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EDITORIALS

Doctors and death row

Should a medical organisation take a position on theinvolvement of doctors in capital punishment withouta clear stance on the death penalty itself? We think not.The American Medical Association (AMA) says thatattitudes to capital punishment are for doctors todecide individually but that it is unethical to take partinan execution "except to determine or certify death".The American College of Physicians and the BritishMedical Association (BMA) have been trying to getthe AMA to be more specific, and at the end of 1992the AMA Council on Ethical and Judicial Affairsresponded. Its recommendations are a significantadvance, especially since the US Federal Bureau ofPrisons now seems minded to write doctors into itsexecution manual. It may seem obvious that doctorsshould not be involved directly in capital punishmentbut it is with the very words "directly" and "involved"that trouble begins. Amnesty International has

catalogued the ways in which doctors might take part. 1The list is longer than you might think, as are the onesproduced by the American College of Physicians andin an excellent BMA working-party report.2 At bestinvolvement is one way for the state to legitimisefurther a cruel and unnatural punishment. This iswhat medical examinations to certify fitness for

execution or death and post-mortem confirmation ofthe obvious amount to. And the worst is bad indeed.Via stethoscope and electrocardiograph medical

personnel also monitor the process of death and advisethereby on the need for further exposure to cyanidegas or yet more jolts of electric current. In Missouri avolunteer physician was found to do a cutdown on aman with poor venous access who had beencondemned to die by lethal injection. Had thathappened in Illinois the doctor would have beenprotected by state-enforced anonymity from anydisciplinary procedures. There is a ghastly logic tosome of the views recorded in Stephen Trombley’sbook published this week.3 Smug in their state capitolsthe politicians get others to do the dirty work.Penitentiary staff aim for what dignity they can andwonder at the aloofness of the medical profession,whose assistance might ensure efficiency in theadministration of an anaesthetic, muscle relaxant, andpotassium chloride. Doctors are there at the beginningand the end so why not in the middle? That question

arises only when guidelines are not based on a clearpolicy of opposition to the death penalty.

The Execution Protocol3 lists 174 judicial killings inthe United States since 1976, when capitalpunishment was reintroduced in many states. Thatwas as of May 31, 1992. On Jan 5 of this year the tollrose to 185, and Tuesday of the week just over was thescheduled day of execution of a man in a wheelchairbecause of injuries sustained in a brawl in prisonwhere he had already spent fourteen years for hiscrime. The United States is not alone. Even todaymore countries retain the penalty than have abolishedit by statute or custom. The latest Amnesty figures4are 106 versus 83. Furthermore in China (both ofthem, though more is documented about Taiwan) andin other Asian countries too the use of organs fromthose condemned has added a novel and unwelcomeform of medical involvement.5 Despite oppositionfrom the international Transplantation Society andthree local medical organisations it is not certain thatthis practice has ceased in Taiwan. By allowingcertification other than on brain death criteria theauthorities could get round some of the opposition,and not every transplant surgeon is opposed it seems.

It is almost thirty years since anyone was hanged inBritain. This is just as well for a country where policeincompetence coupled with judicial sloppiness wouldin recent years have otherwise added hugely to the twofatal miscarriages of justice that are now generallyrecognised. Gruesome accounts2,3,6,7 and the occasionwhen one Taiwan hospital had to return a donor forre-execution add to the horror. Botched executions

strengthen the case against capital punishment, as dothe absence of statistical proof of deterrence, the risk ofmiscarriage, and the sometimes lengthy prison termsserved by those awaiting execution. But even if noneof these arguments applied, professional medical (andnursing) organisations should be persuaded that thedeath penalty, which breaches the UniversalDeclaration of Human Rights in two places, no longerhas any part in a civilised society. Furthermore, theEuropean Court of Human Rights (the Soeringextradition case) has upheld the view that lengthyincarceration before execution breaches the Europeanconvention. The non-involvement of doctors shouldbe total, and professional guidelines should say so. As

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for torture, so for capital punishment, and medicalorganisations should leave no room for ambiguity.

The Lancet

1. Amnesty International. The role of the doctor in executions. In: Healthprofessionals and the death penalty. London: AI, 1989.

2. Anon. Medical participation in capital punishment. In: Medicine

betrayed: the participation of doctors in human rights abuses. London:Zed Books/BMA, 1992: 102-17.

3. The Execution Protocol. By Stephen Trombley. London: Century. 1993.Pp 342. £9.99. ISBN 0-517-59113-8.

4. Amnesty International. The death penalty: list of abolitionist andretentionist countries (June 1992). London: AI, 1992.

5. Guttmann RD. On the use of organs from executed prisoners. TransplantRev 1992; 6: 189-93.

6. Jones GRN. Judicial execution and the prison doctor. Lancet 1990; 335:713-14.

7. Canan RF. Burning at the wire: the execution of John Evans. In: RadeletM, ed. Facing the death penalty. Philadelphia: Temple UniversityPress, 1989: 60-80.

Health sector reform in the formerSoviet Union

The Soviet Union vanished at the end of 1991.Much Communist tradition vanished with it. In the

republics of the former USSR centrally plannedsocialist policies have been cast aside as governmentsmove swiftly towards free markets.1,2 The effects ofradical economic reform on the prices of everydaycommodities are widely known (when Russiaabolished price controls on 90 % of goods on January 2last year, prices rose by an average of 250% the nextday),3 but what about the implications for healthand health services? The market approach to

improvements in the macroeconomy means that

policies aiming to redistribute wealth will be weaker,and increasing poverty and unemployment will lead todeterioration in health status. In health care, the focuson new mechanisms of finance is leading countriestowards adoption of social insurance systems.Consequently the traditional function of healthministries as providers is being taken over byinsurance organisations and by private or local

government agencies.4,5How should the new health ministries respond to

these changes? One option is to do nothing and toaccept that their role will steadily diminish until theyare left with only those tasks that no-one else

wants-eg, inspection of water supplies and sewagedisposal systems. The alternative is to seize the

opportunity to redefine their role as ministries ofhealth rather than of health care and ensure that the

public health is pushed up the agenda. If they choosethe latter course, what should they be doing?Experience in other countries suggests that healthministries have at least three important functions:(a) to monitor the health of their population;(b) constantly to remind and advise senior policymakers on the implications to people’s health ofgovernment policies; and (c) to develop, with otherministries, a national health strategy. The second stepis to look at the changes required to enable ministries

to fulfil these roles. With respect to monitoring healthstatus, most countries have in place some form ofcentralised collation of national morbidity and

mortality data. However, the Soviet model of

epidemiology has been largely confined to the study ofinfectious diseases. Health ministries and centralstatistical offices will have to develop skills in non.communicable-disease epidemiology to assess thehealth problems facing their population and to

monitor the results of policies to reduce them.Armed with information on the health of the

population and knowledge of the multiple causes of illhealth, ministries of health can act as advocates ofhealthy policies at national level. This role will be vitalas other ministries come under pressure to adoptpolicies with important consequences for health. Forexample, a department of industry may be attractedby the economic benefits of a large chemical plant andmay not consider the effect of the resulting toxic waste,Nevertheless, advocacy in these situations is nevereasy: other ministries, with their own priorities andobjectives, may be much stronger. True intersectoralaction in health requires commitment from the mostsenior policy makers within a country. Given thiscommitment, the various government departmentsmay be asked to examine their role in promotinghealth and preventing disease, and to participate indeveloping a national health strategy. Ministries ofhealth should have a major input, but to do so theymust ensure that they have staff who are highly trainedin multisectoral approaches to improving health andwho have the necessary economic and epidemiologicalskills to compare the costs and potential benefits ofvarious interventions.

Meanwhile, health ministries must not neglect theirrole with respect to health services. Withdecentralisation and privatisation they will cease to beproviders of health care. This will enable them todevelop new roles-setting standards; ensuringquality of care; and promoting equity of distributionof health service resources. These changes requirenew legislation, alteration of the organisationalstructure and attitudes within ministries, and effectiveinformation systems.

In the immediate post-reform period, healthministries in some central and eastern Europeancountries were deluged with visitors bringing offers ofall kinds of assistance.6 Apart from the time that iswasted in meeting visiting "experts", many of theprojects on offer were of little long-term value. Hightechnology equipment has been provided with nothought about how spare parts and consumablesmight be paid for or who might operate it.Uncoordinated courses in management, withdifferent groups flying in for a few days to promotetheir own philosophy, led to confusion and cynicismNational policy makers in the former Soviet Unionshould learn from this experience and work withinternational donors to consider first, whether theappropriate institutional development of public health