Better

by Atul Gawande

  States have affirmed that physicians and nurses--including those who are 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?

  IT IS NOT easy to find answers to these questions. Medical personnel who help with executions are difficult to identify and reluctant to discuss their roles, even when offered anonymity. Among the fifteen I was able to locate, however, I found four physicians and one nurse who agreed to speak with me; collectively, they have helped with at least forty-five 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 in his state. He was extremely uncomfortable talking about the subject. Nonetheless, he ultimately agreed to tell me his story.

  Almost sixty years old, he is board certified in internal medicine and critical care, and he and his family have lived in their small town for thirty years. He is well respected. Almost everyone of local standing comes to see him as their primary care physician--the bankers, his fellow doctors, the mayor. Among his patients is the warden of the maximum-security prison that happens to be in his town. One day several years ago, the two of them got talking during an appointment. The warden complained of difficulties staffing the prison clinic and asked Dr. A if he would be willing to see prisoners there occasionally. Dr. A said he would. He'd have made more money in his own clinic--the prison paid sixty-five dollars an hour--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. The state had a death penalty, and the legislature had voted to use lethal injection exclusively. The executions were to be carried out in the warden's prison. He needed doctors, he said. Would Dr. A help? He would not have to deliver the lethal injection. He would 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. "She said, 'Why do you want to go there?'" 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. Another convict had kidnapped, raped, and strangled to death an eleven-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 behavior of some of these people. . . ." Ultimately, 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 a glass window 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 recognized 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 signaled to another physician, who went out before the witnesses to place his stethoscope on the prisoner's unmoving chest. The doctor listened for thirty seconds and 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, to his parked car and headed home.

  In three subsequent executions there were difficulties, though, all with finding a vein for an IV. The prisoners were either obese or past 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 give a try?

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

  This was a turning point, though he didn't recognize 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. I asked him if he was afraid of the prisoner. "No," he said. The man was perfectly cooperative. 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 a local anesthetic. 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 350 pounds. 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 ten or twenty 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 darn close to it. And he seemed troubled by that.

  I asked him whether he had known that his actions--everything from his monitoring the executions to helping officials with the process of delivering the drugs--violated the AMA's ethics code. "I never had any inkling," he said. And indeed, the only survey done on this issue, in 1999, found that just 3 percent of doctors knew of any guidelines governing their participation in executions. The humaneness of a lethal injection Dr. A was 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 KILLER DOCTOR. A challenge to his medical license was filed with the state. If he wasn't aware earlier that there was an ethical issue at stake, he was now.

  Ninety percent of his patients supported him, he said, and the state medical board upheld his license 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 anymore and quit. He still defends what he did. Had he known of the AMA's position, though, "I never would have gotte
n involved," he said.

  DR. B SPOKE to me between clinic appointments. He is a family physician, and he has participated in some thirty executions. He became involved long ago, when electrocution was the primary method, and then 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. "One of my patients was a prison investigator," he said. "I never quite understood his role, but he was an intermediary between the state and the inmates. He was hired to monitor that the state was taking care of them. They had the first two executions after the death penalty was reinstated, and there was a problem with the second one, where the physicians were going in a minute or so after the event and still hearing heartbeats. The two physicians were doing this out of courtesy, because the facility was in their area. But the case unnerved them to the point that they quit. The officials had a lot of trouble finding another doctor after that. So that was when my patient talked to me."

  Dr. B did not really want to get involved. He was in his forties 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. "I wasn't on any bandwagons anymore." 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 judgment"--he agreed, "but only to do the pronouncement."

  The execution was a few days later 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 afterward.)

  Knowing the guidelines reassured him about his involvement and made him willing to continue. It also emboldened him to draw thicker boundaries around his participation. 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 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 agonize 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 agonizing comes instead from his doubts about whether anything is accomplished. "The whole system doesn't seem right," he told me toward the end of our conversation. "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."

  THE MEDICAL PEOPLE most wary of speaking to me were those who worked as full-time employees in state prison systems. Nonetheless, two did agree to speak, one a physician in a southern state prison and the other a nurse who had worked in a prison out west. Both seemed less conflicted about being involved in executions than Dr. A or Dr. B.

  The physician, Dr. C, was younger than the others and relatively junior among his prison's doctors. He did not trust me to keep his identity confidential, and I think he worried for his job if anyone found out about our conversation. As a result, although I had independent information that he had participated in at least two executions, he would speak only in general terms about the involvement of doctors. But he was clear about what he believed.

  "I think that if you're going to work in the correctional setting, [participating in executions] is potentially a component of what you need to do," he said. "It is only a tiny part of anything that you're doing as part of your public health service. A lot of society thinks these people should not get any care at all." But in his job he must follow the law and it obligates him to provide proper care, he said. It also has set the prisoners' punishment. "Thirteen jurors, citizens of the state, have made a decision. And if I live in that state and that's the law, then I would see it as being an obligation to be available."

  He explained further. "I think that if I had to face someone I loved being put to death, I would want that done by lethal injection, and I would want to know that it is done competently."

  The nurse saw his participation in fairly similar terms. He had fought as a marine in Vietnam and later became 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 naivete 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."

  This is not to say that he felt easy about it, however. "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 t
o an official with the state nursing board about the process, and although involvement is against the ANA'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, and 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.