A theatre of death: behind the curtain

ON JULY 2, 1976, the USSupreme Courtlegalisedcapitalpunishmentafteramoratoriumof 10yearson executions.Sixmonthslater, executionsresumedinUtah,withthe death byfiring squad of Gary Gilmoreforthekillingofmotel manager Ben Bushnell. Death by firing squad, however, came to be regarded as too bloody and uncontrolled. (Gilmore's heart, for example, did not stop until two minutes after he was shot, and shooters have sometimes weakened at the trigger, as famously happened in 1951 in Utah when the five riflemen fired away from the target over Elisio Mares's heart, only to hit his right chest and cause him to bleed slowly to death.) Hanging came to be regarded as still more inhumane. Under the best of circumstances, the cervical spine is broken at the second vertebra, the diaphragm is paralysed, and the prisoner suffocates to death, a minutes-long process. Gas chambers proved no better: asphyxiation from cyanide gas took even longer than death by hanging, and the public revolted at the vision of suffocating prisoners fighting for air and then seizing as the ability to use oxygen shut down. In Arizona in 1992, for example, the asphyxiation of triple murderer Donald Harding took 11 minutes, and the sight was so horrifying that reporters began crying, the attorney general vomited, and the prison warden announced he would resign if forced to conduct another such execution. Since 1976, only two prisoners have been executed by firing squad, three by hanging, and 11 by gas chamber.

Many more executions were by electrocution, which was thought to cause a swifter, more acceptable death. But officials found that the electrical flow frequently arced, cooking flesh and sometimes igniting prisoners - postmortem examinations often had to be delayed for the bodies to cool - and yet in some cases, it took repeated jolts to kill. In Alabama, in 1979, for example, John Louis Evans III was still alive after two cycles of 2600 volts; the warden called Governor George Wallace, who told him to keep going, and only after a third cycle, with witnesses screaming in the gallery, and almost 20 minutes of suffering, did Evans finally die. Only Florida, Virginia and Alabama persisted with electrocutions with any frequency, and under threat of supreme court review, they too abandoned the method.

Lethal injection now appears to be the sole method of execution considered sufficiently humane - largely because it medicalises the process. The prisoner is laid supine on a hospital gurney. A white bedsheet is drawn to his chest. An intravenous line flows into his arm. Prisoners are first given 2500 to 5000 milligrams of sodium thiopental, which can produce deathall by itself by causing complete cessation of the brain's electrical activity, followed by respiratory arrest and circulatory collapse. Death, however, can take 15 minutes or longer with thiopental alone, and the prisoner may appear to gasp, struggle or convulse. So 60 to 100 milligrams of pancuronium is injected one minute or so after the thiopental to paralyse the prisoner'smuscles.Finally,120to240 milliequivalents of potassium is given to produce rapid cardiac arrest.

Officials liked this method. Because it borrowed from established anaesthesia techniques, it made execution more like familiar medical procedures than the grisly, backlash-inducing spectacle it had become. The drugs were cheap and routinely available. And officials could turn to doctors and nurses to help with technical difficulties, attesttothepainlessnessandtrustworthiness of the technique, and lend a more professional air to the proceedings.

But medicine balked. In 1980, the American Medical Association (AMA) ruled against physician participation as a violation of medical ethics. Its 1992 Code Of Medical Ethics further clarified the ban, saying it was unacceptable for members of "a profession dedicated to preserving life" to pronounce death at an execution, because the physician is not permitted to revive the prisoner if he is found to be alive.

States,however,wantedamedical presence. In 1982, in Texas, the state prison medical director, Ralph Gray, and another doctor, Bascom Bentley, agreed to attend the country's first execution by lethal injection, though only to pronounce death. But once on the scene, Gray was persuaded to examine the prisoner to show the team the best injection site. Still, the doctors refused to give advice about the injection itself and simply watched as the warden prepared the chemicals. When he tried to push the syringe, however, it did not work. He had mixed all the drugs together, and they had precipitated into a clot of white sludge. "I could have told you that," one of the doctors reportedly said, shaking his head.

Afterwards, Gray went to pronounce the prisoner dead but found him still alive. The doctors were part of the team now, though; they suggested allowing time for more drugs to run in.

Today, all 38 death-penalty states rely on lethal injection. Of 1045 murderers executed since 1976, 876 were executed by injection. Against vigorous opposition from the AMA and state medical societies, 35 of the 38 states explicitly allow physician participation in executions. To protect participating physicians from licence challenges for violating ethics codes, states commonly promise anonymity and provide legal immunity. Nonetheless, several states have produced the physicians in court to vouch publicly for thelegitimacyandpainlessnessofthe procedure. Despite the immunity, several physicians have faced licence challenges, though none has lost as yet.

States have affirmed that physicians and nurses - including prison employees - have a right to refuse to participate in any way in executions. Yet they have found physicians and nurses who are willing to participate. Who are these people? Why do they do it?

Among the 15 medical professionals I located who have helped with executions, four physicians and one nurse agreed to speak with me; collectively, they have helped with at least 45 executions. None were zealots for the death penalty, and none had a simple explanation for why they did this work. The role, most said, had crept up on them.

Dr A has helped with about eight executions. He was extremely uncomfortable talking about the subject. Nonetheless, he agreed to tell me his story.

Almost 60 years old, he is well respected in his small town. One of his patients - the warden of the nearby maximum security prison - complained during an appointment of difficulties staffing the prison clinic and asked if the doctor would be willing to see prisoners there occasionally. Dr A said he would. He'd have made more money in his own clinic but the prison was important to the community, he liked the warden and it was just a few hours of work a month. He was happy to help.

Then, a year or two later, the warden asked him for help with a different problem. Executions were to be carried out in the prison. He needed doctors, he said. Would Dr A help? He would not have to deliver the lethal injection - just help with cardiac monitoring. The warden gave the doctor time to consider the request.

"My wife didn't like it," Dr A told me. But he felt torn. "I knew something about the past of these killers." One of them had killed a mother of three during a convenience store robbery and then, while getting away, shot a man who was standing at his car pumping gas. Another convict had kidnapped, raped and strangled to death an 11-year-old girl. "I do not have a very strong conviction about the death penalty, but I don't feel anything negative about it for such people either. The execution order was given legally by the court. And morally, if you think about the animal behaviour of some of these people " He decided to participate, he said, because he was only helping with monitoring, because he was needed by the warden and his community, because the sentence was society's order and because the punishment did not seem wrong.

At the first execution, he was instructed to stand behind a curtain, watching the inmate's heart rhythm on a cardiac monitor. Neither the witnesses on the other side of the glass nor the prisoner could see him. A technician placed two IV lines. Someone he could not see pushed the three drugs, one right after another. Watching the monitor, he saw the normal rhythm slow, then the waveforms widen. He recognised the tall peaks of potassium toxicity followed by the fine spikes of ventricular fibrillation and finally the flat, unwavering line of an asystolic cardiac arrest. He waited half a minute, then signalled to another physician, who went out before the witnesses to place his stethoscope on the prisoner's unmoving chest. The doctor listened for 30 seconds, then told the warden the inmate was dead. Half an hour later, Dr A was released. He made his way through a side door, past the crowd gathered outside.

In three subsequent executions there were difficulties, though, all with finding a vein for an IV. The prisoners were either obese or previous intravenous drug users, or both. The technicians would stick and stick and, after half an hour, give up. This was a possibility the warden had not prepared for. Dr A had placed numerous lines. Could he try?

OK, Dr A decided. Let me take a look.

This was a turning point, though he didn't recognise it at the time. He was there to help, they had a problem, and so he would help. It did not occur to him to do otherwise.

In two of the prisoners, he told me, he found a good vein and placed the IV. In one, however, he could not find a vein. All eyes were on him. He felt responsible for the situation. The prisoner was calm. Dr A remembered the prisoner saying to him, almost to comfort him: "No, they can never get the vein." The doctor decided to place a central line, an intravenous line that goes directly into the chest. People scrambled to find a kit.

I asked him how he placed the line. It was like placing one "for any other patient", he said. He decided to place it in the subclavian vein, a thick pipe of a vein running under the collarbone, because that is what he most commonly did. He opened the kit for the triple-lumen catheter and explained to the prisoner everything he was going to do. The man was perfectly co-operative. Dr A put on sterile gloves, gown, and mask. He swabbed the man's skin with antiseptic.

"Why?" I asked.

"Habit," he said. He injected local anaesthetic. He punctured the vein with one stick. He checked to make sure he had a good, nonpulsatile flow of dark venous blood coming out. He threaded a guide wire through the needle, a dilator over the guide wire, and finally slid the catheter in. All went smoothly. He flushed the lines with saline, secured the catheter to the skin with a stitch, and put a clean dressing on, just as he always does. Then he went back behind the curtain to monitor the lethal injection.

Only one case seemed to really bother him. The convict, who had killed a policeman, weighed about 350lbs. The team placed his intravenous lines without trouble. But after they had given him all three injections, the prisoner's heart rhythm continued. "It was an agonal rhythm," Dr A said, a rhythm with a widened appearance on the EKG, going only 10 or 20 beats per minute. "He was dead," he insisted. Nonetheless, the rhythm continued. The team looked to Dr A. His explanation of what happened next diverges from what I learned from another source. I was told that he instructed that another bolus of potassium be given. When I asked him if he did, he said: "No, I didn't. As far as I remember, I didn't say anything. I think it may have been another physician." Certainly, however, all boundary lines had been crossed. He had agreed to take part in the executions simply to watch a cardiac monitor, but just by being present, by having expertise, he had opened himself to being called on to do steadily more, to take responsibility for the execution itself. Perhaps he was not the executioner. But he was damn close to it. And he seemed troubled by that.

I asked him whether he had known that his actions violated the AMA's ethicscode."Ineverhadany inkling," he said. The humaneness ofalethalinjectionDrAwas involved in was challenged in court, however. The state summoned him for a public deposition on the process, including the particulars of the execution in which the prisoner required a central line. His local newspaper printed the story. Word spread through his town. Not long after, he arrived at work to find a sign pasted to his clinic door reading: "THE KILLERDOCTOR."Achallengetohis medical licence was filed with the state. If he wasn't aware earlier that there was an ethical issue at stake, he was now.

Some 90% of his patients supported him, he said, and the state medical board upheld his licence under a law that defined participation in executions as acceptable activity for a physician. But he decided that he wanted no part of the controversy any more and quit. He still defends what he did. Had he known of the AMA's position, though, "I never would have gotten involved," he said.

Dr B spoke to me between clinic appointments. A family physician, he has participated in around 30 executions. He became involved long ago, when electrocution was the primary method, and continued through the transition to lethal injections. He remains a participant to this day. But it was apparent that he had been more cautious and reflective about his involvement than Dr A had. He also seemed more troubled by it.

Dr B, too, had first been approached by a patient: a "prison investigator" who said he had been hired to monitor the state's care of the inmates. Dr B did not really want to get involved. He was in his 40s then. He'd gone to a top-tier medical school. He'd protested the Vietnam war in the 1960s. "I've gone from a radical hippie to a middle-class American over the years," he said. But his patient said the team needed a physician only to pronounce death. Dr B had no personal objection to capital punishment. So in the moment - "it was a quick judgement" - he agreed, "but only to do the pronouncement".

The execution by electric chair. It was an awful sight, he said. "They say an electrocution is not an issue. But when someone comes up out of that chair six inches, it's not for nothing." He waited a long while before going out to the prisoner. When he did, he performed a systematic examination. He checked for a carotid pulse. He listened to the man's heart three times with a stethoscope. He looked for a pupil response with his penlight. Only then did he pronounce the man dead.

He thought harder about whether to stay involved after that first time. "I went to the library and researched it," and that was when he discovered the 1980 AMA guidelines. As he understood the code, if he did nothing except make a pronouncement of death, he would be acting properly and ethically. (This was before the 1992 AMA clarification that made pronouncing death at the scene a clear violation of the code but allowed signing a death certificate at a later time.) During the first lethal injections, he and another physician "were in the room when they were administering the drugs", he said. "We could see the telemetry the cardiac monitor. We could see a lot of things. But I had them remove us from that area. I said, I do not want any access to the monitor or the EKGs.' A couple of times they asked me about recommendations in cases in which there were venous access problems. I said, No. I'm not going to assist in any way.' They would ask about amounts of medicines. They had problems getting the medicines. But I said I had no interest in getting involved in any of that."

Dr B kept himself at some remove from the execution process, but he would be the first to admit that his is not an ethically pristine position. When he refused to provide additional assistance, the execution team simply found others who would. He was glad to have those people there. "If the doctors and nurses are removed, I don't think lethal injections could be competently or predictably done. I can tell you I wouldn't be involved unless those people were involved.

"I agonise over the ethics of this every time they call me to go down there," he said. His wife knew about his involvement from early on, but he could not bring himself to tell his children until they were grown. He has let almost no-one else know. Even his medical staff is unaware.

The trouble is not that the lethal injections seem cruel to him. "Mostly, they are very peaceful," he said. The agonising comes instead from his doubts about whether anything is accomplished. "The whole system doesn't seem right," he told me. "I guess I see more and more executions, and I really wonder It just seems like the justice system is going down a dead-end street. I can't say that lethal injection lessens the incidence of anything. The real depressing thing is that if you don't get to these people before the age of three or four or five, it's not going to make any difference in what they do. They've struck out before they even started kindergarten. I don't see executions as saying anything about that."

Themedicalpeoplemostwaryof speaking to me were those who worked as full-time employees in state prison systems. One who did agree to talk had fought as a marine in Vietnam before becoming a nurse. As an army reservist, he served with a surgical unit in Bosnia and in Iraq. He worked for many years on critical care units and, for almost a decade, as nurse manager for a busy emergency department. He then took a job as the nurse in charge for his state penitentiary, where he helped with one execution by lethal injection.

It was the state's first execution by this method, and "at the time, there was great naivety about lethal injection", he said. "No-one in that state had any idea what was involved." The warden had a protocol from Texas and thought it looked pretty simple. What did he need medical personnel for? The warden told the nurse that he would start the IVs himself, though he had never started one before.

"Are you, as a doctor, going to let this person stab the inmate for half an hour because of his inexperience?" the nurse asked me. "I wasn't," he said. "I had no qualms. If this is to be done correctly, if it is to be done at all, then I am the person to do it."

He didn't feel easy about it. "As a marine and as a nurse I hope I will never become someone who has no problem taking another person's life." But society had decided the punishment and had done so carefully with multiple judicial reviews, he said. The convict had killed four people even while in prison. He had arranged for an accomplice to blow up the home of a county attorney he was angry with while the attorney, his wife, and their child were inside. When the accomplice turned state's evidence, the inmate arranged for him to be tortured and killed at a roadside rest stop. The nurse did not disagree with the final judgment that this man should be put to death.

The nurse took his involvement seriously. "As the leader of the health care team," he said, "it was my responsibility to make sure that everything be done in a way that was professional and respectful to the inmate as a human being." He spoke to an official with the state nursing board about the process, and although involvement is against the American Nurses Association's ethics code, the board said that under state law he was permitted to do everything except push the drugs.

So he issued the purchase request to the pharmacist supplying the drugs. He did a dry run with the public citizen chosen to push the injections and with the guards to make sure they knew how to bring the prisoner out and strap him down. On the day of the execution, the nurse dressed as if for an operation, in scrubs, mask, hat, sterile gown and gloves. He explained to the prisoner exactly what was going to happen. He placed two IVs and taped them down. The warden read the final order to the prisoner and allowed him his last words. "He didn't say anything about his guilt or his innocence," the nurse said. "He just said that the execution made all of us involved killers just like him."

The warden gave the signal to start the injection. The nurse hooked the syringe to the IV port and told the citizen to push the sodium thiopental. "The inmate started to say, Yeah, I can feel ' and then he passed out." They completed the injections and, three minutes later, he flatlined on the cardiac monitor. The two physicians on the scene had been left nothing to do except pronounce the inmate dead.

I have personally been in favour of the death penalty. I was a senior official in the 1992 Clinton presidential campaign and in the administration, and in that role I defended the president's stance in support of capital punishment. I have no illusions that the death penalty deters anyone from murder, and have great concern about our justice system's ability to avoid putting someone innocent to death. However, I believe there are some human beings who do such evil as to deserve to die. I am not troubledthatTimothyMcVeighwas executed for the 168 people he killed in the Oklahoma City bombing or that John Wayne Gacy was for committing 33 murders.

Still, I hadn't thought much about exactly how the executions are done. And I have always instinctively regarded involvement in executions by physicians and nurses as wrong. The public has granted us extraordinary and exclusive dispensation to administer drugs to people, even to the point of unconsciousness, to cut them open, to do what would otherwise be considered assault, because we do so on their behalf - to save their lives and provide them comfort. To have the state take control of these skills for its purposes against a human being - for punishment - seems a dangerous perversion. Society has trusted us with powerful abilities, and the more willing we are to use these abilities against individual people, the more we risk and betray that trust.

My conversations with the medical personnel I had tracked down, however, rattled both these views - and no conversation more so than one I had with the final doctor I spoke to. Dr D is a 45-year-old emergency physician. He is also a volunteer medical director for a shelter for abused children. He works to reduce homelessness. He opposes the death penalty because he regards it as inhumane, immoral and pointless. And he has participated in six executions so far.

About a decade ago, a new jail was built near the hospital where he worked. The jail needed a doctor. So, out of curiosity as much as anything, Dr D began working there. "I found that I loved it," he said. Jails, he pointed out, are different from prisons in that they house people who are arrested and awaiting trial. Most are housed only a few hours or days and then released. "The substance abuse and noncompliance is high. The people have a wide variety of medical needs. It is a fascinating population. The setting is very similar to the ER. You can make a tremendous impact on people and on public health." Over time, he shifted more and more of hi

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