A mid a furor over physician participation in California executions, a group of physicians is urging the Texas Medical Association (TMA) to take a stand against its members assisting in the completion of capital sentences.

The longstanding conflict between physicians' roles as healers and states' needs for physicians to assist in lethal-injection cases took a new turn when in March two California anesthesiologists declined to participate in an execution. Soon after, a group of physicians urged the TMA to call for an end to physician involvement in executions.

Every Texas execution requires at least one physician to examine the inmate and pronounce death, an activity that violates the AMA's ethics code, said the physician-activists, who include Abraham Halpern, M.D., a professor emeritus of psychiatry at New York Medical College and a former president of the American Academy of Psychiatry and the Law.

The physicians, who are part of Citizens United for Alternatives to the Death Penalty, urged the TMA to coordinate with the AMA to issue a statement concerning the ethics code's prohibition of participation by physicians in executions.

"The vast majority of physicians do not know what the AMA policy is on this, and they think they are helping the authorities and making the death of these prisoners more comfortable or peaceful, [a goal that] supports the code of medical ethics. All the while they are in violation of the code of ethics," Halpern said.

The AMA did not release a statement of its principles around the time of any of the recent Texas executions, according to an AMA spokesperson, who added that the organization does so when there is significant media interest.

A TMA spokesman said he was unaware of the physician activists' request. The TMA guidelines bar physician involvement beyond confirmation of a prisoner's death. AMA guidelines allow a physician to "certify death, provided that the condemned has been declared dead by another person."

"The AMA's Principles of Medical Ethics state that physicians should be `dedicated to providing competent medical care, with compassion and respect for human dignity and rights,'" said Jonathan Groner, M.D., a clinical associate professor of surgery at Ohio State University. He was among those urging the TMA action.

The TMA has not decided if its policy on physician involvement in the death penalty will be reviewed at its May membership meeting, but policy changes are usually undertaken only after an extensive review.

Ambivalence about the proper role of physicians in capital punishment cases was reflected in a November 2001 survey published in the Annals of Internal Medicine that questioned 100 practicing physicians. It found 41 percent would perform at least one action in capital punishment sentences disallowed by the AMA. Another 25 percent would perform five or more disallowed actions.

Those results reinforced an earlier survey published in the October 2000 Annals of Internal Medicine that found 80 percent thought at least one of the actions related to execution disallowed by the AMA was acceptable. Fifty-three percent indicated that five or more prohibited actions were acceptable, and 34 percent approved of all eight disallowed actions.

APA's position since 1980 has been against physician participation in carrying out capital punishment sentences. The APA position was based on the same arguments opponents of physician involvement continue to offer: that physician involvement with torture and killings in Nazi Germany, the Soviet Union, and other locations has shown that such involvement can smear the entire profession, according to APA's 1980 position paper opposing psychiatrist involvement with the death penalty.FIG1

The results of the surveys and the continued physician participation in executions, Halpern said, show that more physician education is needed to highlight the problems that arise when physicians become involved in state executions.

The AMA has no plans for a national educational effort of physicians on its death-penalty policies, but a publicity campaign describing its guidelines relating to medical conduct in general is under consideration, according to the spokesperson.

The issue of physician involvement in the death penalty was highlighted in March by a federal court mandate that an anesthesiologist participate in a scheduled California execution. The judge's order came after allegations that lethal-injection executions in California may have caused unnecessary suffering through poor sedation and inaccurate drug delivery. Two physicians, whose names were not released, volunteered to participate but balked when they realized the state required them to monitor the inmate actively, rather than passively monitor that proper steps were taken, according to Peter Warren, a spokesperson for the California Medical Association (CMA).

The CMA has since sponsored state legislation to bar the state from using physicians in executions. The CMA does not officially oppose the death penalty and allows physicians to sign the death certificates of executed prisoners but bars physicians from declaring an executed prisoner dead.

The response from hundreds of CMA members has been overwhelmingly in support of its efforts to bar physician involvement with the death penalty, Warren said.

"This is not a conservative/liberal issue. This is a physician issue," Warren said about the CMA's efforts. "It is not our concern whether or not this ends capital punishment in the state."

The CMA's guidelines against advising or observing executions also bar physicians from training prison staff to act in their stead during lethal injection, as some have suggested as a compromise.

The CMA has no position on punishing physicians who violate its guidelines on capital punishment, though there has been discussion recently over whether such a rule is needed, Warren said.

The physician advocates who criticized the TMA were also critical of the North Carolina Medical Society (NCMS) for not taking action against a physician who monitored the inmate's heartbeat as part of a recent execution. The NCMS has endorsed the AMA position on physician participation in executions since 1983.

"The society would frown on physician participation" in an execution, said Mike Edwards, an NCMS spokesperson. The physician would be" acting against the stand of the medical society."

Although the NCMS has no enforcement mechanism for physician members who operate counter to its guidelines, Edwards said, at least one member recently raised the possibility of reviewing that guideline.

Physician members of the AMA who violate its guidelines may be brought for a hearing before its Council on Ethical and Judicial Affairs. Priscilla Ray, M.D., a psychiatrist and chair of the AMA ethics council, said the council does not investigate whether physicians are actively involved in executions, counter to AMA guidelines. She said the council was recently made aware of a Georgia physician who publicly revealed an active role in executions. She would not confirm or deny that the council was investigating the physician's role.

The Georgia legislature recently moved to protect such physicians' medical licenses through legislation to protect any doctor who participates in carrying out a death sentence from being sanctioned by the state medical board.

The AMA position on the death penalty is posted at<www.ama-assn.org/ama/pub/category/8419.html>.▪