In California this week, two anesthesiologists refused to monitor the administering of a barbiturate designed to render unconscious convicted killer Michael Morales before he was to be killed with two other drugs.
The execution was called off - or, at least, postponed. Death-penalty opponents cheered. And the roiling debate over the ethics of medical professionals' involvement in the officially sanctioned ending of human life got a little hotter.
At issue: Should a healer help the executioner?
Beyond abortion (where the question of when life begins remains the major debating point), this includes executions carried out by the state and physician-assisted suicide now legal in Oregon and being considered in other states.
Similarly, medical ethics are involved in growing questions about military doctors taking part in the interrogation of prisoners and the force-feeding of those on a hunger strike.
In the eyes of most professional medical organizations, physicians have the ethical and professional obligation to do what they can to make people well, not to help kill them. The American Medical Association (AMA) code of ethics states, "A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution."
While most states now favor lethal drugs in capital punishment, courts increasingly are taking a skeptical view of a procedure that critics say violates the Constitution.
"The issue is whether the method the government has chosen to employ in our case constitutes cruel and unusual punishment," says Steve Northup, a Richmond, Va., attorney with a client on death row for gang murders. "There's a lot of scientific opinion out there to the effect that it causes a great deal of pain."
In the California case, a federal district judge ordered - for the first time - that licensed medical personnel administer the sedative.
In recent weeks, stays of execution have been granted in four cases, and the US Supreme Court has agreed to hear a Florida case involving lethal injection.
The California Medical Association has proposed legislation that would end the role of physicians in capital punishment. In at least a dozen states, lawmakers are considering proposals that would allow doctors, nurses, pharmacists, and other medical personnel to become, in effect, conscientious objectors regarding certain medical treatments.
In Oregon, doctors' involvement in end-of-life treatment focuses on the nation's only law allowing physician-assisted suicide. The state's 1997 "Death with Dignity Act" specifically prohibits "lethal injection, mercy killing, or active euthanasia." But doctors may prescribe lethal drugs for mentally competent adults who declare their intentions in writing and are diagnosed as terminally ill.
"It's an inherent conflict of interest," says William Toffler, professor of family medicine at Oregon Health & Science University in Portland. "It's an inherent degradation of the role of physicians."
That's a concern among some medical personnel in the armed forces, who worry about doctors in uniform handling of detainees at Guantánamo Bay, Cuba.
"There is a slippery slope that needs to be addressed," says retired Army Brig. Gen. Stephen Xenakis, a psychiatrist who once headed one of the Army's regional medical commands.
Referring to the reportedly harsh treatment of detainees, General Xenakis told a panel last August, "I don't see that compatible with what we do as physicians.... There needs to be guidance from the Defense Department that says that we will not do that, irrespective of what the CIA and the special ops folks want to do."
In a report to the Army Inspector General last year, Maj. Gen. Lester Martinez-Lopez, M.D., recommended that military physicians and psychiatrists not aid interrogators, but that recommendation was rejected by the Pentagon.
More recently, military doctors have been involved in the force-feeding of detainees strapped to chairs. Military officials say the treatment remains relatively humane. And they point out that they, in fact, are preventing the possible loss of life of prisoners who are on a hunger strike.
"If you look at the obligations of the health professions and doctors in particular, UN standards, World Medical Association standards, AMA standards, the responsibility of the physician in war or peace is to improve peoples' health and not to inflict pain or harm," says Leonard Rubenstein, director of Physicians for Human Rights.
It's important for professionals to abide by their ethical standards, says Carl Coleman, a law professor specializing in health policy at Seton Hall Law School. "Part of the nature of a profession is the idea that it's at least to some extent self-regulating, that there are ideals that may go beyond the minimum standards the law requires."
• Maia Ridberg in New York contributed to this article.