“Do No Harm” is perhaps the most famous medical maxim. But reciting it is one thing; living by it is another. Sometimes, the question of “harm” is up for debate. Throughout history, physicians have lent their knowledge to all manner of atrocities, warfare, torture, and mass sterilization, often justified under the supposedly noble pursuit of “reducing harm.”
Capital punishment or the death penalty is another instance of this dilemma. Doctors shouldn’t kill their patients. Kind of blunt, but it needs to be said. But what if the choice isn’t theirs? After all, the decision to execute someone is a decision of the state. What is a doctor’s role when they know someone is going to die? Not from some preventable disease but the state that intends on killing them?
There is an intuitive answer. Say you are a physician, and you are told someone will die tomorrow regardless of what you do. If you possess the knowledge to make their death less painful, wouldn’t you use it? This reasoning is consistent with medical practice. When a patient is diagnosed with terminal cancer, we may not be able to prevent their death, but we can still minimize their suffering.
On paper, it seems obvious, so for more than two centuries, physicians have tried to devise more “humane” methods of killing. Their intentions may have been compassionate. The outcomes were far less so.
Perhaps the most famous tool of execution was the guillotine. The guillotine was originally designed by surgeon Antoine Louis, while its use was famously advocated by its namesake, Dr. Joseph-Ignace Guillotin. His advocacy, however macabre, had a humane motivation: to minimize suffering in death. He opposed the death penalty, but in the absence of abolition, a humane death, he argued, was preferable. Further, inspired by the liberalism of the revolution, he also argued that beheading, usually reserved for nobility, should be available to all. So, a swift, relatively painless method of execution was put forward.
The guillotine created a disturbing irony. A quicker and less painful way to execute people became synonymous with the mass executions of the Reign of Terror. Making execution more humane did not bring about its abolition. It addressed the cruelty of the process, not the cruelty of the system.
Two centuries later, the methods may have changed, but the dilemma did not. Presently, the most common form of execution is lethal injection.
In 1977, pathologist Dr. Jay Chapman was asked by the Oklahoma state legislature to devise a more “humane” method of execution. The result was a three-drug protocol, dubbed the “Chapman Protocol”, that involved a sedative, a paralytic agent, and potassium to stop the heart. As lethal injection has spread across the United States, there have been multiple cases of botched executions, leading to all manner of complications and painful deaths. In an interview, Dr. Chapman recalled, “I had no idea that it would spread so quickly across the states.” Like Dr. Guillotin before him, Chapman helped devise a supposedly more “humane” method of killing that ultimately spread far beyond what he had anticipated.
Crucially, Dr. Chapman did not reject executions in concept and defended the “humanity” of lethal injections. Instead, he attributed the issues to improper administration, such as needles being inserted incorrectly or drugs being injected into tissues.
As pharmaceutical companies have increasingly refused to allow their medications to be used for killing, it has become difficult and costly for states to acquire them. Undeterred, some states have spent exorbitant amounts procuring these drugs. Arizona, for example, spent $1.5 million. Other states have resorted to compounding pharmacies to produce their own cocktails, sometimes with horrific results.
As lethal injections become more challenging politically, ethically, and financially, alternatives have been put forward, again, by doctors. One such example is the firing squad. Dr. James Williams, an ER physician who has testified on behalf of death-row prisoners, has argued that a shot to the brain or brainstem provides the quickest, least painful death. He has framed his support as consistent with his medical values; if execution is inevitable, physicians should advocate for the method that causes the least suffering.
Guillotin, Chapman, and Williams are separated by centuries and technology, yet all wrestled with the same problem: how to minimize the suffering of execution. Yet they all fall into the same trap: trying to find humanity in something inherently inhumane. When doctors lend their names, respectability, and commitment to the betterment of others to the killing arts, they help render these practices palatable.
But I ask, when does making something humane stop, and legitimizing begin? Medical knowledge can reduce suffering while simultaneously giving an inhumane practice a facade of medical legitimacy. State violence is now presented as a medical procedure.
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So if a more humane death is still unethical, how can physicians best advocate for those on death row? The answer isn’t new: abolition. Earlier I drew a parallel between execution and a terminal illness, but the comparison is not quite apt. Cancer is a disease; capital punishment is a policy decision. When a physician attempts to treat a patient’s cancer or provides palliative care, it does not lend legitimacy to the existence of the cancer. The same cannot be said for executions, where medical expertise is incorporated into the process of execution itself. If physicians want to reduce the suffering caused by execution, they should advocate for its abolition rather than for improvements in its methods.
Abolition requires recognizing that some unjust institutions cannot be reformed into ethical ones. Making them less cruel does not necessarily make them just or humane. South Africa offers an instructive example. Apartheid was not made ethical by reforming its worst abuses; it needed to be dismantled entirely. In 1995, the Constitutional Court ruled in S v. Makwanyane that capital punishment was unconstitutional, finding it incompatible with the country’s emerging commitment to human dignity.
For more than two centuries, physicians from Guillotin to Chapman to Williams have pondered how to make execution more humane. But perhaps they were trying to solve the wrong problem. There is no medical solution to execution because execution is not a medical problem.
Ali Abdullah is a nurse and osteopathic medical student.
