The White Coat : A Veil for State Killing?

In this guest post, Joel Zivot, MD, of Emory University Hospital, recounts witnessing an execution by lethal injection, and laments the secrecy surrounding the identity of physicians who participate.

I am dropped off at the Georgia Diagnostic and Classification State Prison as a witness to an execution. I am uncomfortable, but as a physician providing expert anesthesiology testimony in lethal injection cases, I feel compelled to see this for myself.

The afternoon is hot and muggy, and I am standing in a field bounded by a yellow rope. I am overdressed in a suit jacket and was not planning on being outside. What does one wear to an execution?

Several corrections officers soon approach. This staging area is full of corrections officers in paramilitary regalia. It's off-putting, and I can't help but wonder what the show of firepower and force is supposed to convey. What army would attack such an event?

I am expected. My name is found on the invited list, and I am addressed politely as Dr. Zivot, but I am asked to hand over my suit jacket (which actually is a relief) and also my cell phone, watch, pen, and wallet -- everything except for my driver's license. They inform me that all will be returned at my departure.

Now I am alone, unable to communicate with anyone or even note the passage of time. They reassure me that a van will arrive shortly to drive me to the prison. I am struck by my loss of independence. Usually, when it is known that I am a physician, some social deference is shown me without asking, and the loss of control unnerves me. I have been warned in advance that I cannot protest or I will be refused entry, and so I go along obediently.

A corrections officer pulls up in a van and takes me to another building where I pass through a metal detector and am asked to produce my identification. I soon realize that my driver is actually my guard and I am unsure if he is protecting me or constraining me.

We are taken to an office and I am told to wait for further instruction. A clock is on the wall and I am grateful for that information. Five hours pass. From time to time, I am provided with an odd selection of food, a sort of prison hospitality. It doesn't feel like I can refuse these offerings and I cannot imagine what social custom applies here.

At some point, I need to use the restroom and after asking permission, I am followed into the toilet itself. No one is unkind and some are even pleasant. Still, my loss of freedom is complete, and deep within this prison I rely on my host/captors to guide me.

An official arrives and informs me that it is time to leave, and we drive to yet another building. It is dark now and the road is poorly lit, lined by corrections officers in body armor holding automatic weapons. We pass through a barbed-wire gate, probably 20 feet in height. The van is trapped in a fenced area. More corrections officers inspect it. They open the hood and use mirrors to examine its chassis.

When we're waved through, we drive across an open field to a small, unmarked building -- no larger than a trailer -- next to a basketball court. A van marked "Coroner" pulls up next to us. Men in body armor, with weapons drawn, guard this building. We wait outside. The night is still and the air is warm and muggy, typical for Georgia at this time of year.

Looking at the basketball court, I wonder: who uses it?

In the Execution Chamber

Without notice, the door to the small building opens and I am ushered in. The room is small and already full of people. Benches are arranged like church pews and the front row with eight seats is full of men who do not turn around as I take my place, as instructed, in the second row. In a moment another man sits beside me. I see he has a watch and a pen.

Before me on the other side of a large window I see a man lying on a gurney. The gurney is tipped forward, head higher than feet -- reverse Trendelenburg in my lexicon. His arms are at 45-degree angles and secured to arm boards with leather straps. He is covered in a sheet from just below his chin. I count three intravenous puncture sites visible on his arms. Two are connected to IV tubing that disappears through a small hole in the rear of the room. Also at the rear, I see the half-mirrored, one-way viewing window.

My eyes drift back to his arms. Oddly, I notice that his fingers are taped palm-down to each arm board. In the operating room this position might lead to ulnar nerve injury, but here, I see at once that another purpose is intended. With his fingers secured, he will be unable to clench his fists, should he be so inclined.

Now the warden stands next to him and asks if he has a statement to make. In a calm voice, the inmate replies that he does, and the warden informs him that he has 2 minutes. I wonder if someone is actually timing this. The inmate offers an apology, thanks God and his family, and is done. This is broadcast to us. The speakers must have been turned on and off because I heard no other sounds from the chamber until then or after.

The warden leaves that room. Next to the inmate stands a woman in a short white coat. I see two corrections officers standing motionless on either side of the inmate. I have no watch, and I start to count in my head as a way of trying to sort out the timing of all of this. I try to look at the watch of the person next to me, without him noticing.

The inmate has an apparent change in his respiratory pattern and I assume the execution has therefore begun. He twitches strongly once, mostly on the left side of his body. I am looking hard now for something in his breathing or in his movements that I could construe as consciousness or the lack of it.

I lose count, when, suddenly, one of the corrections officers faints and falls forward, striking the legs of the inmate. The officer has his eyes open as he falls but he clearly is without consciousness. It is so startling that I fail to notice if the inmate reacts. In a moment, the execution chamber fills with people who drag out the unconscious officer and another assumes his position.

Somewhere in this room are two doctors who are participating in this execution -- but I wonder why neither of them has come to the aid of the unconscious officer.

The Georgia Secrecy Act

As a practicing doctor, when I see someone collapse in the hospital, I immediately move towards them. Did the doctors overseeing the execution have qualms about helping someone stay alive if it meant leaving their post that required them to monitor the killing of the inmate? Did a grotesque conflict arise in this unlikely circumstance between their interest and their duty?

It begins to strike me that they may have a serious ethical problem.

I can't feel sorry for them, but I do see the shame they can bring to my profession if "doctors" can be hired to assure that death occurs.

Later, I look up the rules about this. The Georgia Composite Medical Board licenses physicians. Like all medical boards in the U.S. and Canada, it is self-governed by physicians who set the standards for all who wish to practice medicine in the state. It operates under legislative authority according to the Medical Practice Act. In this act, to practice medicine means "to hold oneself out to the public as being engaged in the diagnosis or treatment of disease, defects, or injuries of human beings."

Life is not a disease, defect, or injury. Nothing in the Medical Practice Act authorizes a physician to cure someone of his life. In return for being allowed to govern themselves, physicians who are elected by their peers to run these medical boards are bound to protect the public interest from those who do not observe the board's ethical and practice standards. The board is a "public authority" and enjoys certain historic rights and privileges as well as statutory rights to obtain subpoenas and compel disclosure to help it discover what it needs to know to govern doctors in their medical practice, or to discipline those who violate the norms under the Medical Practice Act.

I wonder why the board has allowed the two men who are overseeing the execution to call themselves physicians.

I dig deeper. It appears these doctors cannot easily be governed by the Georgia Composite Medical Board because their identity is a state secret.

In Georgia, House Bill 122: Sexual Offender Registration Review Board and Board of Pardons and Parole Record; Death Penalty Record, signed into law by Governor Nathan Deal in 2013, contains a provision that protects the identity of these men as a confidential state secret.

It effectively forbids the state from divulging information on anyone who participates in executions -- and extends that privacy to "any person or entity that manufactures, supplies, compounds, or prescribes the drugs, medical supplies, or medical equipment utilized in the execution of a death sentence."

In Georgia, and in other states that have secrecy laws, medical boards are usurped and the state now authorizes what behavior constitutes acceptable medical practice.

This cannot be permitted. If the state prevents the board from regulating certain doctors, public health can be undermined in secret. If the state has the power to immunize physicians from oversight of their peers and colleagues, they have a terrible power to pervert the delivery of healthcare for some bureaucrat's idea of the public good. It is a horrific precedent that can be abused, even with the best of intentions.

Let us not allow the continued slide down that slippery slope. Until now, the Georgia Composite Medical Board has remained silent. It could, however, mount a case for the names of the men whom I saw behave discreditably and who should have their licenses to practice as physicians revoked.

Executions will go on in one way or another, just as they have for centuries, without the involvement of physicians. A court may weigh the state's interest in providing a cosmetic appearance of a medical procedure as the veil for an execution by lethal injection against the ancient constitutional or common law right or freedom of public health, which includes an effective system of regulating physicians' practice.

If the Georgia Composite Medical Board, or any other state medical board, refuses to be a plaintiff against the warden for an order of mandamus to force disclosure of the identities of physicians hired to supervise the lethal injections, then probably any resident in that state has a sufficient interest in knowing whether the men in question are his or her doctors (let's call one of them Mr. Jones).

Residents may bring a relator action against the warden and may name the medical board as a defendant in whose name Mr. Jones moves the court for mandamus. The citation of the case would read: Georgia Composite Medical Board, ex rel. Jones v. Warden, Georgia Diagnostic and Classification State Prison.

Final Moments

After the corrections officer fainted, we, the witnesses, sat in stunned silence, although our attention slowly returned to the inmate. I saw no further breathing and in moments, perhaps 10 or 15 minutes after the inmate's last statement, the two doctors finally appeared in the room. Both had stethoscopes and one was wearing a white lab coat.

I am struck by the lab coat, worn by TV doctors and in a few medical specialties, although in the operating room I wear a green top and pants, and in my intensive care unit I wear a shirt and tie.

So, who is that for? The execution is bloodless.

The doctors listen to the inmate's chest and look into his eyes. This takes a few minutes, and then they both turn towards the warden. Finally, the speakers turn on as the warden announces the time of death.

Since neither of these men with their medical equipment came forward when the corrections officer collapsed, is the white coat merely a veil for state killing in the execution chamber?

The official record makes no mention of the collapsed corrections officer. I suppose it was believed to be unnecessary information. The execution did succeed, and the inmate never once clenched his fists.