Hastings Center Report

It is hard to imagine two precepts that enjoy more uniform support among the international medical community than the ethical prohibitions against physician participation in capital punishment and torture. Yet the two articles in this issue of the Hastings Center Report challenge these sacred assumptions, arguing that the ethics of these issues are more complicated than they may seem, and that each deserves more nuanced consideration than it has received in the past.

I have personally written in opposition to the participation of physicians in capital punishment, and while I continue to support this view, I acknowledge that the arguments I used depended to some extent upon the consensus statements of medical societies around the world, and in this sense were circular and question-begging. I agree with Lawrence Nelson and Brandon Ashby that much of the literature on this topic assumes that physician participation in capital punishment is wrong because capital punishment itself is wrong, an argument that is problematic in places like the United States, where the practice is supported by the majority of the population and routinely performed in most of the states. What are needed and lacking are arguments that would convince those who support capital punishment that the involvement of physicians is wrong and should be prohibited.

Opposition to the participation of physicians in capital punishment is most commonly grounded in the view that physicians should not be involved in killing. Yet while the participation of physicians in the legal practice of physician-assisted suicide in Washington and Oregon is tolerated and largely viewed as a reasonable disagreement about a debatable aspect of medical ethics, no such tolerance has been shown to physicians who participate in capital punishment, despite the fact that it is legal in many more states and has been for a much longer period of time. Recently, the American Board of Anesthesiology announced that it would consider revoking the board certification of anesthesiologists who participate in lethal injection, threatening their very livelihood by taking away a qualification necessary for most jobs.

In my view, however, this point misses the critical ethical distinction between physician-assisted suicide and capital punishment, which is that the former is focused upon patient-centered goals, whereas the latter serves the goals of the state. If one believes, as I do, that the physicians' role should always be defined in terms of the individual and collective well-being of patients, then physicians must not participate in capital punishment. This view would not prohibit physicians from participating in a firing squad (in their role as citizens), but it would prohibit their participation in lethal injections (in their role as physicians). Nelson and Ashby provocatively assert that professional norms are not intrinsic to the profession, but must be negotiated with society at large. I disagree and believe that a coherent and internally consistent role morality for physicians can be constructed based upon the goals of medicine. I also think that these norms prohibit the involvement of physicians in state-sponsored killing.

Some physicians might respond by claiming that even if participation in executions falls outside of the norms of the medical profession, their involvement should be permitted because it serves the humanitarian goal of seeking to reduce suffering. But here, Chiara Lepora and Joseph Millum's thoughtful analysis of the ethics of complicity is very helpful. In their view, an important dimension of whether one is complicit in an act is the degree to which one shares the intentions of others who are engaged in the act. As such, they claim that physician involvement with torture victims may be ethically justifiable when the physician does not share the intent to torture. And while administering a sedative to a prisoner before an execution may similarly be justified in terms of the sole intention to benefit the inmate, anyone who engages in the administration of lethal drugs to the prisoner necessarily shares in the intention of the state, thereby rendering the physician complicit and the act unethical.

By courageously taking on these two iconic precepts in medical ethics, these authors have opened up very interesting avenues for further investigation...