Better (17 page)

My conversations with the physicians and the nurse I had tracked down, however, rattled both these views--and no conversation more so than one I had with the final doctor I spoke to. Dr. D is a forty-five-year-old emergency physician. He is also a volunteer medical director for a shelter for abused children. He works to reduce homelessness. He opposes the death penalty because he regards it as inhumane, immoral, and pointless. And he has participated in six executions so far.

About a decade ago, a new jail was built down the street from the hospital where he worked, and it had a large infirmary "the size of our whole emergency room." The jail needed a doctor. So, out of curiosity as much as anything, Dr. D began working there. "I found that I loved it," he said. "Jails are an underserved niche of health care." Jails, he pointed out, are different from prisons in that they house people who are arrested and awaiting trial. Most are housed only a few hours to days and then released. "The substance abuse and noncompliance is high. The people have a wide variety of medical needs. It is a fascinating population. The setting is very similar to the ER. You can make a tremendous impact on people and on public health." Over time, he shifted more and more of his work to the jail system. He built a medical group for the jails in his area and soon became an advocate for correctional medicine.

In 2002, the doctors who had been involved in executions in his state pulled out. Officials asked Dr. D if his group would take the contract. Before answering, he went to observe an execution. "It was a very emotional experience for
me," he said. "I was shocked to witness something like this." He had opposed the death penalty since college, and nothing he saw made him feel any differently. But, at the same time, he felt there were needs that he as a correctional physician could serve.

He read about the ethics of participating. He knew about the AMA's stance against it. Yet he also felt an obligation not to abandon inmates in their dying moments. "We, as doctors, are not the ones deciding the fate of this individual," he said. "The way I saw it, this is an end-of-life issue, just as with any other terminal disease. It just happens that it involves a legal process instead of a medical process. When we have a patient who can no longer survive his illness, we as physicians must ensure he has comfort. [A death-penalty] patient is no different from a patient dying of cancer--except his cancer is a court order." Dr. D said he has "the cure for this cancer"--abolition of the death penalty--but "if the people and the government won't let you provide it, and a patient then dies, are you not going to comfort him?"

His group took the contract, and he has been part of the medical team for each execution since. The doctors are available to help if there are difficulties with IV access, and Dr. D considers it their task to ensure that the prisoner is without pain or suffering through the process. He himself provides the cardiac monitoring and the final determination of death. Watching the changes on the two-line electrocardiogram tracing, "I keep having that reflex as an ER doctor, wanting to treat that rhythm," he said. Aside from that, his main reaction is to be sad for everyone involved--the prisoner whose life has led to this, the victims, the prison officials, the doctors. The
team's payment is substantial--eighteen thousand dollars--but he donates his portion to the children's shelter where he volunteers.

Three weeks after speaking to me, he told me to go ahead and use his name. It is Carlo Musso. He helps with executions in Georgia. He didn't want to seem as if he were hiding anything, he said. He didn't want to invite trouble, either. But activists have already challenged his license and his membership in the AMA, and he is resigned to the fight. "It just seems wrong for us to walk away, to abdicate our responsibility to the patients," he said.

T
HERE IS LITTLE
doubt that lethal injection can be painless and peaceful, but as courts have recognized, ensuring that it is requires significant medical assistance and judgment--for placement of intravenous lines, monitoring of consciousness, and adjustments in medication timing and dosage. In recent years, medical societies have persuaded two states, Kentucky and Illinois, to pass laws forbidding physician participation in executions. Nonetheless, officials in each of these states intend to continue to rely on medical supervision, employing nurses and nurse anesthetists instead. How, then, to reconcile the conflict between government efforts to provide a medical presence and our ethical principles forbidding it? Are our ethics what should change?

The doctors' and nurse's arguments for competence and comfort in the execution process certainly have force and they gave me pause. But however much these practitioners may wish to comfort a patient, it ultimately seems clear to me that
the inmate is not really their patient. Unlike genuine patients, an inmate has no ability to refuse the physician's "care"--indeed, the inmate and his family are not even permitted to know the physician's identity. And the medical assistance provided primarily serves the government's purposes--not the inmate's needs and interests as a patient. Medicine is being made an instrument of punishment. The hand of comfort that more gently places the IV, more carefully times the bolus of potassium, is also the hand of death. We cannot escape this truth.

This truth is what convinces me that we should stand with the ethics code and legally ban the participation of physicians and nurses in executions. And if it turns out that executions cannot then be performed without, as the courts put it, "unconstitutional pain and cruelty," the death penalty should be abolished.

It is far from clear that a society that punishes its most evil murderers with life imprisonment is worse off than one that punishes them with death. But a society in which the government actively subverts core ethical principles of medical practice is patently worse off for it. The U.S. government has shown willingness to use medical skills against individuals for its own purposes--having medical personnel assist in the interrogation of prisoners, for example, adjust their medical documentation and death certificates, place feeding tubes for force-feeding them, and help with executing them. As our abilities to manipulate the human body advance, government interest in our skills will only increase. Preserving the integrity of medical ethics could not be more important.

The four physicians and the nurse I spoke to all acted against long-standing principles of their professions. Their
individual actions have rendered those principles effectively irrelevant; as long as a prison can count on a handful of doctors and nurses helping with executions, the ethics of the many do not matter. Yet, it must be said, most of those I interviewed took their moral duties seriously. It is worth reflecting on this truth as well.

The easy thing for any doctor or nurse is simply to follow the written rules. But each of us has a duty not to follow rules and laws blindly. In medicine, we face conflicts about what the right and best actions are in all kinds of areas: relief of suffering for the terminally ill, provision of narcotics for patients with chronic pain, withdrawal of life-sustaining treatment for the critically ill, abortion, and executions, to name just a few. All have been the subject of professional rules and government regulation, and at times those rules and regulations have been and will be wrong. We may then be called on to make a choice. We must do our best to choose intelligently and wisely.

Sometimes, however, we will be wrong--as I think the doctors and nurses are who have used their privileged skills to make possible 876 deaths by lethal injection thus far. We each should then be prepared to accept the consequences. Above all, we have to be prepared to recognize when using our abilities skillfully comes into conflict with using them rightly. Assistance with executions is a stark instance. But it is far from the only one. Indeed, it is not even the most difficult one.

I
used to think that the hardest struggle of doctoring is learning the skills. But it is not, although just when you begin to feel confident that you know what you are doing, a failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part of being a doctor, I have found, is to know what you have power over and what you don't.

I have a patient, Mr. Thomas, who came to see me in my clinic one autumn with Cushing's syndrome, a hormonal disease in which the adrenal glands become enlarged and start pouring out massive amounts of cortisol, a steroid hormone. It is as if a person is being given a constant intravenous steroid
overdose. And these steroids aren't the kind that build up your muscle; they are the kind that break it down.

Thomas is seventy-two. Until that year, he had been a vigorous man enjoying retirement on Cape Cod with his wife after a career teaching high school history in New York City. He'd been healthy. He took medication for blood pressure and an arthritis that intermittently flared in his right hip, and that was all. The previous winter, however, a question on an X-ray led to a CT scan which revealed a three-inch mass, a cancer, in his left kidney. In retrospect, the adrenal glands looked slightly plump on the scan, but not terribly so, and the cancer was the greater concern. Thomas underwent surgery to remove his kidney. The cancer appeared to have been caught in time, and he recovered without difficulties.

Over the next few months, however, Thomas developed marked swelling of his face, his legs, his arms. He looked rounder, even bloated. He began bruising easily. He developed strange, recurrent pneumonias--fungal pneumonias that usually only afflict people on chemotherapy or with HIV. He was a puzzle to his doctors. They carried out all kinds of tests and eventually his sky-high levels of cortisol were found--Cushing's syndrome. Repeat scans showed that his adrenal glands had grown to at least four times normal size and that they were producing the steroid overload. The doctors did more tests to find the cause of the adrenal surge--a pituitary gland malfunction is a common one, for example--but none was found. He became increasingly weak and so tired that just moving required colossal effort. That summer, he began having difficulty climbing stairs. By September, he struggled just to stand
from sitting. His endocrinologist tried medications to counteract the hormone. But by November, Thomas couldn't stand at all and was bound to a wheelchair. The pneumonias continued to reappear despite antifungal treatments. The hormones flowing uncontrolled out of his adrenal glands were destroying his muscles and shutting down his immune system.

He was sent to see me for a consultation just before Thanksgiving. His wife could not hide the alarm on her face, but he himself was calm, even commanding, despite his wheelchair and the alien, white fluorescent examination room. He was six foot one, of Afro-Caribbean origin, and when he spoke it was clearly and directly, like a man used to the authority of a classroom. I got straight to the point. I told him the only option that could fix his adrenal problem was to remove both of his adrenal glands. I explained that the glands sit atop the kidneys like two fleshy yellow tricornered hats--the right gland is tucked under the liver, the left behind the stomach--and that removing both is a drastic measure. It replaces the problems of having too much hormone with those of having too little: low blood pressure, depression, yet worse fatigue, and a critical inability to muster a stress response to infection or trauma--though hormone pills generally mitigate these effects. The operation is also a major one, with potential for serious complications ranging from bleeding to organ failure, especially given his declining health and the previous operation he'd had to remove his cancerous kidney. If he didn't go through with it, however, it was clear that he would dwindle away and die in a matter of months.

Thomas did not want to die. But he confessed to being more afraid of the surgery and what it might do to him. He
didn't want pain. He didn't want to be away from home. I told him he needed to set his fears aside. I asked him, what were his hopes? He wanted to have a normal life, he said, to be with his wife, to walk the beach near his house again. This was why he should have the operation, I said. No question, there were serious risks. The recovery would be hard. The operation might not work. But it was his only chance, and if all went well, the life he hoped for was possible. He agreed to go ahead.

Technically, the surgery went as smoothly as it could have. With the removal of his adrenal glands, his cortisol level plummeted and could be held in a normal range with medications. He is no longer dying. But seven months after the surgery, as I write this, he has still not gotten home. For three weeks, he was in a coma. His pneumonias recurred. We had to put in a tracheostomy and a feeding tube. Then he developed an abdominal infection that required the insertion of multiple drainage tubes. He developed sepsis from two different bacteria floating around the hospital. He spent a total of four months in intensive care, and the debility only destroyed more of what little muscle he had remaining.

Thomas is now in a long-term care facility. He was brought to my office recently, by ambulance, on a stretcher. He was gaining strength, the rehabilitation doctors told me, but in the office he had difficulty just lifting his head off the pillow. I covered his tracheostomy so he could talk. He asked me when he would be able to stand again, to go home. I didn't know, I told him, and he began to cry.

We have at our disposal today the remarkable abilities of modern medicine. Learning to use them is difficult enough. But understanding their limits is the most difficult task of all.