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U.S. | Execution by nitrogen hypoxia doesn’t seem headed for widespread adoption as bills fall short and nitrogen producers object

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The day after Alabama carried out the first-known US execution using nitrogen gas, its attorney general sent a clear message to death penalty states that might want to follow suit: “Alabama has done it, and now so can you.” Indeed, in the weeks immediately following the January execution of Kenneth Smith, it appeared a handful of states were listening, introducing bills that would adopt the method known as nitrogen hypoxia or a similar one. Officials behind each framed the legislation as an alternative method that could help resume executions where they had long been stalled.

The Death Penalty: A Breach of Human Rights and Ethics of Care

The death penalty is inhumane and violates the fundamental right to life. Physician involvement enables this continuing abuse of human rights and undermines the four pillars of medical ethics—beneficence, non-maleficence, autonomy, and justice.

“The death penalty is, in our common experience, an atavistic relic from the past that should be shed in the 21st century”, said UN High Commissioner for Human Rights, Volker Türk in April, 2023, during the 52nd session of the Human Rights Council. The death penalty has existed since the Code of Hammurabi, with its history seeped in politics and discrimination. Physicians have been involved throughout this history. In the eyes of the public, the medicalisation and very involvement of physicians renders execution palatable, eroding any natural sense of abhorrence. Yet capital punishment is ineffective as a deterrent and morally wrong. At its core, execution is a barbaric practice that goes against the ethical foundation of the physician's role, and draws medical professionals into the state-sanctioned murder of civilians.

On May 15, Amnesty released their global report on death sentences and executions, warning that figures are at their highest for 5 years. Officially documented executions increased by 53%, from 579 in 2021 to 883 in 2022. The world's most prolific executioners in 2022 were: China (thousands), Iran (576), Saudi Arabia (196), Egypt (56), and the USA (18). 93% of global executions, excluding China, were carried out in the Middle East and north Africa. Article 6 of the International Covenant on Civil and Political Rights, an international human rights treaty adopted in 1966, prohibits the use of the death penalty “only for the most serious crimes”. However, executions frequently correlate with areas where dictatorial regimes prevail, often silencing political protest and enforcing views on issues such as drug use and LGBT identities.

In 2022, Amnesty recorded 325 executions for drug-related offences, including 255 in Iran and 57 in Saudi Arabia. Worldwide, 11 countries threaten the death penalty for those in the LGBT community. Uganda's recent introduction of capital punishment for what it terms “aggravated homosexuality” is being closely followed by other countries in the region. There is no question that capital punishment discriminates intersectionally. The Office of the UN High Commission for Human Rights says that at least 45 people from Iranian minority ethnic groups have been executed in recent weeks. Worldwide, those who are from low socioeconomic backgrounds are disproportionately led to death. The death penalty is the most brutal form of structural, state-sanctioned discrimination, racism, and homophobia.

Physicians are involved in executions in several countries. They clinically assess mental competence for execution; physically examine and monitor vital signs before, during, and after execution; and certify death. In extreme cases, physicians take the role of executioner and are implicated in illegal organ procurement from executed prisoners. Many professional bodies have debated and condemned physician participation. The World Medical Association affirms: “it is unethical for physicians to participate in capital punishment, in any way, or during any step of the execution process, including its planning and the instruction and/or training of persons to perform executions”. The American Medical Association's Code of Medical Ethics speaks directly to a physician's ethical responsibility, stating that they should not participate in legally authorised executions, and yet numerous US physicians assist in death row executions. Several human rights organisations, including Physicians for Human Rights, vehemently oppose the participation of health-care professionals in executions.

Why then do physicians continue to be complicit? Some argue that they are simply trying to ensure a person's final moments are as safe and pain-free as possible—a moral obligation to reduce suffering. Others assert that in repressive states, physicians are coerced and acting under duress. In many countries that still impose the death penalty (eg, China, Iran, and Saudi Arabia), medical associations remain silent on the ethics of physician involvement. WHO's position on the death penalty is unclear. Its press team was unable to direct The Lancet to any public statements or clarify the organisation's stance before we went to press. This uncertainty creates a dangerous vacuum where global health leadership is urgently needed.

The death penalty is inhumane and violates the fundamental right to life. Physician involvement enables this continuing abuse of human rights and undermines the four pillars of medical ethics—beneficence, non-maleficence, autonomy, and justice. Universal condemnation of the death penalty, by physicians and medical associations alike, is an essential step on the path to abolition.

Source: The Lancet, Staff, May 20, 2023


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"One is absolutely sickened, not by the crimes that the wicked have committed,
but by the punishments that the good have inflicted."


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