Physicians & The State Execution of Murderers: No Ethical/Medical Dilemma
The Hippocratic Oath and “Do No Harm” have nothing to do with executions
Dudley Sharp, Justice Matters, contact info below
Some in the medical community have attempted to create an ethical prohibition against medical professionals involvement in state executions by invoking the famous “do no harm” credo and the Hippocratic Oath.
It is a dishonest effort. Neither reference is in the context of the state execution of murderers. I find the effort to ban medical professionals participation in executions an unethical effort to fabricate professional ethical standards, based upon personal anti death penalty feelings.
The Hippocratic Oath: Classical Version
The select Hippocratic Oath quote, in its original (translated) form, is
“I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.” (1)
This is a prohibition against euthanasia and abortion and has nothing to do with the fabricated medical prohibition of participation in state sanctioned executions.
I am unaware of any other ancient texts or translations which indicate a historical context, with that quote, that prohibits physicians from participation in executions.
In 2004, Dr. Markel, a medical historian, writes, “There are two highly controversial vows in the original Hippocratic Oath that we continue to ponder and struggle with as a profession: the pledges never to participate in euthanasia and abortion.” (2)
In reality, these are, barely, controversial, now. They are, however, inconvenient. Dr. Markel’s article never mentions a context of state execution of murderers, because the oath has nothing to do with it.
Dr. Markel continues: “The Hippocratics’ reasons for refusing to participate in euthanasia may have been based on a philosophical or moral belief in preserving the sanctity of life or simply on their wish to avoid involvement in any act of assisted suicide, murder, or manslaughter.” (2)
Dr. Markel is speculating. What we do know is that it was a reference to euthanasia and abortion, specifically. There is not even speculation, by Dr. Markel, that the reference had anything to do with the state execution of murderers.
The following are ” . . .the results of a study . . . in which 157 deans of allopathic and osteopathic schools of medicine in Canada and the United States were surveyed regarding the use of the Hippocratic Oath”: (3)
1. In 1993, 98% of schools administered some form of the Oath.
2. In 1928, only 26% of schools administered some form of the Oath.
3. Only 1 school used the original Hippocratic Oath.
4. 68 schools used versions of the original Hippocratic Oath.
5. 100% of current Oaths pledge a commitment to patients.
6. Only 43% vow to be accountable for their actions.
7. 14% include a prohibition against euthanasia.
8. Only 11% invoke a diety.
9. 8% prohibit abortion.
10. Only 3% prohibit sexual contact with patients.
There is no mention of the state execution of murderers, because the Hippocratic Oath has nothing to do with it.
Although there is no prohibition on the death penalty, there is one against both euthanasia and abortion. Yet, various medical associations have fabricated an imagined ethical problem with the death penalty and have, nearly, fully accepted both abortion and euthanasia.
Now, only 3% prohibit sexual contact with patients, but the original Hippocratic Oath states:
“Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.”
100% pledge a commitment to their patients, but only 43% vow being accountable for their medical actions. Some commitment. What ethics?
With these survey results and with medical professionals bringing up the Hippocratic Oath, as if it has something to say in the death penalty debate, possibly we should, now, in the true context of euthanasia and abortion, and other issues, call it what it has become, the Hypocrisy Oath.
For example, In January 2007, The North Carolina Medical Board adopted a policy that physicians participating in executions may lose their licence. In 2009, The North Carolina Supreme Court vacated the Board’s policy, finding that they had exceeded their authority.
Did the Board attempt to prevent physicians from performing abortions or have they issued a statement condemning physicians’ participation in euthanasia? Of course not.
The Oath of Hippocrates – Modern Version
The modern version is, most often, identified as that penned by Louis Lasagna in 1964.
It states: “it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.” (4)
This is in the context of killing innocent lives through either abortion or euthanasia.
Quite the about face.
The quote shows physicians’ medical ethical/moral acceptance of taking innocent lives.
Do No Harm
The famous physician credo “First, do no harm” (a phrase translated into Latin as “Primum non nocere”) is often mistakenly ascribed to the (Hippocratic) oath, although it appears nowhere in that venerable pledge.” (2)
“Hippocrates came closest to issuing this directive in his treatise Epidemics, in an axiom that reads, “As to disease, make a habit of two things — to help, or at least, to do no harm.” (2)
“As to disease”. Nothing else. There is no relevance outside medicine and, most certainly, no prohibition against medical professionals participation in the state execution of murderers.
Reason & Reality
Those ethical codes pertain to the medical profession, only, and to patients, only.
Judicial execution is not part of the medical profession and executions do not make death row inmates patients. Is that news?
The editors of The Public Library of Science (PLoS) Medicine agree. They write:
“Execution by lethal injection, even if it uses tools of intensive care such as intravenous tubing and beeping heart monitors, has the same relationship to medicine that an executioner’s axe has to surgery.” (”Lethal Injection Is Not Humane”, PLoS, 4/24/07).
So to, The American Society of Anesthesiologists:
“Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine. (”Statement on Physician Nonparticipation in Legally Authorized Executions,” 10/18/06).
Both confirm the obvious point: The state execution of murderers is not equivalent or connected to the medical treatment of patients. There is no ethical or moral connection. Hardly a mystery.
Any rational person can see that the state execution of murderers is not a medical treatment, but a criminal justice sanction. The basis for medical treatment is to improve the plight of the patient, for which the medical profession provides obvious and daily exceptions. The basis for execution is to carry out a criminal justice sentence where death is the sanction.
Doctors and nurses can be police and soldiers and can kill, when deemed appropriate, within those lines of duty and without violating the ethical codes of their medical profession, because there is no ethical connection. Similarly, medical professionals do not violate medical codes of ethics, when participating in the state execution of murderers.
Physicians are often part of double or triple blind studies where there is hope that the tested drugs may, someday, prove beneficial. The physicians and other researchers know that many patients, taking placebos or less effective drugs, will suffer more additional harm or death because they are not taking the subject drug or that the subject drug will actually harm or kill more patients than the placebo of other drugs used in the study.
Physicians knowingly harm individual patients, in direct contradiction to their “do no harm” oath.
For the greater good, those physicians sacrifice innocent, willing and brave patients. Of course, there have been medical experiments without consent and, even, today, they continue (”Critical Care Without Consent”, Washington Post, May 27, 2007; Page A01).
Physicians knowingly make exceptions to their “do no harm” requirement, every day, within their profession, where that code actually does apply. And, in many cases, they should. There are obvious ethical nuances and we should consider and pay attention to them, as is done within the medical profession.
SEE DO NO HARM: Additional Notes, at bottom.
Physicians and medical institutions should chose ethical guidelines which are truly relevant to their profession.
Many medical professionals need to stop the ridiculous ethical posturing and tell the truth – they don’t like the death penalty. In medical writings, against executions, you can easily find a strong bias, evidenced by use of the common and inaccurate anti death penalty claims, with no apparent effort at fact checking or balance. (5)
Any participation in executions by medical professionals should be a matter for their own personal conscience. In fact, 20-40% of doctors surveyed would participate in the execution process.
If this physician created mess had been about long standing medical ethics, based upon Hippocrates or “do no harm”, then there would be an effort to stop medical professionals from participating in euthanasia and abortion. In fact, the opposite has occurred. Instead, irresponsible medical professionals have turned those obvious, historical ethical standards upside down and have fabricated, out of thin air, a prohibition against the death penalty.
Why? For personal reasons, some have decided the formerly unethical medical practices of abortion and euthanasia are, now, just fine and that the non medical death penalty is prohibited by a fabricated medical ethic.
There is no foundation for an ethical prohibition against medical professionals participating in executions. Stop using personal bias to fabricate one.
DO NO HARM: Additional Notes:
40,000 to 100,000 innocents die, every year, in the US because of medical misadventure or improper medical treatment. (6)
It appears that some 500-1000 innocent patients die, every year, in the US, due to some type of medical misadventure, with anesthesia. (6)
There is no proof of an innocent executed in the US since 1900.
Furthermore, even with errors in lethal injection, those cases resulted in the death of the inmate – the intended outcome for the guilty murderer.
In the errors of medical professionals, we are speaking of a large number of deaths and injuries to innocent patients – the opposite of the intended outcome.
1) The Hippocratic Oath: Classical Version, http://www.pbs.org/wgbh/nova/doctors/oath_classical.html
2) “‘I Swear by Apollo’ – On Taking the Hippocratic Oath”, New England Journal of Medicine, May 13, 2004 article, by Howard Markel, PhD, MD, Director of the Center for the History of Medicine at the University of Michigan Medical School
3) “The Use of the Hippocratic Oath: A Review of 20th Century Practice and a Content Analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993.” by Robert D. Orr, M.D. and Norman Pang, M.D. http://www.imagerynet.com/hippo.ama.html
4) The Hippocratic Oath – Modern Version, http://www.pbs.org/wgbh/nova/doctors/oath_modern.html
5) “An absolute: Doctors don’t kill”, op/ed, by Dr. Charles van der Horst, News and Observer, Dec 04, 2008). My response to him can be found as “Is Dr. van der Horst just ignorant or something else? Doc?” in the comments section for “Clap hands, here comes Charlie”, UNC Healthcare Blog, December 8, 2008, 4:30 pm
6) “Deaths from Medical Misadventure”at
“Health Grades Quality Study: Patient Safety in American Hospitals, July 2004″
Dutch Protocol for Euthanasia
The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:
Intravenous administration is the most reliable and rapid way to accomplish euthanasia and therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.
originally written May, 2005. Updated as merited.
copyright 2005-2009 Dudley Sharp – Permission for distribution of this document, in whole or in part, is approved with proper attribution.
Dudley Sharp, Justice Matters
e-mail firstname.lastname@example.org, 713-622-5491,
Mr. Sharp has appeared on ABC, BBC, CBS, CNN, C-SPAN, FOX, NBC, NPR, PBS , VOA and many other TV and radio networks, on such programs as Nightline, The News Hour with Jim Lehrer, The O’Reilly Factor, etc., has been quoted in newspapers throughout the world and is a published author.
A former opponent of capital punishment, he has written and granted interviews about, testified on and debated the subject of the death penalty, extensively and internationally.
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Tradition is a construct to ensure beneficial behaviors, honed by trial and error or by innovative conjecture, developed by earlier generations are continued. It is a means for best practices from past collective knowledge to persist for the benefit of current and future generations. From the cultural perspective, a tradition may evolve that directs desired behaviors beneficial to maintain accepted standards or establish positive aspirations defined at that moment in time. But if following tradition becomes outdated, less relevant, and problematic to apply, then it should be overhauled, or if necessary, discarded entirely. Updating the old traditions or formulating new doctrine shall address the current environment without the compromise of an artificially constructed link to past precepts. The mindset of tradition for tradition’s sake must be severed. At least to a sufficient extent that there is no unwarranted hysteresis, but retention of relevant lessons learned should still inform the update.
The application of the Hippocratic Oath to capital punishment is problematic and inappropriate on at least two significant grounds. The Hippocratic Oath has metastasized into scores of variants that are contradictory concerning life ending procedures. Secondly, capital punishment being a process of law is outside the scope of the Hippocratic Oath.
As is historically recorded, the Oath is mutable to such an extent that, at present, there is a proverbial Tower of Babel number of variants pledged across the medical landscape. The incorporation of fluctuating politics, morality, and technological capability generates the multiplicity of Oaths that we see today. In so doing, the eventuality of having contradictory Hippocratic Oaths addressing the two capital punishment alternatives is inevitable. Since no extant, historical, or devisable Hippocratic Oath representing the consensus of the medical community can be comprehensive, absolute, applicable, and infallible, or more succinctly, universally agreed upon, Hippocratic Oaths are then relative. This makes the fundamental decidability of whether capital punishment is ethical or not becomes indeterminate. Bottom line? For the medical profession to involve themselves in executions is neither right nor wrong, regardless of the Oath in question. This unresolvable ambiguity nullifies any attempt to use an ethical argument as the basis of refusing involvement in lethal injection if contrary to any particular Hippocratic Oath. There is no fundamental conflict for a doctor to perform an execution by lethal injection.
Doctors are requested to perform a procedure as part of the compliance for a determination of law, not an act subject to medical ethics. The Hippocratic Oath clearly addresses only attending those who are sick or injured. It is clear within the medical community that if an individual does not require medical treatment, a doctor will stand firm on this precept and deny any treatment. This is what makes procedures carried out under the law, and not medicine, allowable. Complying with criminal law requires no merit-based authorization for entitlement. The scope of civil law, wherein capital punishment exists, is defined politically, hence no ethical review is necessary. (Said somewhat in jest, but not entirely. “Is there ethics in politics?” is a topic for another day!)
In the United States, capital punishment is held to be controversial on moral grounds. Corporal punishment is enacted by individual states, but still subject to overarching guidelines specified by the Constitution of the United States and the Bill of Rights. Wherever capital punishment by means of lethal injection is allowed, the law has restricted the role of performing the operations that result in the death of the offender to licensed medical professionals only. What is the reason for this restriction? Federal and state constitutional law does not specify any restriction on who may perform any capital punishment procedures. The main impetus for the restrictions is the provision contained within the United States Bill of Rights stating that citizens shall be free from “cruel and unusual punishment.” It is the United States citizenry’s wide range of this right’s interpretation, which includes capital punishment, that underpins the controversy. For a state wanting to legislate capital punishment as a constitutionally lawful act, and to avoid it’s overturning by judicial review, the strongest position is to restrict the responsibility of performing an execution to that group representing the most qualified to perform the defined procedures. A doctor performing an execution procedure can rely on her training and her years of experience to guarantee a successful and incident free outcome. No other occupation deals with a procedure so in common with standard medicine
However, the safety engineering community can devise more than enough effective and reliable solutions to accurately perform a lethal injection, evaluate the outcome, and overcome any irregularities. Doctors receive training to make them proficient for a wide variety of medical situations they will encounter. This makes the formidable licensing requirement a reasonable demand. In this context, the process of lethal injection is a simple, limited, and repeated procedure with few complications. Reliability can be easily designed in the procedure and for effective potential backup procedures as may be necessary. In this case, it requires far less comprehensive knowledge and training to become as proficient as a medical doctor. Many other professions that involve direct responsibility for the lives of others require training and certification, and are available for any citizen to pursue. Airline pilots are an exemplar profession requiring significant training and skill in service of the prime directive. That, of course, is being responsible for protecting the lives of the passengers and crew, and any others becoming involved by cause of pilot decision making. This responsibility includes the potential choice of the ultimate sacrifice to ensure the well-being of their passengers and others.
Then what could be the issue with a sufficiently robust licensing program for non-medical citizens to qualify as lethal injection specialists? There are no issues.