Dr. Marc Stern, the for­mer assis­tant sec­re­tary of health­care for the Washington Department of Corrections, recent­ly com­ment­ed on physi­cian par­tic­i­pa­tion in exe­cu­tions in the wake of the botched lethal injec­tions in Oklahoma and Arizona. Dr. Stern resigned rather than coop­er­ate with his state’s exe­cu­tion plan. He explained his views, ​“Although its foun­da­tion is in med­ical sci­ence, lethal injec­tion is not a med­ical pro­ce­dure: it has no ther­a­peu­tic val­ue, and it is not taught in med­ical school. A ​‘suc­cess­ful’ lethal injec­tion would require the train­ing and exper­tise of a med­ical pro­fes­sion­al. Finding and access­ing a vein – espe­cial­ly in some­one who is old­er, obese or has abused drugs – can be chal­leng­ing. Choosing a prop­er med­ica­tion dose for a patient, mon­i­tor­ing med­ica­tion admin­is­tra­tion and its effects, and mak­ing nec­es­sary course cor­rec­tions need the exper­tise of a pro­fes­sion­al. But legit­i­mate med­ical pro­ce­dures are sub­ject to sci­en­tif­ic study, open dis­cus­sion among peers, train­ing, super­vi­so­ry over­sight and improve­ments in tech­nique. Lethal injec­tion will nev­er ben­e­fit from these safe­guards for one crit­i­cal­ly impor­tant rea­son: it vio­lates med­ical ethics.” He acknowl­edged that some med­ical pro­fes­sion­als are will­ing to anony­mous­ly par­tic­i­pate in the process. ​“However,” Stern wrote, ​“we will con­tin­ue to risk botched exe­cu­tions because they are con­duct­ed in a scientific vacuum.”

Read the op-ed below.

I was told to approve a lethal injection, but it violates my basic medical ethics

Marc Stern

I peered through the small win­dow of an oth­er­wise sol­id steel door of the iso­la­tion wing of the prison, and saw a small man on his knees in front of his steel framed bed. He had com­mit­ted many mur­ders and was sen­tenced to life with­out the pos­si­bil­i­ty of parole. Perhaps he was pray­ing. Perhaps he was look­ing for a pen­cil. But that’s when it struck me: There might be a pun­ish­ment worse than execution.

Other than a max­i­mum of one hour per day when he could be escort­ed to a recre­ation­al cage out­doors, he would spend the next 10, 20, per­haps 30 years of his life in this very room – eight feet by 10 feet. He would have lit­tle con­tact with oth­er human beings aside from offi­cers and med­ical pro­fes­sion­als. Forging a new friend­ship or hug­ging a loved one, if pos­si­ble at all, would be rare, super­vised and not like­ly spon­ta­neous. His life would be restrict­ed to the same 80 square feet – forever.

It was 2005. I was mak­ing rounds as the assis­tant sec­re­tary for health­care of the Washington State Department of Corrections. The death penal­ty and exe­cu­tions sim­ply were not on my radar. My respon­si­bil­i­ty was only to ensure that incar­cer­at­ed cit­i­zens were receiv­ing safe, con­sti­tu­tion­al­ly ade­quate and humane healthcare.

But the death penal­ty even­tu­al­ly inched its way onto my screen as a med­ical pro­fes­sion­al – dead cen­ter, just as it did once again for so many peo­ple around the world Tuesday night in Missouri, and espe­cial­ly after the recent exe­cu­tions gone wrong in Oklahoma and Arizona.

In 2008, prison offi­cials asked health­care pro­fes­sion­als under my super­vi­sion to pro­cure the drugs for the lethal injec­tion of a dif­fer­ent cit­i­zen at Washington’s Walla Walla state prison, Darold Ray Stenson, despite assur­ances that depart­ment health­care staff would not assist in any way in the exe­cu­tion. I learned about the drug pro­cure­ment only a week before the scheduled execution.

It became clear to me: health­care pro­fes­sion­als can­not eth­i­cal­ly par­tic­i­pate in exe­cu­tions. Procurement of the drugs was a direct vio­la­tion of ethics by the per­son­nel involved. But it was also a vio­la­tion of med­ical ethics by me, indi­rect­ly, as their super­vi­sor. This kind of vio­la­tion could be cured if lethal-injec­tion drugs were returned to the phar­ma­cy stores and obtained through a different source.

But prison author­i­ties refused. The only cure remain­ing was to recuse myself. My res­ig­na­tion took effect three days pri­or to the sched­uled exe­cu­tion, even though Stenson’s exe­cu­tion received a stay and he got a new tri­al. He waits in Walla Walla to this day, as Governor Jay Inslee’smora­to­ri­um on exe­cu­tions remains intact.

Ethicists, prison reform­ers and activists have long argued against cap­i­tal pun­ish­ment in the 32 states that still mete out the death penal­ty. And in many reli­gious and moral frame­works, it is wrong. Of the world’s 196 coun­tries, the US is among only about 67 that impose the death penal­ty, shar­ing that dis­tinc­tion with oth­er like-mind­ed nations such as China, Cuba, North Korea and Iran.

The lethal injec­tion was orig­i­nal­ly a three-drug cock­tail invent­ed by a physi­cian in 1977. Although its foun­da­tion is in med­ical sci­ence, lethal injec­tion is not a med­ical pro­ce­dure: it has no ther­a­peu­tic val­ue, and it is not taught in med­ical school. A ​“suc­cess­ful” lethal injec­tion would require the train­ing and exper­tise of a med­ical pro­fes­sion­al. Finding and access­ing a vein – espe­cial­ly in some­one who is old­er, obese or has abused drugs – can be chal­leng­ing. Choosing a prop­er med­ica­tion dose for a patient, mon­i­tor­ing med­ica­tion admin­is­tra­tion and its effects, and mak­ing nec­es­sary course cor­rec­tions need the exper­tise of a professional.

But legit­i­mate med­ical pro­ce­dures are sub­ject to sci­en­tif­ic study, open dis­cus­sion among peers, train­ing, super­vi­so­ry over­sight and improve­ments in tech­nique. Lethal injec­tion will nev­er ben­e­fit from these safe­guards for one crit­i­cal­ly impor­tant rea­son: it vio­lates medical ethics.

Physicians, nurs­es and oth­er med­ical pro­fes­sion­als are bound to do things in their patients’ best inter­ests, to do no harm, to be guid­ed in all this by the wish­es of their patients, all of which are incom­pat­i­ble with par­tic­i­pa­tion in exe­cu­tions. These pre­cepts are cap­tured in the Hippocratic oath and ethics guide­lines from top medical organizations.

So could states just use med­ical pro­fes­sion­als who are will­ing to anony­mous­ly sneak through the back door of the prison? They could, and they do. However, we will con­tin­ue to risk botched exe­cu­tions because they are con­duct­ed in a sci­en­tif­ic vac­u­um. And it is fair to say that these pro­fes­sion­als oper­ate devoid of any eth­i­cal com­pass. What, then, pre­vents them from cut­ting oth­er crit­i­cal cor­ners dur­ing a pro­ce­dure that kills someone?

Americans like things to be neat, clean and error-free … basi­cal­ly, nice. When we wrench the last breath out of a fel­low cit­i­zen, we want to do it polite­ly. So death by hang­ing, fir­ing squad, elec­tro­cu­tion and the gas cham­ber have fall­en out of favor because they can be grue­some and don’t always go so smoothly.

We can­not ignore the very prac­ti­cal bar­ri­er that there is no method of exe­cu­tion that meets our ​“needs” as a soci­ety – a method that is ​“nice”, ​“reli­able” and that does not require med­ical pro­fes­sion­als to act uneth­i­cal­ly. And we can’t get there from here.

(M. Stern, ​“I was told to approve a lethal injec­tion, but it vio­lates my basic med­ical ethics,” The Guardian, August 6, 2014). Executions in Washington are on hold due to mora­to­ri­um imposed by the gov­er­nor. See Lethal Injection and New Voices.

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