330:935-937March 31, 1994
- Article
To the Editor:
In their article (Oct. 28 issue)1 on the participation of physicians in capital punishment, Truog and Brennan argue that “involvement in capital punishment is grounds for revoking a physician's license.” Adopting this view could lead to the revocation of a license because of involvement in other legal activities that may not be endorsed by the majority of physicians. I personally have no desire to participate in an execution. However, capital punishment is legal in some states. . . .
If we follow the authors' argument, physicians in the future may risk losing their licenses for performing abortions or being involved in vivisection -- two activities that are legal at present but that are highly controversial ethically and are vehemently opposed by some members of the profession. The cost of a free society is that we must accept behavior by others that does not necessarily agree with our own ethical position. Let participation in capital punishment remain an individual physician's choice.
1 ReferencesAndrew M. Knoll, M.D.
State University of New York, Syracuse, NY 132101
Truog RD ,Brennan TA . Participation of physicians in capital punishment. N Engl J Med 1993;329:1346-1350
Full Text | Web of Science | Medline
To the Editor:
Truog and Brennan marshal their arguments by calling on historical precedents. Hippocrates's dictum “First, do no harm” is cited and discussed, as are euthanasia and Nazi atrocities. In evoking Hippocrates one must acknowledge that his views evolved, like the ethics of his society. The Hippocratic oath proscribes physicians from performing abortions (“Nor will I give a woman a pessary to procure abortion”). . . . In addition, some arguments are not necessary to pursue. Comparing capital punishment in the United States with the atrocities of the concentration camps belittles the memories of those who survived the Holocaust.
Alan Berkenwald, M.D.
Medical West Associates, Chicopee, MA 01020To the Editor:
Truog and Brennan single out capital punishment for the application of ethical standards and principles, whereas they make a passing comment that euthanasia is different. I find this difficult to accept. Surely, if there is an ethical problem with doctors killing humans, it should apply in all situations.
The authors also appear to accept the idea that if the medical profession absolves itself of responsibility, other professions are expected to take on that responsibility. It would have been more practical to argue for the complete abolition of capital punishment rather than to mount an ethical argument that protects the doctor from the difficulties of taking part in legal killing while allowing the nursing profession or another profession to take on the task of terminating the life of a fellow human being.
Robert G. Batey, M.D.
John Hunter Hospital, New Lambton Heights, NSW 2305, AustraliaTo the Editor:
The basic question is whether a profession has the right to make rules governing the practice of its craft that its members are obliged to follow regardless of their personal opinions and the desire of the state. As Truog and Brennan note in the case of capital punishment, the issue is not the individual opinion of a physician in the role of a lay citizen, but rather the behavior of a person acting in an official capacity as a certified member of the medical profession.
A profession is a secular organization that creates and sustains a set of ethical principles designed to protect the integrity of its practice and its relationship with its clientele. Many principles merely reiterate what the law and everyday morality demand, but the most distinctive deal with issues stemming from the practice of a particular, specialized craft for which neither law nor everyday morality provides adequate guidelines. Central to medicine is the need to limit the way physicians may use their potentially lethal, specialized knowledge and skill in order to protect the relationship of the profession as a whole with its clients. If the profession does not enforce such a basic ethical principle, it ceases to govern itself and becomes a passive instrument of the state.
Professional associations in medicine have an obligation to make an official protest every time the state requires the participation of physicians in activities that have been declared unethical. Professional associations also have an obligation to press licensing boards to discipline physicians who do participate in such activities, even though that may raise difficult issues of rights under the 14th Amendment. To do anything less is to confirm the view of the critics of medicine that its ethical code is mere window dressing for self-interested privilege and that the profession must be stripped of what independence it has left.
Eliot Freidson, Ph.D.
New York University, New York, NY 10003To the Editor:
Truog and Brennan assert that physicians should not be permitted to certify deaths resulting from judicial execution. Presumably, such certification is tantamount to participation and tacitly condones capital punishment. This same logic would make forensic pathologists “participants” in the crimes that result in the homicide victims whose autopsies they perform and whose deaths they certify.
The deaths of those who are judicially executed should receive a medicolegal investigation like that carried out after any other homicide. The aim is not to determine the cause of death (which, in the United States at least, has been dutifully recorded, publicized, and witnessed), but to document the presence or absence of any injuries, drugs, or chemicals that may have been inappropriately administered before or during the execution. The autopsy and death certification help provide answers to allegations of impropriety on the part of corrections personnel.
We concur with both the British1 and American2 Medical Associations that certification of the death of judicially executed persons does not constitute participation by the physician in capital punishment, provided the death is pronounced by others and that the forensic examination is performed some hours later and in a separate facility. The independent, competent examination of judicially executed persons will curb the possibility of human-rights violations against those who are incarcerated.
2 ReferencesCharles V. Wetli, M.D.
Joseph H. Davis, M.D.
Dade County Medical Examiner Department, Miami, FL 331361
British Medical Association. Medicine betrayed: the participation of doctors in human rights abuses. London: Zed Books, 1992:116-7, 200.
2
Council on Ethical and Judicial Affairs, American Medical Association
CrossRef | Web of Science
To the Editor:
Truog and Brennan repeat the myth that hanged subjects “die instantly.” Hanging causes death by hypoxia. Depending on the force generated, this may be due to occlusion of the airway, obstruction of venous return, elimination of arterial-blood flow to the brain, or in a “long-drop” hanging (a free fall of roughly twice the victim's height, designed to cause cervical dislocation), by the elimination of respiratory motion. Paralysis does not immediately affect the subject's mental status, however. I have discussed this with patients who survived high traumatic quadriplegia. I suspect that the victims of judicial hanging suffer both the agony of air hunger and that of traumatic spinal injury for an extended period. Long-drop hanging was not developed primarily to decrease the suffering of the victim, but rather to eliminate the unpleasant thrashing about that accompanied lesser drops; hence, it serves the same basic function as the victim's hood.
Mark Hauswald, M.D.
University of New Mexico, Albuquerque, NM 87131-5246Author/Editor Response
The authors reply:
To the Editor: Knoll worries that by revoking the licenses of physicians for an activity that is legal, we will be starting down a slippery slope whereby physicians may be prohibited from engaging in all controversial activities. We believe, however, that the question of physicians' participation in executions is categorically distinct from the issues of abortion, vivisection, and euthanasia. Every medical organization that has commented on this topic, both in the United States and abroad, has condemned the involvement of physicians in capital punishment. We are unaware of any published reasoned ethical justification for this practice. If this does not constitute sufficient grounds for enforcing a prohibition on involvement by physicians, it is difficult to know what would. None of the views on the other controversial questions mentioned even begin to approach this degree of consensus. By failing to take action on this issue, as Freidson notes, medicine is abrogating its responsibility to establish and enforce the high ethical standards that will continue to merit the respect of our patients and of society.
Wetli and Davis argue that certification of death after an execution should not be construed as “participation.” We noted that certification of death does not require the involvement of a physician in all jurisdictions and asserted that such participation should be avoided because of its symbolic association with the execution. The authors claim that the purpose of certification in these cases is not to determine the cause of death, but to monitor for human-rights violations during the execution process. Before we would change our position, we would have to be convinced that such abuses are a matter of realistic concern, and more important, that the certification process after executions is in fact oriented toward the purposes they claim.
We do not suggest, as Batey implies, that the responsibility for carrying out executions should be shifted to nurses or any other professionals. Indeed, we hope that our colleagues in nursing will adopt our views for their own profession. We do, however, reject the argument that because our society currently sanctions capital punishment, physicians have a responsibility to provide the “service.” This view severely undermines the ethical integrity of the profession and reduces the physician's role to that of technician.
We were reluctant to refer to the Nazi experience for precisely the reasons cited by Berkenwald. The analogy is accurate on many points, however. Refusing to learn from those atrocities would be an even greater affront to the victims of that time.
National and state medical societies should have the conviction to enforce the ethical standards that they themselves have adopted. They should actively support efforts to make participation in executions a reason for the loss of medical licensure.
Robert D. Truog, M.D.
Harvard Medical SchoolTroyen A. Brennan, M.D., J.D., M.P.H.
Harvard School of Public Health, Boston, MA 02115
