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SCIENCE POLICY: PHYSICIANS AND EXECUTIONS

The following points are made by Atul Gawande (New Engl. J. Med. 2006 354:1221):

1) On February 14, 2006, a U.S. District Court issued an unprecedented ruling concerning the California execution by lethal injection of murderer Michael Morales. The ruling ordered that the state have a physician, specifically an anesthesiologist, personally supervise the execution, or else drastically change the standard protocol for lethal injections.[1] Under the protocol, the anesthetic sodium thiopental is given at massive doses that are expected to stop breathing and extinguish consciousness within one minute after administration; then the paralytic agent pancuronium is given, followed by a fatal dose of potassium chloride.

2) The judge found, however, that evidence from execution logs showed that six of the last eight prisoners executed in California had not stopped breathing before technicians gave the paralytic agent, raising a serious possibility that prisoners experienced suffocation from the paralytic, a feeling much like being buried alive, and felt intense pain from the potassium bolus. This experience would be unacceptable under the Constitution's Eighth Amendment protections against cruel and unusual punishment. So the judge ordered the state to have an anesthesiologist present in the death chamber to determine when the prisoner was unconscious enough for the second and third injections to be given -- or to perform the execution with sodium thiopental alone.

3) The California Medical Association, the American Medical Association (AMA), and the American Society of Anesthesiologists (ASA) immediately and loudly opposed such physician participation as a clear violation of medical ethics codes. "Physicians are healers, not executioners," the ASA's president told reporters. Nonetheless, in just two days, prison officials announced that they had found two willing anesthesiologists. The court agreed to maintain their anonymity and to allow them to shield their identities from witnesses. Both withdrew the day before the execution, however, after the Court of Appeals for the Ninth Circuit added a further stipulation requiring them personally to administer additional medication if the prisoner remained conscious or was in pain.[2] This they would not accept. The execution was then postponed until at least May, but the court has continued to require that medical professionals assist with the administration of any lethal injection given to Morales.

4) This turn of events is the culmination of a steady evolution in methods of execution in the United States. On July 2, 1976, in deciding the case of Gregg v. Georgia, the Supreme Court legalized capital punishment after a decade-long moratorium on executions. Executions resumed six months later, on January 17, 1977, in Utah, with the death by firing squad of Gary Gilmore for the killing of Ben Bushnell, a Provo motel manager. Death by firing squad, however, came to be regarded as too bloody and uncontrolled. (Gilmore's heart, for example, did not stop until two minutes afterward, and shooters have sometimes weakened at the trigger, as famously happened in 1951 in Utah when the five riflemen fired away from the target over Elisio Mares's heart, only to hit his right chest and cause him to bleed slowly to death).[3]

5) Hanging came to be regarded as still more inhumane. Under the best of circumstances, the cervical spine is broken at C2, the diaphragm is paralyzed, and the prisoner suffocates to death, a minutes-long process. Gas chambers proved no better: asphyxiation from cyanide gas, which prevents cells from using oxygen by inactivating cytochrome oxidase, took even longer than death by hanging, and the public revolted at the vision of suffocating prisoners fighting for air and then seizing as the hypoxia worsened. In Arizona, in 1992, for example, the asphyxiation of triple murderer Donald Harding took 11 minutes, and the sight was so horrifying that reporters began crying, the attorney general vomited, and the prison warden announced he would resign if forced to conduct another such execution.[4] Since 1976, only 2 prisoners have been executed by firing squad, 3 by hanging, and 12 by gas chamber.[5]

6) Electrocution, thought to cause a swifter, more acceptable death, was used in 74 of the first 100 executions after Gregg. But officials found that the electrical flow frequently arced, cooking flesh and sometimes igniting prisoners postmortem examinations frequently had to be delayed for the bodies to cool and yet some prisoners still required repeated jolts before they died. In Alabama, in 1979, for example, John Louis Evans III was still alive after two cycles of 2600 V; the warden called Governor George Wallace, who told him to keep going, and only after a third cycle, with witnesses screaming in the gallery, and almost 20 minutes of suffering did Evans finally die.[3] Only Florida, Virginia, and Alabama persisted with electrocutions with any frequency, and under threat of Supreme Court review, they too abandoned the method.

References (abridged):

1. Michael Angelo Morales v. Roderick Q. Hickman, No. C 06 219 JF, (Dist. Ct. Northern Dist. of Cal. February 14, 2006)

2. Michael Angelo Morales v. Roderick Q. Hickman, No. CV 06 00926 JF (9 th Cir. February 20, 2006)

3. Trombley S. The execution protocol: inside America's capital punishment industry. New York: Crown, 1992

4. Solotaroff I. The last face you'll ever see: the private life of the American death penalty. New York: HarperCollins, 2001:7

5. Death Penalty Information Center execution database. (Accessed March 1, 2006, at http://www.deathpenaltyinfo.org/executions.php

New Engl. J. Med. http://www.nejm.org

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