Executioner/Doctor

There was a very bad op-ed published in the NY Times Saturday by the writer/cardiologist, Dr. Sandeep Jauhar.  It's called "Why It's OK for Doctors to Participate in Executions" and that pretty much tells you all you need know.  If you were to  read something online entitled "Why It's OK for Rapists to Babysit Your Child" you would feel the same filthy layer of scum descend upon your skin as I felt when I read Dr Jauhar's inexplicable ode to Doctors of Death.

The piece comes on the heels of a recent decision by the good ol' state of Arkansas to execute 8 men on death row over the next 11 days--- not because their crimes were particularly heinous or irrefutable, or just from sheer coincidence, or some other fluke of timing in the sentencing--- but rather because the state's supply of IV drugs used in executions is due to expire by the end of the month.  There's enough in that last batch, apparently, to knock off 8 inmates.  So...while the iron is hot....

Dr Jauhar makes the error of assuming that capital punishment will never go away, that all we can do as a society is to figure out ways of rendering it in a less mendacious, less barbaric, more telegenic fashion.  And who better to assure that a lethal drug cocktail will be administered with elan and efficacy than a practicing physician?  After all, medical errors are the 3rd leading cause of death in our great country! Allegedly.

I need to break Dr Jauhar's piece down paragraph by excruciating paragraph.  It's the only way to do this with any justice.  Here's one paragraph:

The three drugs in Arkansas’s execution protocol — midazolam; vecuronium bromide, a paralytic used during surgery that halts breathing; and potassium chloride, which stops the heart — are administered intravenously. The execution procedure therefore requires the insertion of catheters, controlled injection of lethal drugs and monitoring of a prisoner’s vital signs to confirm death. This makes it important that a doctor be present to assist in some capacity with the killing.

What is it about "insertion of catheters, controlled injection of lethal drugs, and monitoring of a prisoner's vital signs" unequivocally necessitate the presence of a physician?  The next time I witness an actual real live doctor place a peripheral IV in a patient, inject a medication all by himself, and then check a set of vital signs will be the first in at least a decade of practice.  There is nothing about the act of lethal injection that is inseparable from physician presence.  The idea that basic procedures performed every day by nurses and EMT personnel cannot be duly done without a physician watching over their shoulders is both condescending and ill-informed.

Here's another paragraph:

 The American Medical Association, however, strongly opposes physician participation in executions on ethical grounds. Selecting injection sites, starting intravenous lines and supervising administration of lethal drugs, the association says, violate a doctor’s oath to heal or at least to do no harm. Doctors who defy the association’s guidelines face censure and the threat that a state medical board might revoke their license, though it is doubtful such punishment has ever been carried out. I disagree with this view. Though I oppose capital punishment as a matter of principle, as a doctor I believe physician presence at executions is consistent with our mandate to alleviate suffering.

Who edited this piece? Here we have a physician outlining the American Medical Association's firm stance opposing any physician participation in lethal injection executions and then, blithely, distancing himself from that view while still claiming to hold a higher moral ground---- he only wants to alleviate suffering!  That's obnoxious, man.  You want to stick a doctor in a death chamber with vials full of instant death and call yourself a hero because you are allowing for the state to eradicate a human in a way that seems quiet and unobtrusive and clean.  Even the kids can come out to watch.  Watch the bad man go to sleep, Johnny.  See?  See how peaceful he looks?  Is that a smile on his lips?  He's happier now!  His sin has been purified! Christ has smited him!.  Satan has him now!

I have to go to another paragraph before I start writing 3000 words in the voice of a Evangelical Christian from Little Rock talking to his kid at a state sanctioned execution:

A lot can go wrong during lethal injections. In 2014 in Oklahoma, to cite just one gruesome example, a 38-year-old convicted murderer named Clayton Lockett writhed in pain at his execution, clenching his teeth and straining to lift his head off the pillow, according to witnesses, after a botched injection into a vein in his groin.

A lot can go wrong?  Even with lethal injection?  State sanctioned murder for more civilized and  sophisticated tastes?  You don't say!   You mean that when dangerous drugs are given off label for purposes they weren't meant for that sometimes things can "get a little hairy"?  That's some wild and wacky shit.  Short side tangent here: Do you know why vecuronium is always included in lethal injection cocktails?  Because it is a strong paralyzing agent.  My anesthesiologist colleagues often use it to render a patient completely still when I perform abdominal surgery.  The purpose of the drug in a death chamber is pure optics.  The third drug administered, the actual killer, is generally a lethal dose of potassium chloride.  Once injected it causes a massive myocardial infarction--- which is excruciating.  Even the injection of KCL into the veins itself will make it feel like your arm has been lit on fire.  So to spare us the "theatrics" of a condemned man writhing and groaning in agony while strapped to a gurney, we give the paralyzing agent as cloak; to hide the unsavory awfulness of what an execution actually entails.

Here's 2 paragraphs in a row:

The A.M.A.’s position is principled and respects a long history of bioethics in this country. However, it is not practical. States that do not require physician presence typically use other medical professionals, such as emergency medical technicians or paramedics, to insert IV lines and possibly mix the drugs. Barring doctors from executions will only increase the risk that prisoners will unduly suffer.

 Physician participation does not guarantee an execution won’t be bungled (a doctor administered the injection at Mr. Lockett’s execution), and I know of no studies of its efficacy (physician participation has been largely shrouded in secrecy because of the stigma attached). But it is hard to believe there would be more chance of a botched injection or inadequate anesthesia if medically qualified personnel were present.

Man, this is bad writing.  Bad in the way of coherence.   Paragraph one avers that physician absence from executions will unduly increase suffering of prisoners.  Paragraph two alludes to a notorious case where unnecessary suffering endured by prisoner was caused entirely by the physician present who negligently placed the IV and monitored the proceedings.  So, ok.  Forget about that one.  Mulligan rule in effect.  In general, it would be better if a doctor was present.  Got ya Dr Jauhar.

Another fucking paragraph:

Discouraging physician participation, as the American Medical Association does, will not lead to a ban on capital punishment or lethal injection. If anything, it will lead only to the reinstatement of more brutal forms of execution that do not require medical expertise, such as electrocution or death by firing squad. A few states have already decided to use these methods as possible alternatives.

Well fuck yes.  Bring back the firing squad, the hang man's noose, Old Sparky.  The goddam guillotine.  Get that shit out of the attic and fire it up.  If we want to keep up with our remaining capital punishment brethren like Pakistan and China and Saudi Arabia and North Korea then we need to have all options available, on the table, plugged in, ready to roll.  All these goddam snowflake liberals putting pressure on pharmaceutical companies to not sell perfectly fine killer drugs to state executioners is preventing us from actualizing our potential as world leaders in the realm of State Murder.

I mean seriously, Dr Jauhar.  You're afraid we might have to resort to "more brutal forms of execution"?  OMG.  Then we, as a nation, might have to actually be exposed to what it actually means to clinically and dispassionately murder under the auspices of state power.  How awful and...inconvenient.  Much better to just shove an IV into some random bad guy and inject him with MAGIC MEDICINE that sends him off to eternal sleep.  Fuck that man.  All the better to bring back the firing squads.  Maybe then the tide of public opinion  will turn and we can rejoin the rest of advanced western civilization and ban the practice outright.

Here are 3 final  paragraphs I did not like:

Doctors have a duty to alleviate suffering. No one would object to a doctor’s providing comfort — spiritual or narcotic — to a terminally ill patient at the hour of death. It is not a stretch to think of death-row inmates who have exhausted their appeals as having a terminal disease with 100 percent mortality.

I recognize the moral quandary that the situation presents for doctors whose hope is that killing by the state will end. But as Arkansas has shown, states will go to great lengths to execute criminals, even at the risk of causing undue suffering.

Doctors can act as a safeguard against this brutality. Participating in executions does not make the doctor the executioner, just as providing comfort care to a terminally ill patient does not make the doctor the bearer of the disease

Ok.  I had to shower before finishing this blog post.  It seems that Dr Jauhar is equating the role of a doctor/executioner with that of a palliative care physician tending to a terminally ill patient with cancer.  This is just brutally obtuse.  Beyond issues of consent and autonomy (a prisoner isn't looking for a more chill, more comfortable way to die; he is looking for ways to not die while a terminal cancer patient generally comes to terms with his/her fate and seeks a more humane exit and thus invites the palliative care physician willingly), Dr Jauhar once again mistakenly assumes there must be a direct link between lethal injection and the practice of medicine.  Presumably because of all the accoutrements of what we ordinarily associate with health care, i.e. the white coats, gurneys, sterile equipment, latex gloves, IV tubing, vials of medications.  But he's fallen for the 3 card Monte scam.  It's pure artifice.  All the medical legerdemain cannot completely hide the fact that murder is murder is murder, no matter how prettily one chooses to gussy it up.  We'd be better off lining up inmates against brick walls of old abandoned urban factories and unleashing the firing squads..  At least it would be honest.

Dr Jauhar's piece doesn't entirely elide the controversy of capital punishment (he actually claims to be opposed to it in his 4th paragraph) but he simply accepts it as inevitable.  This is the stance of complacency in the face of authoritarianism.  He doesn't want to stake out a position on the real moral question.  Instead, he aims to convince his readers that one must make the best of things by involving physicians in an act that repudiates and undermines the essence of what it means to be a doctor.  For the sake of compassion.  His tears and, more likely, his squeamishness at seeing a man struggle while strapped to a state owned gurney, have clouded his judgment.  He rushes forward to assuage the pain of the condemned without first pausing and asking himself if it is the pain that ought to cease or the act of murder itself.

He referenced Ledell Lee in his first paragraph.  Mr Lee was put to death 2 days ago in Arkansas.  He was convicted of a murder in 1993 that he adamantly denied.  His case hinged on the testimony from a jail house snitch.  There were no eye witnesses.  No DNA evidence tying him to the murder.  The judge at his trial was having an active affair with the prosecuting attorney in the case.  His own court appointed defense attorney was a known substance abuser who showed up drunk to at least one of his hearings,

Yeah.  I guess what he really needed on Thursday was a board certified anesthesiologist or general surgeon to be present for the central line insertion and the drawing up of the drugs.  Because compassion.

I'll give Dr Jauhar the benefit of the doubt and assume he unwittingly allowed himself to be co-opted by capital punishment proponents for the purpose of glazing the whole sordid spectacle of state sanctioned murder with a thin sheen of legitimacy by arguing for physician participation in the brutal, horrific act disavowed by all other advanced liberal democracies.  We all make mistakes.  But as a physician who has taken the Hippocratic Oath, he really ought to retract his piece.....