Better: Executions

Atul Gawande's book, Better: A Surgeon's Notes on Performance contains a chapter on doctors and executions. The chapter explains graphically why firing squads, electrocution, hanging and the gas chamber have all been declared unconstitutional as cruel and unusual punishment; it also explains why the courts are concerned with the process of lethal injection, which may also be excessively cruel. (I think execution is by definition cruel, and with just over 1,000 executions performed in the United States in the last three decades, executions are surely unusual.)

In the context of this blog, however, I want to mention Gawande's interviews with health professionals who take part in executions. Medical and nursing ethical guidelines both state that it is unethical to do so, except in the very limited role of prescribing tranquilizers before an execution and signing a death certificate after and execution. Yet Gawande found doctors and a nurse who did participate more fully in executions.

He does not explain how the professional associations decided that it was unethical for doctors or nurses to help the state conduct executions in as humane a way as possible, given that the laws of the country and of 38 states still permit them, and indeed in some cases specifically call for medical professionals to participate.

He does however describe how individual practitioners came to participate in contravention of their professional ethical guidelines, against family advice, and usually overcoming personal ethical conflicts. The participation seemed to come as a result of a gradual process -- first agreeing to "be there", and then stepping in to help in a process for which others present were less well prepared, until the doctor was a full participant.

The chapter reminded me of Stanley Milgram's experiments in the 1960's in which most subjects appeared to exhibit a willingness to participate in torturing others with only the excuse that the responsibility for ordering the torture was in the hands of another. The Stanford Prison Experiment is another example. It had to be shut down because students playing the role of guards quickly became so brutal towards students playing the role of prisoners in the experiment conducted in the 1970s.

I think in all three cases people came to act unethically in a process in which they came to participate more fully in the behavior step by step. Rather than an initial informed decision to participate in an execution, torture or brutality, there were piecemeal decisions to do a little more and a little more until full participating fully.

The papers have told the story of a man beaten to death the other day after the car he had been riding in struck and injured a toddler. Apparently after dropping the man off, the car had hit and injured a two year old; when the man went to help the driver, three of four men beat him while 20 or more others watched. The man died as a result of the beatings before he reached the hospital.

Again, I wonder about the decision process that took place in the minds of those administering a fatal beating to someone who appears to have been an innocent bystander to the triggering accident, or in the minds of the people who stood by and watched. There is something in all these examples relating to the willingness of people to act unethically rather than to challenge social pressure.

Think about the public policy aspect of this situation. If we make laws requiring physicians to administer lethal injections, those laws require physicians to act unethically. Abu Ghraib's abuses were predictable when the policy was created of imprisoning large numbers of detainees collected during sweep operations under the control of guards without specialized training for prison work. Indeed, as long as neo-Nazi's gain power, regular people will be recruited to commit atrocities under their orders.

We have to educate people to decide to say "no" to unethical behavior; we have to organize public policy to avoid situations in which people are encouraged or enabled to act unethically.