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The California Medical Association, the American Medical Association (AMA), and the American Society of Anesthesiologists (ASA) immediately and loudly opposed such physician participation as a clear violation of medical ethics codes. "Physicians are healers, not executioners," the ASA's president told reporters. Nonetheless, in just two days, prison officials announced that they had found two willing anesthesiologists. The court agreed to maintain their anonymity and to allow them to shield their identities from witnesses. Both withdrew the day before the execution, however, after the Court of Appeals for the Ninth Circuit added a further stipulation requiring them to personally administer additional medication if the prisoner remained conscious or exhibited pain. This they would not accept. The execution was then postponed (Morales remained on death row as of January 2007), but federal courts have since continued to require that medical professionals assist with the administration of any execution by lethal injection.

Execution has become a medical procedure in the United States. That fact has forced a few doctors and nurses, asked to participate in executions, to choose between the ethical codes of their professions and the desires of broader society. The codes of medical societies are not always right and neither are the laws of society. There are vital but sometimes murky differences between acting skillfully, acting lawfully, and acting ethically. So how individual doctors and nurses have sorted these out and made their choices interested me.

The
Morales
ruling is the culmination of a steady evolution in methods of execution in the United States. On July 2, 1976, in deciding the case of
Gregg v. Georgia,
the Supreme Court legalized capital punishment after a decadelong moratorium on executions. Executions resumed six months later, on January 17, 1977, in Utah, with the death by firing squad of Gary Gilmore for the killing of Ben Bushnell, a Provo motel manager.

Death by firing squad, however, came to be regarded as too bloody and uncontrolled. (Gilmore's heart, for example, did not stop until two minutes after he was shot, and shooters have sometimes weakened at the trigger, as famously happened in 1951 in Utah when the five riflemen fired away from the target over Elisio Mares's heart, only to hit his right chest and cause him to bleed slowly to death.)

Hanging came to be regarded as still more inhumane. Under the best of circumstances, the cervical spine is broken at the second vertebra, the diaphragm is paralyzed, and the prisoner suffocates to death, a minutes-long process.

Gas chambers proved no better: asphyxiation from cyanide gas, which prevents cells from using oxygen by
inactivating a vital enzyme known as cytochrome oxidase, took even longer than death by hanging, and the public revolted at the vision of suffocating prisoners fighting for air and then seizing as their ability to use oxygen shut down. In Arizona, in 1992, for example, the asphyxiation of triple murderer Donald Harding took eleven minutes, and the sight was so horrifying that reporters cried, the attorney general vomited, and the prison warden announced he would resign if forced to conduct another such execution. Since 1976, only two prisoners have been executed by firing squad, three by hanging, and eleven by gas chamber.

Many more executions, 74 of the first hundred after
Gregg
and 153 in all, were by electrocution, which was thought to cause a swifter, more acceptable death. But officials found that the electrical flow frequently arced, cooking flesh and sometimes igniting prisoners--postmortem examinations often had to be delayed for the bodies to cool--and yet in the case of some prisoners, it took repeated jolts to kill them. In Alabama, in 1979, for example, John Louis Evans III was still alive after two cycles of 2,600 volts; the warden called Governor George Wallace, who told him to keep going, and only after a third cycle, with witnesses screaming in the gallery, and almost twenty minutes of suffering, did Evans finally die. Only Florida, Virginia, and Alabama persisted with electrocutions with any frequency, and under threat of Supreme Court review, they too abandoned the method.

Lethal injection now appears to be the sole method of execution accepted by courts as humane enough to satisfy Eighth Amendment requirements--largely because it medicalizes the process. The prisoner is laid supine on a hospital
gurney. A white bedsheet is drawn to his chest. An intravenous line flows into his arm. Under the protocol devised in 1977 by Dr. Stanley Deutsch, the chairman of anesthesiology at the University of Oklahoma, prisoners are first given 2,500 to 5,000 milligrams of sodium thiopental (five to ten times the recommended maximum for ordinary therapeutic use), which can produce death all by itself by causing complete cessation of the brain's electrical activity, followed by respiratory arrest and circulatory collapse. Death, however, can take fifteen minutes or longer with thiopental alone, and the prisoner may appear to gasp, struggle, or convulse. So 60 to 100 milligrams of pancuronium (ten times the usual dose) is injected one minute or so after the thiopental to paralyze the prisoner's muscles. Finally, 120 to 240 milliequivalents of potassium is given to produce rapid cardiac arrest.

Officials liked this method. Because it borrowed from established anesthesia techniques, it made execution more like familiar medical procedures than the grisly, backlash-inducing spectacle it had become. (In Missouri, executions were even moved to a prison-hospital procedure room.) It was less disturbing to witness. The drugs were cheap and routinely available. (Cyanide gas and 30,000-watt electrical generators, by comparison, were awfully hard to find.) And officials could turn to doctors and nurses to help with technical difficulties, attest to the painlessness and trustworthiness of the technique, and lend a more professional air to the proceedings.

But medicine balked. In 1980, when the first execution was planned using Deutsch's technique, the AMA passed a resolution against physician participation as a violation of core medical ethics. The resolution was quite general. It did
not address, for example, whether pronouncing death at the scene--something doctors had done at previous executions--was acceptable or not. So the AMA clarified the ban in its 1992 Code of Medical Ethics. Article 2.06 states, "A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution," although an individual physician's opinion about capital punishment remains "the personal moral decision of the individual." The code further stipulates that unacceptable participation includes prescribing or administering medications as part of the execution procedure, monitoring vital signs, rendering technical advice, selecting injection sites, starting or supervising placement of intravenous lines, or simply being present as a physician. Pronouncing death is also considered unacceptable, because the physician is not permitted to revive the prisoner if he or she is found to be alive. Only two actions are acceptable: provision, at the prisoner's request, of a sedative to calm anxiety beforehand and signing a death certificate after another person has pronounced death.

The code of ethics of the Society of Correctional Physicians establishes an even stricter ban: "The correctional health professional shall . . . not be involved in any aspect of execution of the death penalty." The American Nurses Association (ANA) has adopted a similar prohibition. Only the national pharmacists' society, the American Pharmaceutical Association, permits involvement, accepting the voluntary provision of execution medications by pharmacists as ethical conduct.

States, however, wanted a medical presence. In 1982, in Texas, the state prison medical director, Ralph Gray, and another doctor, Bascom Bentley, agreed to attend the country's
first execution by lethal injection, though only to pronounce death. But once on the scene, Gray was persuaded to examine the prisoner to show the team the best injection site. Still, the doctors refused to give advice about the injection itself and simply watched as the warden prepared the chemicals. When he tried to push the syringe, however, it did not work. He had mixed all the drugs together, and they had precipitated into a clot of white sludge.

"I could have told you that," one of the doctors reportedly said, shaking his head.

After a second effort, Gray went to pronounce the prisoner dead but found him still alive. The doctors were part of the team now, though; they suggested allowing time for more drugs to run in.

Today, all thirty-eight death-penalty states rely on lethal injection. Of 1,045 murderers executed since 1976, 876 were executed by injection. Against vigorous opposition from the AMA and state medical societies, thirty-five of the thirty-eight states explicitly allow physician participation in executions. Indeed, seventeen require it: Colorado, Florida, Georgia, Idaho, Louisiana, Mississippi, Nevada, North Carolina, New Hampshire, New Jersey, New Mexico, Oklahoma, Oregon, South Dakota, Virginia, Washington, and Wyoming. To protect participating physicians from license challenges for violating ethics codes, states commonly promise anonymity and provide legal immunity from such challenges. Nonetheless, despite the promised anonymity, several states have produced the physicians in court to vouch publicly for the legitimacy and painlessness of the procedure. And despite the immunity,
several physicians have faced license challenges, though none have lost as yet.

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?

I
T 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.