Last November, when Kentucky governor Ernie Fletcher, a physician, signed a death warrant for Thomas Bowling, a 51-year-old man convicted of killing a couple in 1990, many called for revocation of his medical license. In a grievance against the governor filed that month with the Kentucky Board of Medical Licensure, a group of physicians and attorneys wrote, "The law gives the Governor/Doctor authority to sign the death warrant, but neither the law nor the Governor's oath of office require him to do so. He also has the authority not to sign a death warrant. . . . Is it a violation of medical ethics for [Dr. Fletcher] to sign a death warrant for Thomas Bowling?" On January 13 the eight-member board said no, unanimously rejecting the grievance against the governor.
Professional organizations, including the ANA, the International Council of Nurses, the American Medical Association (AMA), and the American Public Health Association, have expressed their opposition to members' involvement in executions. The ANA position statement says: "The Code for Nurses, nursing's ethical code of conduct, stipulates that 'the nurse does not act deliberately to terminate the life of any person.' The obligation to refrain from causing death is longstanding and should not be breached even when legally sanctioned." Participation is defined as "assessment, supervision, or monitoring of the procedure or the prisoner; procuring, prescribing, or preparing medications or solutions; inserting the intravenous catheter; injecting the lethal solution; and attending or witnessing the execution as a nurse." The AMA's Council on Ethical and Judicial Affairs likewise states that "a physician . . . should not be a participant in a legally authorized execution."
The governor's legal counsel, John Roach, has said that medical ethics do not prohibit a governor who also happens to be a doctor from signing a death warrant. As of this writing, Bowling's execution has been postponed by the Franklin County Circuit Court, which is considering the constitutionality of Kentucky's method of administering lethal injections, and by the Kentucky Supreme Court because of claims that Bowling is mentally retarded.
But the question of health care workers' involvement in executions goes beyond Fletcher's case. According to the Death Penalty Information Center, 37 of the 38 states with the death penalty prefer lethal injection, and of 945 executions since 1976, 777 have been through lethal injection.
"Unlike other methods of execution, participation of health care professionals is essential for lethal injection," writes Jonathan Groner in the November 2, 2002, issue of the British Medical Journal. "Medical skills are needed to start intravenous lines, set up intravenous infusion sets, and measure out and administer the appropriate drugs." For example, at the execution of Jose High in Jackson, Georgia, in 2001, it was a nurse who first tried to start a peripheral IV line in the inmate. After about 30 minutes of unsuccessful attempts, a physician was called in to insert a central catheter in High's right subclavian vein.
According to Human Rights Watch, at least 23 of the 38 states with the death penalty "require that a physician 'determine' or 'pronounce' death"; 28 states mandate the presence of a physician at executions. In Oregon the law stipulates that a "medically trained" individual administer a lethal injection. Even in states that require a private citizen to deliver the lethal dose, nurses are often relied on to do almost everything else.
Calista H. was one such nurse. While employed as a prison nurse, H. found himself not only involved in an execution, but actually orchestrating it. He ordered the drugs, explained the procedure to the prisoner a few days before the execution, and ran a practice drill with the guards. On the night of the execution, he picked up the private citizen who had been hired to administer the drugs, hooked the prisoner to a cardiac monitor, started the IV line, and ordered the injection to begin. "The only thing we heard was the inmate start to say, 'Yeah, I can feel . . .' and that was it," H. writes in Tending Lives: Nurses on the Medical Front, a book of essays collected by Echo Heron (Ballantine Publishing Group, 1998). "It didn't hit me for a while, I think because I regarded the inmates, the warden, the guards, and the rest of my staff as being my responsibility. They needed support and someone to do the job right. . . . It wasn't until weeks later that I broke down and cried."
Refusing to participate is not simple. According to Human Rights Watch, in the early 1980s California's corrections department successfully lobbied against legislation that would have protected state-employed physicians who refused to participate in executions, retaining the right to force them to do so.
Although a few states, such as New Mexico, specifically exempt health care workers employed by the department of corrections from taking part in executions, in most states their participation remains a murky topic. This has led such critics as Groner to compare the practice to Nazi Germany's euthanasia program, in which the state used clinicians to kill physically and mentally handicapped people.
Whether clinicians' involvement in executions constitutes a violation of ethics isn't obvious to all nurses. On an Internet nursing forum at http://www.allnurses.com, a nurse recently posted the question, "I'm wondering if nurses administer lethal injection in places like [Texas] or any other states that take part in capital punishment. If so, what is the salary like?" To which another nurse replied, "How dare you try to steal my ideal job!!!!!! I too am very interested in this kind of job."-Dalia Sofer