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Should Physicians Participate in Capital Punishment?
Correction: An incorrect number was published on page 1047, third paragraph, left-hand column, fourth sentence. The sentence should read as follows: Six nations (including the United States) permit the execution of children defined as <18 years of age.4
EDITORIAL EDITORIAL
Should Physicians Participate in Capital Punishment?
S
hould physicians participate in capital punishment? Nearly every organized medical and nursing group in the world opposes physician participation in state-ordered executions.1 Despite this near-universal stance against participation, some argue that if executions are to be carried out, then physicians have a legitimate role to play in minimizing “the harm to…condemned individuals.”2 Such an argument contends that physician involvement in executions is morally justified by the duty of compassion toward the person to be killed. Although conceding that no physician is obligated to participate in an execution, the argument holds that “organized medicine has an obligation to permit physician participation in legal execution”2 on the grounds of the duty of mercy to the condemned. To assess the permissibility of physician involvement in state-directed executions on the grounds of mercy, it is necessary to understand where, how, and for what reasons the death penalty is being carried out. Also, it is important to know whether physicians who participate are doing so as agents of trustworthy legal systems, ie, those that ensure that proper execution-related processes are followed. If executions are carried out for blatantly immoral reasons by untrustworthy legal systems, then arguments based on mercy are weakened because the primary duty of the physician should be to stop such executions by all means possible and practical. THE STATE OF THE DEATH PENALTY AROUND THE WORLD The United States had the sixth largest number of executions in the world in 2006 after China, Iran, Pakistan, Iraq, and the Sudan.3 During 2006, at least 3861 people were sentenced to death in 55 countries. At least 1591 people were executed in 25 countries.3 Six nations (including the United States) permit the execution of children (defined as <8 years of age).4 Three economically advanced, industrialized nations (ie, Japan, South Korea, and some states within the United States) permit the death penalty for heinous crimes.3 China permits executions for heinous crimes but also for offenses including tax fraud, political crimes, nonviolent theft, accepting bribes, and minor drug offenses. Libya permits the death penalty for many crimes including the importation of alcohol. Afghanistan permits the death penalty for various crimes including conversion from IsAddress correspondence to Arthur L. Caplan, PhD, Chair, Department of Medical Ethics and Director, Center for Bioethics, University of Pennsylvania, 3401 Market St, Suite 320, Philadelphia, PA 19104-3308 (caplan @mail.med.upenn.edu). © 2007 Mayo Foundation for Medical Education and Research
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lam to another religion. Iran permits the death penalty for murder and also for adultery, homosexuality, and operating a brothel.3 Worldwide, the following methods are allowed in carrying out executions deemed legal: beheading, electrocution, hanging, lethal injection, shooting, stoning, and stabbing. It is obvious from these facts that the case for physician participation in state-ordered execution must be overwhelmingly powerful to be convincing, given the barbarous and ill-founded nature of many executions. The argument based on mercy for the See also doomed rests on 2 claims—that physicians page 1073 have a general duty to condemned persons and that physician participation will not influence the overall ethical assessment of the practice of execution by the public. Neither is true. IS THERE A DUTY TO ASSIST THOSE CONDEMNED TO DIE? There is no duty owed by any physician to any particular condemned prisoner unless that prisoner has a previous medical relationship with the physician. In the absence of such a relationship, at most physicians have a weak general obligation to try and reduce individual suffering. This duty does not translate into a specific duty to assist a specific condemned prisoner. Positing a duty to alleviate the suffering of condemned persons makes little sense unless one is willing to acknowledge a duty to minimize their suffering before their execution. Indeed, it seems a bit late for physicians to step forward in the context of an execution and say they are motivated by a duty of mercy given that many prisoners suffer miserably because of the poor state of prison-based medicine without eliciting any involvement from these same physicians. Assisting in executions does have consequences for the overall moral standing accorded the practice of execution. Physician prestige and the respect afforded medicine are in part transferred to executions when physicians are involved. A medical presence, as those who favor or carry out executions are well aware, lends credibility and moral legitimacy to the practice. Despite the possible cost of suffering to individuals who undergo crude modes of or a poorly administered execution, physician involvement in moderating suffering in the final minutes of the lives of the condemned is too high a price for medicine to bear relative to the harms caused by legitimizing the practice of execution through physician involvement. Physician involvement on “humanitarian” grounds in executions involving homosexuality, tax fraud, religious
September 2007;82(9):1047-1048
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1047
EDITORIAL
conversions, or political offenses is morally implausible on its face. Nor is it obvious how physicians could make hanging, shooting, stoning, or stabbing more humane through their involvement. Physicians who participate in executions of children, in those using patently morally offensive and barbaric means, or in executions in states that permit capital punishment for morally bankrupt reasons, even from motives of mercy toward the condemned, both grant such systems ethical legitimacy and are complicit in the unethical killing of sometimes helpless, hapless, and vulnerable persons. IS IT ETHICAL FOR PHYSICIANS TO ADMINISTER LETHAL INJECTIONS? The argument for physician involvement in lethal injection boils down to a technical one: Only highly trained physicians can successfully administer lethal cocktails of drugs in ways that minimize suffering.2,6 An argument for technical expertise does not justify medicine’s acceptance of physician involvement in executions. It simply requires that appropriate training be given by the state to a person who can then competently handle the job. It is difficult to believe that the only persons capable of administering lethal injections are graduates of medical schools and residency programs. If humanitarian execution is a desirable goal, then properly trained personnel should carry it out. But physicians are not needed to serve in the role of executioners. The argument that decency demands that physicians be permitted if they choose to minimize the suffering of the
1048
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condemned has initial appeal but ultimately fails. It presumes a fairness, decency, and accuracy about executions that barely exist anywhere in the world. It posits a duty toward prisoners that is somehow only triggered by execution. It ignores the moral legitimacy that participation transfers to executions—a small amount of suffering possibly minimized at a huge cost in maintaining a mode of punishment morally suspect for many reasons. And it presumes that only physicians can carry out humane killing via lethal injection, when in fact governments and societies committed to execution using this technique can achieve this goal by properly training executioners. Arthur L. Caplan, PhD Department of Medical Ethics Center for Bioethics University of Pennsylvania Philadelphia 1. Truog RD, Brennan TA. Participation of physicians in capital punishment. N Engl J Med. 1993;329(18):1346-1350. 2. Waisel D. Physician participation in capital punishment. Mayo Clin Proc. 2007;82(9):1073-1080. 3. Amnesty International. Facts and figures on the death penalty. Available at: http://web.amnesty.org/pages/deathpenalty-facts-eng. Accessed August 6, 2007. 4. Human Rights Watch. Children’s rights. Available at: www.hrw.org/children /justice.htm. Accessed August 6, 2007. 5. Leo RA, Drizin SA, Neufeld PJ, Hall BR, Vatner A. Bringing reliability back in: false confessions and legal safeguards in the twenty-first century. Wis L Rev. 2006;(2):479-538. 6. Gawande A. When law and ethics collide—why physicians participate in executions. N Engl J Med. 2006;354(12):1221-1229.
September 2007;82(9):1047-1048
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
EDITORIAL EDITORIAL
Should Physicians Participate in Capital Punishment?
S
hould physicians participate in capital punishment? Nearly every organized medical and nursing group in the world opposes physician participation in state-ordered executions.1 Despite this near-universal stance against participation, some argue that if executions are to be carried out, then physicians have a legitimate role to play in minimizing “the harm to…condemned individuals.”2 Such an argument contends that physician involvement in executions is morally justified by the duty of compassion toward the person to be killed. Although conceding that no physician is obligated to participate in an execution, the argument holds that “organized medicine has an obligation to permit physician participation in legal execution”2 on the grounds of the duty of mercy to the condemned. To assess the permissibility of physician involvement in state-directed executions on the grounds of mercy, it is necessary to understand where, how, and for what reasons the death penalty is being carried out. Also, it is important to know whether physicians who participate are doing so as agents of trustworthy legal systems, ie, those that ensure that proper execution-related processes are followed. If executions are carried out for blatantly immoral reasons by untrustworthy legal systems, then arguments based on mercy are weakened because the primary duty of the physician should be to stop such executions by all means possible and practical. THE STATE OF THE DEATH PENALTY AROUND THE WORLD The United States had the sixth largest number of executions in the world in 2006 after China, Iran, Pakistan, Iraq, and the Sudan.3 During 2006, at least 3861 people were sentenced to death in 55 countries. At least 1591 people were executed in 25 countries.3 Six nations (including the United States) permit the execution of children (defined as <8 years of age).4 Three economically advanced, industrialized nations (ie, Japan, South Korea, and some states within the United States) permit the death penalty for heinous crimes.3 China permits executions for heinous crimes but also for offenses including tax fraud, political crimes, nonviolent theft, accepting bribes, and minor drug offenses. Libya permits the death penalty for many crimes including the importation of alcohol. Afghanistan permits the death penalty for various crimes including conversion from IsAddress correspondence to Arthur L. Caplan, PhD, Chair, Department of Medical Ethics and Director, Center for Bioethics, University of Pennsylvania, 3401 Market St, Suite 320, Philadelphia, PA 19104-3308 (caplan @mail.med.upenn.edu). © 2007 Mayo Foundation for Medical Education and Research
Mayo Clin Proc.
•
lam to another religion. Iran permits the death penalty for murder and also for adultery, homosexuality, and operating a brothel.3 Worldwide, the following methods are allowed in carrying out executions deemed legal: beheading, electrocution, hanging, lethal injection, shooting, stoning, and stabbing. It is obvious from these facts that the case for physician participation in state-ordered execution must be overwhelmingly powerful to be convincing, given the barbarous and ill-founded nature of many executions. The argument based on mercy for the See also doomed rests on 2 claims—that physicians page 1073 have a general duty to condemned persons and that physician participation will not influence the overall ethical assessment of the practice of execution by the public. Neither is true. IS THERE A DUTY TO ASSIST THOSE CONDEMNED TO DIE? There is no duty owed by any physician to any particular condemned prisoner unless that prisoner has a previous medical relationship with the physician. In the absence of such a relationship, at most physicians have a weak general obligation to try and reduce individual suffering. This duty does not translate into a specific duty to assist a specific condemned prisoner. Positing a duty to alleviate the suffering of condemned persons makes little sense unless one is willing to acknowledge a duty to minimize their suffering before their execution. Indeed, it seems a bit late for physicians to step forward in the context of an execution and say they are motivated by a duty of mercy given that many prisoners suffer miserably because of the poor state of prison-based medicine without eliciting any involvement from these same physicians. Assisting in executions does have consequences for the overall moral standing accorded the practice of execution. Physician prestige and the respect afforded medicine are in part transferred to executions when physicians are involved. A medical presence, as those who favor or carry out executions are well aware, lends credibility and moral legitimacy to the practice. Despite the possible cost of suffering to individuals who undergo crude modes of or a poorly administered execution, physician involvement in moderating suffering in the final minutes of the lives of the condemned is too high a price for medicine to bear relative to the harms caused by legitimizing the practice of execution through physician involvement. Physician involvement on “humanitarian” grounds in executions involving homosexuality, tax fraud, religious
September 2007;82(9):1047-1048
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1047
EDITORIAL
conversions, or political offenses is morally implausible on its face. Nor is it obvious how physicians could make hanging, shooting, stoning, or stabbing more humane through their involvement. Physicians who participate in executions of children, in those using patently morally offensive and barbaric means, or in executions in states that permit capital punishment for morally bankrupt reasons, even from motives of mercy toward the condemned, both grant such systems ethical legitimacy and are complicit in the unethical killing of sometimes helpless, hapless, and vulnerable persons. IS IT ETHICAL FOR PHYSICIANS TO ADMINISTER LETHAL INJECTIONS? The argument for physician involvement in lethal injection boils down to a technical one: Only highly trained physicians can successfully administer lethal cocktails of drugs in ways that minimize suffering.2,6 An argument for technical expertise does not justify medicine’s acceptance of physician involvement in executions. It simply requires that appropriate training be given by the state to a person who can then competently handle the job. It is difficult to believe that the only persons capable of administering lethal injections are graduates of medical schools and residency programs. If humanitarian execution is a desirable goal, then properly trained personnel should carry it out. But physicians are not needed to serve in the role of executioners. The argument that decency demands that physicians be permitted if they choose to minimize the suffering of the
1048
Mayo Clin Proc.
•
condemned has initial appeal but ultimately fails. It presumes a fairness, decency, and accuracy about executions that barely exist anywhere in the world. It posits a duty toward prisoners that is somehow only triggered by execution. It ignores the moral legitimacy that participation transfers to executions—a small amount of suffering possibly minimized at a huge cost in maintaining a mode of punishment morally suspect for many reasons. And it presumes that only physicians can carry out humane killing via lethal injection, when in fact governments and societies committed to execution using this technique can achieve this goal by properly training executioners. Arthur L. Caplan, PhD Department of Medical Ethics Center for Bioethics University of Pennsylvania Philadelphia 1. Truog RD, Brennan TA. Participation of physicians in capital punishment. N Engl J Med. 1993;329(18):1346-1350. 2. Waisel D. Physician participation in capital punishment. Mayo Clin Proc. 2007;82(9):1073-1080. 3. Amnesty International. Facts and figures on the death penalty. Available at: http://web.amnesty.org/pages/deathpenalty-facts-eng. Accessed August 6, 2007. 4. Human Rights Watch. Children’s rights. Available at: www.hrw.org/children /justice.htm. Accessed August 6, 2007. 5. Leo RA, Drizin SA, Neufeld PJ, Hall BR, Vatner A. Bringing reliability back in: false confessions and legal safeguards in the twenty-first century. Wis L Rev. 2006;(2):479-538. 6. Gawande A. When law and ethics collide—why physicians participate in executions. N Engl J Med. 2006;354(12):1221-1229.
September 2007;82(9):1047-1048
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.