November 2001

From University of Michigan Health System

Many doctors willing to take part in executions, despite profession's ban

Researchers: Doctors unaware of guidelines on the conflict between their oaths and their opinions ANN ARBOR, MI - More than 40 percent of randomly surveyed physicians say they would help execute a prisoner by lethal injection, despite the fact that their acts would go against their sworn oath and the guidance of nearly all major professional societies, a new study finds.

This willingness to participate in at least one aspect of carrying out capital punishment may be mostly due to a lack of awareness of those ethical guideposts, the study's authors warn in the new issue of the Annals of Internal Medicine. Only 3 percent of the more than 400 doctors surveyed even knew that major medical organizations had already wrestled with the thorny issues pitting medical professional ethics against duty to society, and ruled against aiding execution.

But whatever the reasons might be for such a high percentage would say they'd help in a lethal injection, the study's authors warn that far more education of physicians is needed to help clarify the line between being a doctor sworn by the Hippocratic oath to "first, do no harm", and being an American citizen with personal opinions of any kind on capital punishment.

"This issue really gets to the heart of the special place physicians hold in society, with the white-coat reputation of healers," says senior author Peter Ubel, M.D., a medical ethicist and associate professor of internal medicine at the University of Michigan Health System and the Veterans Affairs Ann Arbor Healthcare System. "The astonishing lack of awareness of the guidance barring participating in lethal injection, coupled with the high willingness to take part in at least some of the actions necessary to kill a prisoner, make for a troubling combination."

Ubel notes that the research team's intent was not to criticize the personal beliefs of physicians as individual citizens, but rather to assess the level to which doctors had squared those beliefs with their professional obligations. The result of the survey, he says, may have implications for the public's perception of doctors, and therefore for the privileges and responsibilities entrusted to the medical profession.

In an accompanying editorial, a physician and an attorney from Northwestern University concur that the survey's results indicate the need for further education of physicians on the ethical challenge of execution. Ethical guidelines alone may not be able to bar an individual physician from taking part in executions, but, they write, education could help "morally confused" doctors.

"In this hard-fought effort to keep the white coat clean, the findings provide a wake-up call," write Linda Emanuel, M.D., Ph.D. and Leigh Biernen, J.D. "It is time to eliminate moral confusion by re-establishing the deliberate dissent of the medical profession regarding physician involvement in executions."

That involvement, Ubel explains, has been the subject of ethical debate for centuries, but in recent decades has centered around more humane ways of executing convicted criminals under state and federal laws. The debate has led the American Medical Association, and the hundreds of medical societies that help guide the AMA on specific issues on behalf of 98 percent of American physicians, to set specific guidelines.

For example, physicians are generally given guidance that they can prescribe tranquilizers to inmates on the eve of their execution, and that they can certify the death of an executed prisoner. But other steps, from formulating the dose of chemicals in the injection, to identifying the injection site, to injecting the lethal dose, to declaring the prisoner dead, are barred.

Physicians are not officially bound by these bans and guidelines, and in fact prison physicians routinely take part in lethal injections as mandated by the laws of certain states. But the nearly unanimous recommendations of the nation's medical societies are the profession's only mechanism for guiding physicians, Ubel says, and are designed to help individual physicians make decisions about their conduct.

Still, the new survey shows that despite this guidance, or perhaps due to lack of awareness of it, many physicians say they would go against at least one of the bans. Of the 413 physicians from the initial randomly sampled group of 1,000 who responded, 41 percent said they would take part in one of eight disallowed actions described in the survey. Twenty-five percent were willing to perform five or more of the banned acts, while 14 percent said they'd perform all eight.

Even if all the rest of the 1,000 doctors had responded and said they would not perform any of the actions, the totals would be 18 percent for one action and 11 percent for five or more. Both the initial random sample group and the group of respondents had demographic characteristics similar to those of all American physicians.

The survey asked the physicians about their personal opinions on capital punishment, and cross-referenced their responses to those questions with their assessment of what actions they would assist in. Those who favored capital punishment were more likely to say they'd participate in it, as were those who said that physicians had a duty to society to participate in executions.

Of course, says Ubel, saying you would participate in a lethal injection is different from actually doing it, and the survey did not ask respondents whether they had already participated in a capital case. But the result points to the need for more professional dialogue on the issue.

"Physicians may be basing their reasoning on their perceived duty to society, rather than their responsibility to the prisoner, and by extension to all their patients," says Ubel. "This needs to be discussed by society as a whole, even as more efforts are made to educate physicians."

The study's lead author is Neil Farber, M.D., FACP, of the Department of Medicine at the Christiana Care Health System in Delaware. The research team also included members from Drexel University and St. Joseph's University. Ubel was a member of the University of Pennsylvania's Center for Bioethics at the time the survey was performed in 1999. The study was funded by a grant from the Osler Fund of the Christiana Department of Medicine.












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