I see the needle and the damage done
A little part of it in everyone
July 14, 2006 -- Today the weekly PBS television show "NOW" ran a segment about U.S. health worker participation in executions. "Do No Harm?," by senior correspondent Maria Hinojosa and producer Michelle Smawley, is accompanied by a wealth of related materials on the PBS web site. These include a web-only extended interview with "Nurse Karen," a Georgia nurse who has participated in 14 executions but who, like virtually all such health workers, fears the disclosure of her identity. The materials present a balanced and thoughtful picture of health worker participation in executions, which, broadly speaking, violates nursing and physician ethics. The 38 U.S. states that execute prisoners using lethal injection seem to have trouble finding health professionals willing to help, even as judicial decisions addressing whether the practice is "cruel and unusual" punishment are increasing the need for such personnel. The PBS materials give greater weight to the ethical issues and consequences for physicians. And they consult only physician experts on broad policy issues, primarily Harvard physician and author Atul Gawande. We assume "Nurse Karen" received attention because she was the only one willing to speak on camera. But the NOW story does recognize the extent to which the issues involve nurses to a surprising degree. In addition to the "Nurse Karen" quotes, the materials include nurses in their accounts of executions. And they mostly avoid direct suggestions that the nurses report to physicians. A posted excerpt from a recent medical journal article by Gawande includes an interesting account of the management of an execution by an authoritative "nurse-in-charge" for a state penitentiary. And the PBS pieces include statements that the American Nurses Association's Code of Ethics bars nurse involvement in executions. Indeed, we count it as a victory that a mainstream press piece simply tells the public that nursing ethics exist. We thank those responsible for this piece.
The main piece is a mix of narration from Hinojosa and interview footage. It relies on "Karen" mainly for ground-level description of how lethal injection works and of some strong public opposition to the health workers' participation, including harassment. "Karen" tells how she puts the tourniquet on, cleans the site, and inserts the IV catheter. For the larger policy implications, the piece consults the conflicted Gawande, and to a lesser extent "attorney with a medical degree" Ken Baum, a vocal supporter of physician involvement. Hinojosa notes that in Georgia, three nurses and two physicians must attend executions. "Karen" and another nurse insert the IV's, corrections officers actually push the drugs, and "doctors are on hand to monitor the procedure and to pronounce death." This implies that the physicians supervise the nurses. At another point, Hinojosa describes a challenge to lethal injection filed by an inmate in which a physician "testified about inserting a catheter into a prisoner's arm after nurses, including Karen, were unable to do so." That statement, without explanation, will suggest that physicians generally have greater expertise than nurses in starting IV's, which is incorrect. Hinojosa does note that "Karen" believes she is there to act as a nurse, which means "to provide her medical expertise and comfort to the inmate."
Otherwise, the main piece is somewhat physician-centric. It does at times refer to the participation of "doctors and nurses," but there are a number of suggestions that only physicians really matter. Host David Brancaccio, in introducing and closing the piece, refers only to "doctors," and he quotes the Hippocratic oath. And the American Medical Association and its policies are mentioned in the main piece more than once; the ANA is not. There is discussion of the loss of medical licenses as a result of participation, but nothing about the loss of nursing licenses.
In the interview clips, "Karen" comes off as down-to-earth, but somewhat in denial about what she is doing. Hinojosa asks "Karen" if she was "aware" that the death penalty was "part of a huge national discussion"--which sounds like she's saying, we know you're just a nurse and probably not engaged with complex social issues, but did some physician who watches PBS perhaps mention it to you? In any case, "Karen" answers that she thought death penalty opponents would work to "get more legislation against it" rather than targeting those like herself who were "just carrying out a law." Indeed, several of her statements in the main piece suggest that "Karen" has persuaded herself that no one is actually executing the inmate:
I don't know that I consider anybody an executioner. Even the people that--that I know who push the drugs...I look at it as the state is the executioner. We're just carrying out procedures.
The "just carrying out procedures" line is chillingly reminiscent of a long line of "just following orders" justifications for wrongful acts. History would seem to show that the rightness of an act does not depend solely on whether a government wants you to do it. In particular, the death penalty may be right or wrong, but obviously it is the humans who are doing the killing who are doing the killing. At another point, in the web-extended interview, "Karen" suggests that participating even though she's a nurse is OK because she only does it a couple times a year, and that "somebody's got to do it."
Also in that interview, "Karen" elaborates on how she copes with her participation in executions. She says that after the execution "you just kind of leave and it's over...You don't do a lot of thinking about it." But despite that claim, she does note that she supports the death penalty, and she also seems to have a framework for thinking about it:
I look at them at an execution as [going through] a terminal illness. At the time that they were sentenced, they were diagnosed with a terminal illness. When they go through all of their appeals and everything, that's just like going on any kind of chemotherapy, radiation, whatever. And if all their appeals fail, then basically it's their terminal illness coming to an end. And therefore, I think it's with any patient, they need to have the dignity up until the very end. And I think that dignity is by having actual trained people to help them.
This is actually not a unique perspective. One of the physicians Gawande interviewed for his medical journal piece also said he saw the execution as a "terminal disease" that just happened to involve "a legal process rather than a medical process," and that he as a physician had the duty to make the execution "painless," though he would not "play the role of the executioner." That physician, Carlo Musso--the only execution participant mentioned in the piece who allowed his real name to become public--is actually a death penalty opponent who wishes the state would allow him to "cure" the disease by abolishing executions. In the main piece, "Karen" also says she would not actually give the drugs herself because of ethical concerns:
I guess it's very strange because I don't know what the real big difference is...I don't mind actually inserting the lines because that is something that I have been trained to do. But as far as administering an overdose, I just wouldn't want to do that.
Of course, this makes little sense. Karen has also been trained to give drugs.
We understand that "Karen" may have been the only execution participant willing to speak on camera, and we commend her for having the courage to do so. She has helped to make the public more aware of the key role nurses play in these difficult situations. But having the only nurse who appears on camera be someone who does not seem particularly well-qualified to discuss the larger policy and ethical implications, then offering the articulate Gawande and Baum to handle those big issues, sends the message that physicians handle the deep thinking and nurses are mostly busy hands. Indeed, at the end of the main piece, Gawande links physician participation in executions with other ways in which he believes the government is asking physicians to go against their profession's "core principles," citing the role of "medical personnel" in interrogations and the force-feeding of hunger strikers at Guantanamo. The issue of involvement in government-sponsored activities that may conflict with health care ethics is also a critical one for nurses, and many thoughtful, highly articulate nurses would have been willing and able to discuss it.
The PBS site also provides a separate page on which it sets forth brief statements of the positions of health care groups on participation in executions, along with relevant links. Three of the four items relate to the views of physicians. Indeed, the title of the page is: "Perspectives: Doctors Speak Out." The piece states the position of the American Society of Anesthesiologists, which seems to oppose all participation, though the item has nothing about the position of nurse anesthetists, who now provide most of the anesthesia given in the U.S. The piece explains that the AMA opposes most types of participation, such as starting the IVs or consulting with injection personnel. But the piece also describes the results of a 2000 study finding that about 80% of physicians surveyed approved of at least one of the eight types of participation the AMA forbids, that more than half approve of at least five, and that 34% approve of all of them.
But we were surprised to see that the last item under "Doctors Speak Out" describes the position of the ANA, which is "strongly opposed to nurse involvement in capital punishment." The item notes that the Code for Nurses, "nursing's ethical code of conduct," says that nurses do not "act deliberately to terminate the life of any person." The piece also notes that the ANA says nurses' obligation not to cause death should not be breached "even when sanctioned by the law," which seems to address "Nurse Karen"'s views on whether government orders confer ethical immunity. And the piece even provides a link to the ANA's position statement. In fact, as we noted in a June 2004 analysis, the ANA has maintained this position since at least 1994. We also noted then that the nature of execution by lethal injection--now the predominant form in the U.S.--is such that nursing would be a more relevant profession for the discussion. It is nurses who typically give injections, monitor vital signs and patient pain, and generally advocate for appropriate pain relief for patients. But the impression given by most of the PBS piece is that nurses mainly insert the IV line and provide "comfort."
The PBS site includes a long excerpt from Gawande's article about health worker participation in executions, which was published earlier this year in the New England Journal of Medicine. The title here is "When Law and Ethics Collide--Why Physicians Participate in Executions," although one of the five health workers who agreed to speak with the author was a nurse. The piece is a well-written and thoughtful exploration of health worker participation. Gawande concludes that although he does not personally oppose the death penalty, health workers should be legally barred from participating in it. He argues that medicine is being made an "instrument of punishment," that the participating health worker cannot really say that the inmate is her patient--what she does really serves the government's interests, not those of the inmate--and at the end of the day, the "hand of comfort" should not be "the hand of death." If that means we'll have executions that the courts find unconstitutionally "cruel and unusual," he asserts, then the death penalty should be abolished. This seems logical, though it could also be seen as a dodge, or even elitist: how can something be wrong for health workers but right for others? Is the idea that corrections officers or other citizens are less responsible for behaving humanely?
The nurse Gawande describes, whose identity is not disclosed, "fought as a Marine in Vietnam and later became a nurse." He had also served with an Army surgical unit in Bosnia and Iraq. This nurse had spent almost a decade as "nurse manager for a busy emergency department." Then he "took a job as the nurse-in-charge for his state penitentiary, where he helped with one execution by fatal injection." The nurse told Gawande that this was the state's first execution by lethal injection, and it sounds like he acted in part to prevent the inexperienced prison warden from causing unnecessary pain by trying to start the IV himself: "If this is to be done correctly, if it is to be done at all, then I am the person to do it." The nurse also seemed to be motivated in part by the particular facts of the case--the inmate had apparently killed many people, including four through accomplices even while he was in prison. But Gawande also notes that the nurse was not "easy" about his role; the nurse stated that "[a]s a Marine and a nurse...I hope I will never become someone who has no problem taking another person's life."
Gawande says that the nurse took his specific role in the execution seriously. He quotes the nurse: "As the leader of the health care team, 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." Gawande notes that the nurse consulted his state nursing board, which assured him that he could do everything but push the drugs--despite the ANA's ethical position. The nurse ordered the drugs from the pharmacist, and did a "dry run" with prison personnel and the "public citizen" chosen to push the drugs. For the execution, the nurse dressed in full surgical gear, "explained to the prisoner exactly what was going to happen," placed the IVs, and, at the warden's signal, told the citizen to push the drugs. The inmate's cardiac monitor reading was flat in three minutes, and Gawande writes that two physicians "had been left nothing to do except pronounce the inmate dead." The nurse did tell Gawande about the inmate's final words: "He didn't say anything about his guilt or innocence. He just said that the execution made all of us involved killers just like him."
This is a portrait of an assertive, capable, and articulate nursing leader with a more nuanced vision of what he was doing at one execution, although it is buried near the back of a lengthy web-only article that far fewer people will see. Some might also say the words "nurse" and "Marine" could stand to be combined in the media more often, as that could certainly help to dispel some stereotypes. This nurse recognized that he was helping to take a human life, and that there was an ethical issue with his participation--that he could not simply rely on the fact that what he was doing was lawful, and abdicate responsibility for thinking about whether it was ethical or right. But his state nursing board appears to have given him guidance that was inconsistent with the ANA position and the Code of Ethics. Of course, a nurse at this level could obviously be expected to learn for himself what the ethical standards were, and it's not clear from this piece if he made an effort to do so.
As Gawande suggests, health worker participation in executions is a just one example of health worker involvement in apparently lawful activities that may raise ethical or moral issues. These include end-of-life situations that may raise questions about stopping treatments or support, the use of certain pain relief methods, or euthanasia; situations involving government treatment of non-death row prisoners, such as those being interrogated; and situations involving pre-delivery human life, such as abortion, contraception, and stem cell research. As technology offers more ways to manipulate human life, and social pressure builds to use or not use them, there may be more situations in which health workers are unsure of their role.
So Gawande is correct that these are vital issues for the professions involved. They affect the level of trust the public will place in these practitioners, and indeed, the very nature of the professions themselves. At what point should a nurse refuse to engage in a lawful activity because it is inconsistent with her profession's ethical standards? Who decides what is "ethical" for a profession? Where should the ethical standards stop, and personal notions of morality take over? And there is one issue that the PBS materials oddly do not seem to raise directly--what are the ethical implications of helping the state execute someone who turns out to have been not guilty, as has occurred? Can nurses really trust the flawed legal system to tell them when someone has waived the right to life, or, if you prefer, when someone has developed a "terminal illness"? What about the possibility of misdiagnosis?
Bedside nurses are perhaps more likely than any other type of health professional to be deeply involved with patients in many of these situations and to need guidance on how to proceed. Sadly, the media rarely acknowledges that in stories like this. Instead, it often relies on physicians only for expert input, and frames its discussion in terms of the effects on physicians. Society tends to allocate its intellectual and other resources accordingly, and nurses suffer. But the PBS story is a partial exception to this media trend. We thank those responsible.