Sunday, December 12, 2004

Sins of Commission....
The Atlanta Journal-Constitution reprinted an opinion piece out of the L.A. Times about the ethical drama surrounding the Governor of Kentucky:Doctor, Reread Your Oath
A physician is a member of a profession "dedicated to preserving life when there is hope of doing so." That's from the American Medical Assn.'s Code of Medical Ethics. The recent reports of physician participation in prisoner torture in Abu Ghraib and Guantanamo are shockingly reminiscent of Nazi doctors' flagrant violations of the codes of their profession.

But there is another case worth examining, closer to home. On Nov. 8, Kentucky Gov. Ernest S. Fletcher signed a death warrant for convicted murderer Thomas Clyde Bowling, an order later temporarily stayed until the Kentucky courts had more time to consider the issues presented to them. Evidence had been offered that Bowling, who killed two people in 1990, was mentally retarded......Objections flooded his office, and complaints were filed with the Kentucky Board of Medical Licensure, charging him with violating the AMA's ethics code and Kentucky law. The licensure board is expected to consider the matter in January.

The code of the AMA, and of almost every national and international health-related organization, states that physician participation in executions is prohibited. Originally formulated in 1980 and updated in 2000, the AMA principle is clear: A physician should not be a participant in a legally authorized execution, and it defines participation to include an action that could automatically cause an execution to be carried out on a condemned prisoner.

In a case in which the method of execution is lethal injection — the method now used in all 38 states with the death penalty — the code proscribes any involvement with the procedure, including consulting with or supervising lethal-injection personnel.
The AMA's policy may be found here. It reads in part:
Physician participation in an execution includes, but is not limited to, the following actions: prescribing or administering tranquilizers and other psychotropic agents and medications that are part of the execution procedure; monitoring vital signs on site or remotely (including monitoring electrocardiograms); attending or observing an execution as a physician; and rendering of technical advice regarding execution.

In the case where the method of execution is lethal injection, the following actions by the physician would also constitute physician participation in execution: selecting injection sites; starting intravenous lines as a port for a lethal injection device; prescribing, preparing, administering, or supervising injection drugs or their doses or types; inspecting, testing, or maintaining lethal injection devices; and consulting with or supervising lethal injection personnel.

The following actions do not constitute physician participation in execution: (1) testifying as to medical history and diagnoses or mental state as they relate to competence to stand trial, testifying as to relevant medical evidence during trial, testifying as to medical aspects of aggravating or mitigating circumstances during the penalty phase of a capital case, or testifying as to medical diagnoses as they relate to the legal assessment of competence for execution; (2) certifying death, provided that the condemned has been declared dead by another person; (3) witnessing an execution in a totally nonprofessional capacity; (4) witnessing an execution at the specific voluntary request of the condemned person, provided that the physician observes the execution in a nonprofessional capacity; and (5) relieving the acute suffering of a condemned person while awaiting execution, including providing tranquilizers at the specific voluntary request of the condemned person to help relieve pain or anxiety in anticipation of the execution.
The policy does not specifically address Governor Fletcher's situation, since it deals with direct physician participation with the actual execution. I agree that a physician shouldn't be the one to push the plunger, but Dr. Zitrin doesn't think that is enough:
Fletcher's legal advisor says the governor did not violate AMA guidelines or other ethical standards in signing the death warrant. Fletcher's role under the law is consistent with the roles of judges fulfilling their legal duty and jurors fulfilling their legal obligations regardless of their professions, he said.

But I believe that a physician is not freed of his obligation to comply with his profession's ethical mandates. If Fletcher wanted to forgo that obligation, he should have surrendered his license when he was elected.
Why? I thought the earning of a medical degree made one a physician, not a license to practice. Why should election preclude one to holding a medical license? What if the situation were such that Gov. Fletcher did not sign the death warrant himself, but had the power to commute the sentence? Would his refusal to do so constitute "participation" in an execution? Would physicians who served on juries considering capital cases be liable for sanction if they voted for the death penalty?
Dr. Zitrin however, is not merely an impartial observer, as illustrated in this October American Medical News article:
Arthur Zitrin, MD, is very familiar with this portion of the ethics code. Dr. Zitrin, an 86-year-old retired New York University psychiatrist and self-described death penalty abolitionist, is initiating one of the more controversial attacks on lethal injection. He is identifying physicians who participate in executions in hopes of getting their licenses revoked.

"My effort, and it's been a quixotic effort in some respects, is to identify doctors who participate in executions and work to have charges filed against them for violating medical ethics," Dr. Zitrin said. "It's very hard to identify these doctors. They're paid in cash and the department of corrections won't release their names."
So Dr. Zitrin is using the medical board as a political weapon against those that disagree with him. He has filed a complaint against a physician in Georgia for his involvement in executions:
Jim McNatt, MD, medical director for the Georgia board, would not comment on the case specifically but said that this type of complaint was not unique.

"The board gets put into political [arguments] all the time in several areas, and we have to look at the facts in each one," he said.

Dr. McNatt said complaints also are filed against doctors who perform abortions but that neither performing abortions nor participating in executions is illegal in Georgia.
I wonder how many more complaints will be filed against physicians performing abortions in Kentucky if Governor Fletcher is sanctioned? Others agree that Dr. Zitrin has gone too far:
New Haven, Conn.-based attorney Kenneth F. Baum, MD, disagrees. "Reasonable people can disagree on the death penalty, and reasonable people can disagree whether physicians should participate," he said. "But it's another thing for one physician to say 'My opinion is right' and to hunt down physicians who are participating in executions and take their licenses away."
While the complaint against the Georgia physician may have merit (he personally monitored executions and started a subclavian line in a prisoner who had no peripheral access) the crusade against Gov. Fletcher is silly and demeans the debate at hand.
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