Doctors at executions: The debate continues

16 states have executions on hold

In recent months, 16 of the 38 states that have the death penalty have put executions on hold, primarily over objections raised regarding the lethal injection method. At the center of the storm in several states are physicians caught between legislatures that require they be present at executions and ethical boundaries that demand they play no part in capital punishment.

"I think the problem is that once you start having medical people — physicians or nurses — directing the killing of a person, you start blurring the lines of what a medical provider should be doing," says Jeffrey Uppington, MBBS, professor of anesthesiology and vice chair of the department of anesthesiology and pain medicine at UC Davis Health System in Sacramento.

Generally regarded as unethical

Uppington, who serves as a spokesman for the American Society of Anesthesiology (ASA), says most state and national medical associations adhere to policies that mirror the ones set forth by the ASA and American Medical Association (AMA), both of which flatly reject the participation of physicians in the execution process.

According to the AMA, the only death penalty-related actions ethically acceptable for its member physicians are testifying as to mental competence at trial; certifying death after the condemned person has been declared dead by another; witnessing an execution in an unprofessional capacity; witnessing the execution at the request of the condemned, again in an unprofessional capacity; and relieving the acute suffering of a condemned person awaiting execution, including providing tranquilizers at the condemned's request.

Many states have built physician participation or attendance into their laws governing the death penalty, and the refusal of individual physicians and state medical boards to comply have led to some states having to temporarily halt executions. The North Carolina Superior Court recently ruled that that state's medical board overstepped its authority in threatening sanctions against physicians who participate in executions there.

The judge in the North Carolina case ruled that executions are not medical procedures, and therefore, the medical board has no say in the debate over whether executions are cruel and unusual.

"Although the current effort by the medical board to prohibit physician participation in executions may well be viewed as humane and noble, such a decision rests entirely with (elected officials)," the court's ruling stated. "As of this date, the legislature has taken no such action."

"Some states have medicalized executions, even having them take place in prisons' medical wings, to further sterilize the procedures," says Uppington.

Physicians, he says, have an ethical duty to avoid participation in executions. It wasn't long ago, he points out, that physicians participated in government-ordered procedures during the Nazi rule of Germany, and even more recently in the Tuskeegee venereal disease experiments; those memories linger in the minds of the public and of physicians.

Easing suffering or inflicting death?

In a 2006 article in the New England Journal of Medicine, a rarely heard voice was included — that of a Georgia physician, Carlo Musso, who agreed to be named and quoted as a physician who participates in lethal injections in his state.1

Musso related that he believes execution under statutory death penalty laws "is an end-of-life issue," and that his duty as a physician is to care for the condemned as a patient, in a humane way, to alleviate suffering and pain at the time of death.

However, Uppington takes exception to that opinion.

"The view that we are minimizing suffering is ethically flawed, because you shouldn't be there at all," he says. "You are assisting in the death of a person. That's not the role of a physician."

In the September 2007 issue of Mayo Clinic Proceedings, author David Waisel, MD, an anesthesiologist at Children's Hospital Boston, writes that the problems associated with lethal injection — pain, for example — are the reasons that the AMA should reassess its stand and allow doctors to participate so that the condemned have more humane deaths.2

But countering that commentary is an editorial in the same issue of the journal by William Lanier, MD, and Keith Berge, MD, anesthesiologists at Mayo Clinic, who say Hippocratic principles prohibit doctors from assisting in executions, and that the "theoretical good" of easing the process is outweighed by the harm of "causing the death of a person under a physician's care."3


  1. Gawande A. When law and ethics collide — Why physicians participate in executions. N Engl J Med 2006;354:1221-1229.
  2. Waisel D. Commentary: Physician involvement in capital punishment. Mayo Clin Proc 2007;82:1073-1080. Available at
  3. Lanier W, Berge K. Physician involvement in capital punishment: Simplifying a complex calculus. Mayo Clin Proc 2007;82:1043-1046. Available at


For more information, contact:

  • Jeffrey Uppington, MBBS, professor of anesthesiology, vice chair of the department of anesthesiology and pain medicine, UC Davis Health System, Sacramento, CA. Phone: (916) 734-5031.