Douglas R. Bacon, M.D., Editor

Descent Into Darkness?

The opinions expressed here are solely that of the editor.

ne of the classic episodes of “Star Trek,” the original series, is titled The Enemy Within. On a mission to survey a class “M” planet, Captain James T. Kirk beams down to the planet’s surface with various crew members to study flora and fauna and the environment in an effort to determine if the planet could support colonization. On return to the ship, there is a transporter malfunction, one which splits Kirk into two beings — one good, the other bad. The “evil” Kirk indulges his vices, essentially wine, women and song. The good Kirk is increasingly unable to make decisions and vacillates unlike the strong leader the captain has always been. Spock, the cerebral science officer, glimmers the reason — the “evil” Kirk is integral to making decisive decisions, but only under the discipline and the motivations of the “good” Kirk. In the end, the brilliant engineer Scotty fixes the transporter and beams the two beings into one whole Kirk. In a classic line, Kirk tells Spock that he has seen a part of himself that no man ought to see.

Perhaps the creators of “Star Trek” were on to something. The ethics with which we practice on a daily basis are in many respects a balance of our “good” and “bad” selves. Our internal moral compass gives us an intuitive sense of what is permissible and what is not. When conflict develops between our internal moral compass and the external societal expectations of correct ethical behavior, the practice of medicine becomes morally difficult; for example, the Jehovah’s Witness patient who for whatever reason begins to experience life-threatening hemorrhage during an operation and quite literally is dying before the anesthesiologist’s eyes. A simple blood transfusion will save the patient’s life, and in patients who are not Jehovah’s Witnesses, red cell and blood product transfusion is routine care. Yet, morally, we know that the Jehovah’s Witness patient has refused this treatment. We are obligated as physicians to respect this religious tenet and work hard to save the patient by all means short of transfusion. For some physicians, though, letting anyone die who can be saved is unethical, and balancing the wishes of patient autonomy with paternalistically appropriate medical care remains extremely difficult.

One of the more contentious ethical issues that has come before the anesthesiology community in the last 18 months is the participation of anesthesiologists in capital punishment. The American Medical Association (AMA) has a clear policy¹ on physician participation in this act of the state, and ASA has endorsed AMA’s position. In essence, the AMA policy is that any participation by a physician in any aspect of capital punishment is unethical, including determining if the condemned is dead and witnessing the execution as a professional witness. As a policy, it is well written and clear, with little room for interpretation. Thus it is easy to understand and follow and makes obvious the behavior deemed by AMA to be unethical.

In the September issue of the Mayo Clinic Proceedings, an anesthesiologist and ethicist, David Waisel, M.D., argues against the AMA policy in an article titled “Physician Participation in Capital Punishment.”² Additionally, his article outlines reasons why it may be permissible for physicians to be involved with executions, though his writing does not address the larger issues surrounding the ongoing debate about the appropriateness of capital punishment in general. Dr. Waisel’s essay is accompanied by two editorial comments — one by two respected anesthesiologists (William Lanier, M.D., and Keith Berge, M.D.)³ and another by a well-known ethicist (Arthur Caplan, Ph.D.).⁴ Taken as a whole, these three documents make fascinating reading, leaving the reader wondering which of the persuasive arguments should be internalized and become part of a personal ethical code and which are less valuable to the reader.

Dr. Waisel bases his argument on compassion for the condemned criminal in that the improper administration of execution drugs constitutes cruel and unusual punishment. For physicians who care for patients on a daily basis — and for anesthesiologists specifically, who rarely deal with the complications of drugs inadvertently administered subcutaneously — this argument almost engenders a reaction on the subconscious level. We, as anesthesiologists, do not like to see people hurt. Perhaps that is why the dismissive editorial of the nonphysician, Dr. Caplan, bothers me the most. His editorial consists of the usual ethical principle and moral arguments, ones that could easily be used to teach undergraduate courses in ethics. The answer is clear, concise and sterile. Yet for physicians, who have to apply these principles and opinions to the clinical situation before them, the answer never seems to be so transparent. Dr. Waisel’s unique perspective, that viewing the condemned as a patient will allow for physician participation in capital punishment, is something that Dr. Caplan cannot understand.

Drs. Lanier and Berge, both practicing anesthesiologists, acknowledge in their editorial this undercurrent of patient care, despite all reluctance on their part to call the condemned a patient. The opposition to Dr. Waisel’s arguments from Drs. Lanier and Berge are well reasoned, and they point out the underlying assumption that the issue of participation cannot be pulled out of the greater discussion surrounding capital punishment. As they point out, however, there are concerns with the current process and the means by which execution is carried out. Training executioners to monitor depth of anesthesia and intravenous access, the two areas where many of the problems with lethal injection have occurred, violates AMA — and by extension ASA policy. The convenient argument that veterinarian drugs and hence veterinarians should be substituted for physicians is passing the buck to another group that may be as reluctant to address or participate in the execution. The condemned is treated by an “animal doctor,” further dehumanizing the prisoner.

Throughout the three essays, the specter of the Nazi doctors, the purely evil side of medicine, haunts the debate. But almost always, there is little discussion of why Nazi physicians acted as they did. Dr. Waisel, an accomplished historian of anesthesiology in World War II, offers some insight. What is often forgotten is that while the crimes were horrific and the atrocities still scream out for retribution some 60 years later, the medical personnel were products of their time. The eugenics movement, taken to extremes in Nazi Germany, was, however, openly discussed in America. Anti-semitism, the cornerstone of Nazi political thought, had its dark underside in the United States as well. During medical school in the early 1980s, one of the professors, a semi-retired pathologist who taught me, spoke about the quota for acceptance of Jewish medical students in the 1930s. In point of fact, many of the leading medical schools and universities in this country in the 1920s and 1930s limited Jewish enrollment.5,6 The Nazi physicians had followed one branch of teaching to what they perceived as a logical conclusion — one that only the "evil" Kirk could imagine. To prove their hypothesis, they often massaged data to fit their hypothesis and ignored other observations that were contrary to what they wished to prove. As 21st-century physicians, it would be nice to say that we do not have these faults and that clearly they are not prevalent to the extent present in Nazi Germany. There are instances, though, whereby zealots have falsified data and published what amounted to fiction to further their goal. Only vigilant work by other doubting scientists in a society that encourages debate has demonstrated these grievous errors.

In the final analysis, what keeps us from descending into the abyss of Nazi Germany, as Dr. Waisel argues, is our open and free society. The importance of Dr. Waisel’s article, Drs. Berge and Lanier’s editorial and the thoughts of Dr. Caplan are not that any one particular individual is right but that there is respectful debate on all aspects of these questions. The first sentence of the AMA’s position on capital punishment states, “An individual’s opinion on capital punishment is the personal moral decision of the individual.”¹ Why then is participation condemned by AMA? If an individual favors capital punishment, why is it unethical for that person to participate? The AMA position is extremely restrictive, for an overt act such as starting an intravenous line is prohibited as well as the more covert rendering of technical advice about the amount of drug to be used.

In 2001, Faber et al.⁷ did an interesting study. In an anonymous questionnaire, they asked physicians if they would be willing to participate in capital punishment. The striking finding is that 19 percent of the respondents were willing to administer the lethal drugs, while 36 percent were willing to declare the patient dead — both actions specifically prohibited by AMA. If this study is accurate, there are a significant number of physicians who do not feel the AMA policy, and by extension the ASA policy, fully covers the situation. Has the time come for ASA to study this question? As this issue continues to smolder, anesthesiologists and other members of the anesthesia care team will most likely be asked to help develop skills for the executioner in intravenous line insertion and monitoring of anesthetic depth. If we choose to enter into this debate, we must ensure that voices that represent a minority, such as David Waisel’s, are heard and allowed to participate in the discussion. We must learn to allow our intellect to help discipline our emotions — yet we cannot forget that those very emotions are often the determining factor in what makes us good physicians. This is the essential lesson of The Enemy Within.

While we must acknowledge that it is within us, may we, as anesthesiologists, never see our evil side.

— D.R.B.

References:
1. www.ama-assn.org/ama/pub/category/8419.html. Accessed on September 4, 2007.
2. Waisel D. Physician participation in capital punishment. Mayo Clin Proc. 2007; 82(9):1073-1080.
3. Lanier WL, Berge KH. Physician involvement in capital punishment: Simplifying a complex calculus. Mayo Clin Proc. 2007; 82(9):1043-1046.
4. Caplan AL. Should physicians participate in capital punishment? Mayo Clin Proc. 2007; 82(9):1047-1048.
5. Steinberg S. The Academic Melting Pot. New Brunswick, NJ: The Carnegie Foundation. 1977:1-32.
6. Oren DA. Joining the Club: A History of the Jews and Yale. New Haven, CT: Yale University Press; 1986:146-167.
7. Faber NJ, Aboff BM, Weiner J, Davis EB, Boyer EG, Ubel PA. Physicians’ willingness to participate in the process of lethal injection for capital punishment. Ann Int Med. 2001; 135:884-888.

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