The 11th-hour refusal by two anesthesiologists to participate in the planned execution of convicted killer Michael Morales underscored the ethical concerns of many physicians, who are bound by the rules of their profession to "do no harm."
"Physicians are healers, not executioners," said the American Society of Anesthesiologists, in a statement typical of those issued by other physician groups. "The doctor-patient relationship depends upon the inviolate principle that a doctor uses his or her medical expertise only for the benefit of patients."
Originally, the two unidentified private anesthesiologists agreed to monitor Morales' consciousness as he was being executed to ensure that he could not feel pain.
They had volunteered to comply with an order by U.S. District Court Judge Jeremy Fogel in response to claims by Morales' attorneys that lethal injection violated a constitutional ban on cruel and unusual punishment.
Fogel offered three options for the execution: giving a lethal injection of barbiturates only (which is not believed to cause pain); a stay of the execution pending a hearing; or having an anesthesiologist on hand to ensure Morales was unconscious when a three-chemical injection was administered.
State corrections officials chose the three-chemical option involving anesthesiologists -- one primary and one backup. In past executions, if a physician has been on hand, it has been outside the death chamber and strictly to confirm that death has occurred, or, in rare cases, to help access a vein, according to the Death Penalty Information Center based in Washington, D.C.
The two anesthesiologists who were to attend the Morales execution apparently objected to intervening if Morales appeared to regain consciousness or displayed signs of pain. The court had specified that the anesthesiologists would in that case have to step in to render the inmate unconscious or "otherwise alleviate the painful effects" of the drugs.
"I don't know of any other case where a physician has sat through and ordered an increased drip or whatever," said Richard Dieter, director of the nonprofit, nonpartisan center. "That seems to be a participation in the execution."
"Any such intervention would clearly be medically unethical," the anesthesiologists said in a written statement Tuesday. "As a result, we have withdrawn from participation in this current process."
The California Medical Assn., which represents about 30,000 physicians in California, strongly opposes such participation as well, saying Tuesday that it was sponsoring legislation that would outlaw physician assistance in executions. Illinois has such a law, and Georgia has considered one.
Dieter said that concerns about possible pain and suffering involved in the lethal injections were raised recently, in an April 2005 article in the British medical journal Lancet. The article reported that in 43 of 49 executions, the anesthetic administered during lethal injections was lower than that required for surgery.
In nearly half of the inmates from Arizona, Georgia, North Carolina and South Carolina, post-mortem concentrations of the anesthetic sodium thiopental in the blood were low enough that the prisoners might have been conscious during the execution and in severe pain.
The Lancet article led some courts to temporarily halt planned executions by lethal injection, Dieter said.
That is the method most states now use.
Of the 1,012 executions in the U.S. since 1976, 844 have been done using lethal injections of the three-drug cocktail. The inmate first is injected with sodium thiopental, which induces sleep. Next flows Pavulon (also called pancuronium bromide), which paralyzes the entire muscle system and stops the inmate's breathing. Finally, the flow of potassium chloride stops the heart. Death results from anesthetic overdose and respiratory and cardiac arrest while the condemned person is unconscious.
Some experts said Tuesday that the presence of anesthesiologists should not have been necessary.
Dr. William J. Loskota, an anesthesiologist and assistant professor at USC's Keck School of Medicine, said the state should be using medical brain-monitoring devices to evaluate the consciousness of prisoners being executed, which perform the function the court had asked the anesthesiologists to do.
Without one of the devices -- the Aspect BIS monitor or the Hospira SEDLine -- even an anesthesiologist is no better than a lay person in guessing what levels of consciousness exist in a patient or prisoner under anesthesia, said Loskota, who has a doctorate in neuropharmacology in addition to his medical degree.
Any participation by an anesthesiologist is unethical in an execution, Loskota said. "The role of an anesthesiologist is the last bastion on the abyss of death. Our whole job is life support and inherently directed toward saving the person and making him better."