Doctors’ Dilemma : Physicians attending executions? Increasingly, many are wrestling with their consciences--and saying no.

When it was over, the convicted murderer lay lifeless, an intravenous line still plugged into his vein.

Ten minutes after William Andrews succumbed to the poisonous concoction injected into his arm, Dr. Robert Jones performed a task from which, he said, he would never quite recover: He entered the chamber of death, checked the condemned man’s vital signs and confirmed that he was, in fact, dead.

The medical director for the Utah State Prison system did not witness the July, 1992, execution. But his limited role so troubled him that he decided never again to have anything to do with a state-ordered killing.

“It was much more stressful, much more disconcerting than I thought it would be,” Jones says. “I literally slept for a whole day afterward, and I thought, ‘That’s an experience in life that you don’t want to have to go through again.’ . . . Physicians usually try to preserve life, not end it.”

As a prison doctor, Jones sits at the uncomfortable intersection of medicine and criminal justice. His dilemma highlights an ethical debate that is raging in the medical community: Should doctors, who take the Hippocratic oath not to harm their patients, take part in carrying out the death penalty? When state laws and regulations require physicians to be present at executions--as in California, where doctors watch the heart monitor that charts the prisoner’s final moments in the gas chamber--should the physician comply?

Long a controversial subject, this issue has attracted renewed attention since 1990, when Illinois lawmakers voted to protect the privacy of three physicians who assisted in the lethal injection of an inmate by starting an intravenous line. Now, an unlikely alliance of physicians groups and death-penalty foes is pressing state legislators across the country to eliminate laws that call upon doctors to participate in executions.

Four groups--the American College of Physicians, Physicians for Human Rights, Human Rights Watch and the National Coalition to Abolish the Death Penalty--made the recommendation recently in the report “Breach of Trust.” Their nationwide survey found that, despite an ethics ban by the American Medical Assn., doctors play a variety of roles in executions--including acting as witnesses and rendering advice to executioners.

Yet some prison officials, so accustomed to having doctors on hand, say the aid of physicians is a must. Says Don Lindsey, a spokesman at the California State Prison at San Quentin where there have been two executions in the past two years: “How can you certify that it’s all over if the doctor is not there?”

Many medical ethicists, as well as the AMA, have concluded that doctors should have no role in executions other than to arrive afterward to certify that an inmate is dead. (The AMA shies away from the word pronouncing , which implies that the physician is standing by waiting for the inmate to die.) But others, including Jones, the Utah physician, say that even certifying death can pose a quandary. They would prefer that the body be taken to a morgue, where a coroner could make the certification.

For instance, what if the inmate isn’t dead when the doctor comes in, as was the case in Alabama in 1989, when convicted rapist and murderer Horace Franklin Dunkins was discovered still breathing in the electric chair? Doctors had to tell the executioner that the job wasn’t done.

“That is deeply problematic,” says Gregg Bloche, a doctor and lawyer who teaches medical ethics at Georgetown University. “If the doctor comes out and says, ‘No, the person is not dead,’ then the executioner administers another jolt and finishes the killing. I think that puts the doctor very close to the killing itself.”

Historically, doctors became involved in executions to ensure that the procedures were humane. During the French Revolution, for instance, Dr. Joseph Guillotin promoted the neck-severing device that now bears his name because he believed that it was less painful than other methods.

In the United States, many states have passed laws requiring the presence of doctors, theorizing that with dispassionate medical experts on hand, condemned prisoners would not suffer unnecessarily. Of the 36 states that have death-penalty statutes, 28 require physicians to be present. Five more have laws saying doctors may be present. (The issue is not as pressing in the federal prison system. Although federal law permits executions, the last one was in 1963.)

There are an estimated 1,500 doctors working in state prisons nationwide, according to the National Commission on Correctional Health Care, but this debate does not apply to them alone. Because many prison doctors refuse to become involved in executions, some states have been forced to contract with outside doctors.

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But what constitutes involvement?

Clearly, administering lethal drugs or flipping the switch on an electric chair is involvement--and is prohibited by the AMA. Also prohibited are starting IV lines or inspecting veins to prepare for lethal injection; reading a heart monitor or tracking vital signs during an execution; attending as a physician witness, and rendering technical advice to executioners.

Doctors who engage in such activities risk sanction from state licensing boards, although experts know of no one who has been so disciplined. The “Breach of Trust” report urges state boards to take strong action against doctors who violate the ethics ban; because of this threat, the identity of doctors present at executions is often a closely held secret.

“We look at this as a bedrock ethical issue for physicians,” says Dr. M. Roy Schwarz, senior vice president of the AMA, “and we don’t think there is any compromise on it.”

In practice, the issues are complex. For instance, despite the AMA policy regarding heart monitors, Schwarz says, “that’s kind of a gray zone.”

The role of psychiatrists is also controversial and has not been addressed by the AMA. At issue is whether it is acceptable for forensic psychiatrists to determine if an inmate is mentally competent to be executed. And if the inmate is not competent, should the psychiatrist prescribe drugs to make him so?

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For doctors who must choose between state laws and personal ethics, the decision can be agonizing. Dr. Dan Cashman is one who knows.

Cashman was the chief medical examiner at San Quentin during the much publicized April, 1992, execution of convicted murderer Robert Alton Harris. He refused to become involved. Instead, two unnamed prison doctors watched the heart monitor attached to Harris and later took his vital signs.

Like many of his colleagues, Cashman believes that it would have ruined his credibility with people he treats--the inmates--to be present at an execution. “The state has decided, in its wisdom, that it will proceed with these procedures in dealing with criminals,” Cashman says, “and as a medical provider, it just doesn’t fit with my goal of having humane treatment of people.”

His decision, he says, was not without consequences. After the execution, he felt he had lost credibility with the warden. His proposals for improving treatment were not greeted as enthusiastically as they had been, and he wound up leaving San Quentin to become chief medical director of the California Youth Authority. There, he does not have to grapple with such sticky matters; juveniles cannot be sentenced to death.

Cashman is not the first doctor at San Quentin to have the death penalty collide with his career. In the mid-1980s, Dr. Kim Marie Thorburn applied to become the prison’s chief medical officer. Although she was the top-ranked physician on the state’s civil service exam, she says she didn’t get the job after she told the warden that she wouldn’t participate in executions.

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Others who do get involved, even in a limited way, often wrestle with their consciences for years. In January, 1993, Dr. Donald T. Reay, Seattle’s chief medical examiner, found himself trapped in a legal debate over whether hanging constituted cruel and unusual punishment.

At issue was the fate of Westley Allan Dodd, who was to be hanged that month. Reay is an expert on hanging; he has reviewed more than 400 cases, all of them suicides or homicides (with the exception of Dodd) during his 20-year career. While the courts weighed the matter, state lawyers turned to Reay for an explanation of what happens when someone is hanged.

As a death penalty opponent, Reay considered refusing to talk, but decided that he had an obligation to share his knowledge. Although he was careful to keep the conversation focused on hanging in general, refusing to answer such questions as how much rope was optimal, he was required to review military procedures for execution by hanging.

“It was uncomfortable,” he says, “because it was clear to me that what I was trying to (say) was going to be used probably in some other fashion. I did not want to get into this position of advising them in any way how to kill someone.”

The courts approved the hanging, and a doctor was present. But it was not Reay; he refused to go.