Medical Bag: What are the key takeaways of your paper?

Dr Litton: Focusing on the implications of the Hippocratic Oath and other bioethical principles, independent of the morality of the death penalty, cannot answer the question of whether physician participation in executions is permissible. Almost all commentary on the issue deems the moral status of capital punishment to be irrelevant. However, that is just not true. If the death penalty is terribly immoral or barbaric, then physicians have good reason to avoid participating in it. They should not be complicit in an immoral practice, especially if their participation only slightly reduces the risk of suffering in any particular case.

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On the other hand, imagine that the death penalty is crucial to justice. Then perhaps there is good reason to divorce the Hippocratic Oath applied in the clinical care setting from the ethics of this context. After all, in some contexts we permit the ethical rules governing physicians to deviate from the ethics of clinical care if an important social goal is at stake. For example, regardless of what many physicians think, the ethical framework governing medical research is distinct from the ethical framework governing clinical care. The bottom line is that this is an extremely complex issue, and foot stomping about the requirements of the Hippocratic Oath in the clinical care setting does not settle the matter.

Dr Zivot: Physicians cannot improve lethal injection by tinkering with it and have no mandate to generally reduce suffering. If they did, physicians would be faced with an enormous task. Suffering, only in the context of the physician-patient relationship, is within the ethical scope of the Hippocrattic Oath, and suffering itself might be considered an example of maleficence, which must be considered within a much broader ethical therapeutic mandate. Finally, some physicians may go further and claim that death itself is a form of treatment. Here, death by lethal injection transforms killing into healing. This same argument is offered as a justification for some forms of physician-assisted suicide and euthanasia.

Execution is not a disease cured by lethal injection. Suffering as a consequence of death by lethal injection is not a symptom of a terminal illness managed by palliative care. Lethal injection is an impersonation of medicine populated by real doctors who don’t acknowledge or understand the deception. It is not the job of medicine to fix lethal injection or capital punishment. Medicine should call for a moratorium on all executions by lethal injection. Lethal injection, by masking the signs of killing, has set the larger debate about our views on capital punishment back.

Lethal injection is fundamentally flawed by masking the outward signs of cruelty while permitting inward cruelty. A series of autopsies done on inmates executed by lethal injection revealed a common finding of organ failure including pulmonary edema, heart failure, and hepatic congestion. Lethal injection pretends to be causing an individual to die during sleep. In fact, lethal injection is killing and death by multi-organ failure. Up to now, medical practice remains culpable and time will tell whether lethal injection will be rightly set aside.

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Medical Bag: What should be the next steps in moving this discussion forward?

Dr Litton: We need to stop thinking that the issue is totally separate from the morality of the death penalty, and start learning the facts about the death penalty. I find that more knowledge about the death penalty makes people more skeptical about it. It costs the state more money to execute someone than it does to keep them in prison for life, and given constitutional requirements, there is no way to undermine that fact. The overwhelming bulk of evidence fails to show that it deters crime. It is barely used, and it is really relegated to a few counties in a few states.

The evidence clearly demonstrates that “who gets death” and “who gets life” is based on arbitrary facts, like the race of the victim or who had good representation. Moreover, we have a better sense of how often the criminal justice system gets it wrong, and there is no question that innocent people have been executed. Everyone — physicians included — must learn more about the death penalty and see that there is no reason to be complicit in this vanishing form of punishment.


  1. Medical assistance in dying. Government of Canada. Accessed December 11, 2017.
  2. Richardson B. D.C. physician-assisted suicide law goes into effect. The Washington Times. December 11, 2017.
  3. Tabo T. If Oregon can give death with dignity, why can’t death row? Above the Law. Accessed December 11, 2017.
  4. Radelet ML. Botched executions. Death Penalty Information Center. Accessed December 11, 2017.
  5. Truog RD, Cohen IG, Rockoff MA. Physicians, medical ethics, and execution by lethal injection. JAMA. 2014; 311(23):2375-2376.
  6. Litton P. Physician participation in executions, the morality of capital punishment, and the practical implications of their relationship. J Law Med Ethics. 2013;41(1):333-352.
  7. Zivot JB, Arensen K. Lessons learned from physician participation in lethal injection: Is Carter v. Canada a death knell for medical self-regulation? Can J Anaesth. 2016. 63:246-251.