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Ethical Prohibition Against Physician Participation in Capital Punishment

      David Waisel, MD,
      • Waisel D
      Physician participation in capital punishment.
      noted in his commentary that “humane methods of executions should be sought and applied.” Although we agree that this is an appropriate goal of those working to ensure just and humane executions, the remainder of Waisel's commentary promotes something that should not be done regardless of a physician's personal beliefs: physician participation in executions.
      The American Medical Association (AMA) has a long-standing policy on capital punishment that has been adopted by many state and specialty societies and some medical licensing authorities. The Code of Medical Ethics of the American Medical Association is clear about physician participation in capital punishment: “An individual's opinion on capital punishment is the personal moral decision of the individual. A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”
      • American Medical Association Council on Ethical and Judicial Affairs
      E-2.06 Capital punishment.
      None of the justifications offered by Waisel are sufficient to outweigh the basic ethical foundation of the current AMA policy. Indeed, his arguments, if accepted, place physicians in a role antithetical to their education and training. The current national discussion on lethal injection demonstrates the central role that ethics must play in our commitment to the profession of medicine.

      The Short Slope To Assisted Suicide

      The actions taken by Nazi physicians during World War II are an anomaly in the recent history of medicine. Their unethical experiments and cruel treatment of patients are in steep contrast to the medical profession's ethical commitment to maintain life and not cause harm. The American medical profession's participation in executions could be the first step in a long slope that leads to such reprehensible perversion of the physician's role. Clearly, we must not go there.
      Physician participation in lethal injection is, however, a short step toward physician-assisted suicide, which is already permitted in Oregon. The link between lethal injection and physician-assisted suicide is much closer than that of lethal injection and Nazi atrocities. Yet, Waisel does not address this topic, choosing instead to focus on the slippery slope leading to Nazi Germany.
      The Code of Medical Ethics of the AMA also considers physician-assisted suicide to be unethical for many of the same reasons as participation in capital punishment. Primarily, it puts physicians in the role of causing or assisting in the intentional death of a person, and this is unacceptable. If it became ethically permissible to cause the death of a person through execution, it would then become untenable to argue against the same action when the death is voluntary, rather than government mandated. Assisted suicide is the much shorter and more dangerous slope that the profession must be concerned about if physician participation in lethal injection is allowed.

      Public Trust

      One basis for the prohibition on physician participation in capital punishment is that the public and, more importantly, individual patients may lose trust in the profession. If physicians are viewed as facilitators of death, patients might not believe that their physicians are always acting in their best interests.
      The past examples of medical disgraces cited by Waisel—the Tuskegee Syphilis Study, radiation experiments, and the Sunbeam incident with the AMA—are accurately depicted as having harmed public trust in the profession. Nonetheless, the fact that physician participation in executions may not harm the public trust more than these other incidents, as argued by Waisel, is not a valid reason for permitting physician involvement.
      The early to mid-20th century is often used as an example of what modern medicine should not do, and for good reason. However, changes in consent procedures for medical experimentation and treatment, as well as the widespread public knowledge of past errors, should make us increasingly hesitant to place physicians in the position of breaching public trust. Our views on individual rights and government limitations have been dramatically altered during the past 60 years, and we must be even more vigilant than ever in preventing the erosion of public trust.
      Even if physician involvement in lethal injection proved less injurious to the profession than did these earlier events, any loss of trust could be detrimental to those needing legitimate health care. This is not a result that the profession or society should invite.

      No Need for Physician Participation in Lethal Injection (or Lethal Injection, for That Matter)

      Lethal injection is a recently devised method of execution, not an intrinsic requirement of a sentence of capital punishment. Past methods in the United States have included hanging, firing squad, electrocution, and lethal gas. Each of these methods had flaws, leading to the acceptance of lethal injection as the primary means of execution today.
      Waisel suggests that competent people must participate in lethal injections to ensure humane executions—the most competent people being physicians. Although others could be trained by physicians, Waisel recognizes that even this limited use of physicians violates ethical standards. Hence, he argues, it is only physicians who can prevent pain associated with executions.
      Physicians could arguably be the best trained to ensure a proper and painless execution, but this is not the intent of their education and training. Nor should physicians' expertise be applied to this use. Physicians are often considered the most qualified to perform other acts—such as assisted suicide, euthanasia, and the design of or participation in interrogation—but this does not mean they should do so. The possession of a special set of skills does not imply license to use them in any manner.
      The solution to ensuring painless and humane executions is not to ask physicians to alter their ethical standards. Such a solution merely exchanges one problem for a potentially larger one. Policymakers, rather than physicians, must design a method that meets legal requirements and does not erode the foundation of the profession.

      Ethics: The Foundation of the Profession

      The purpose of an ethical code for a profession is to set forth guidelines that apply to all members of the profession. It is not one or a few physicians who determine these standards, but the profession as a whole. Although individual physicians may not agree with the ethical standards set forth by the profession, part of being a physician is abiding by all these guidelines, not just those that the physician agrees with.
      The profession must also enforce these standards as an obligation of professional autonomy to ensure that those who are unqualified or who act illegally or unprofessionally do not harm patients. Ethical standards, of which the Code of Medical Ethics of the AMA is the most comprehensive compilation, further this requirement of self-regulation and serve to protect patients in a way that laws and regulations cannot.
      The ability to set and enforce ethical standards is paramount to the basic functioning of medicine. In large part, the patient-physician relationship relies on trust. As noted previously, patients must be comfortable sharing intimate details for medical care to be most effective. Ethical standards provide assurance to patients that their physician is acting in their best interest.
      In the case of lethal injection, adherence to ethical standards is paramount. Medicine is a profession of beneficence: the health and safety of the patient are the primary duties.
      • American Medical Association
      Principles of medical ethics: Principles I and VIII.
      Although it is understandable that physicians would want to assist individuals at the end of their lives, physicians have no role in executions. There is no justification for allowing an exception to ethical standards for lethal injection; doing so would discredit the ethical foundation of the profession and could cause the loss of trust of those whom physicians are charged with helping and protecting.


      Physician participation in capital punishment is unethical. This has been clear since the first Opinion on this matter appeared in the Code of Medical Ethics of the AMA in 1980.
      • American Medical Association Judicial Council
      The Opinion has been revised a number of times in the 27 years of its existence to address questions not answered in previous versions. In its current form, the Opinion provides specific guidelines regarding what physicians are and are not permitted to do to assist in carrying out a sentence of capital punishment.
      • American Medical Association Council on Ethical and Judicial Affairs
      E-2.06 Capital punishment.
      Waisel proposes that this policy be altered once again, but in a direction it has never taken: to permit physician participation in lethal injection. Although we welcome this discussion as a means to further educate physicians about their ethical obligations, no rationale advanced by Waisel overrides the basic premise for the prohibition. Physicians are healers, not executioners.
      To ask the profession to reconsider a core concept of ethics could have far-reaching effects beyond just capital punishment. Many other ethical standards are based on the same reasoning: physicians are obligated to alleviate pain and prolong life, not hasten death. To diminish or alter the effect of one standard can have unintended consequences on others, as well as on the profession's ability to police the behavior of physicians and, in the end, to ensure the safety and best interests of patients.
      Physicians must resist these calls to participate in lethal injection. Although it is easy to view the provision of comfort, appropriate in some venues, as a duty of physicians, it is simply not ethical to participate in an action that has as its sole purpose the death of an individual. The responsibility of ensuring that punishment is legally carried out is not the medical profession's, and physicians should not be asked to sacrifice their ethics by participating in an action so antithetical to the basic precepts of medicine. The public, as well as the government, must recognize that ethical standards exist for their protection.


        • Waisel D
        Physician participation in capital punishment.
        Mayo Clin Proc. 2007; 82: 1073-1080
        • American Medical Association Council on Ethical and Judicial Affairs
        E-2.06 Capital punishment.
        in: Code of Medical Ethics of the American Medical Association. 2006/2007 ed. American Medical Association, Chicago, Ill2006: 19-20
        • American Medical Association
        Principles of medical ethics: Principles I and VIII.
        in: Code of Medical Ethics of the American Medical Association. 2006/2007 ed. American Medical Association, Chicago, Ill2006: xv
        • American Medical Association Judicial Council
        Report A-A-80. Capital punishment.
        (Published 1980. Accessed November 27, 2007.)