A physician's perspective on 'Dead Man Walking' the opera.

This is one where my interests in medicine and music overlap.

First, some personal background—and why I almost canceled going to an opera I really wanted to see.

I traveled to New York to attend the dress rehearsal of the opera Dead Man Walking at the Metropolitan Opera on Friday. The opera was written by Jake Heggie and premiered in 2000 at the San Francisco Opera. A couple of years later, Jake and I became acquainted and have maintained a warm friendship since. I’ve conducted some of his music (and even arranged some for chorus), and he has occasionally and graciously advised me on my own musical compositions, including a piece I wrote towards the end of medical school.

I’ve always admired Jake’s music, but until this week, I had never seen or even heard this particular opera in its entirety. The stars just hadn’t aligned—though it is the single most produced opera written this century. I had heard bits and pieces—famous sections performed in concerts or on YouTube. I’d tried to listen to recordings, but opera without the live action can feel a bit like ballet without the music.

As it happened, the only time Jake would be at the Met that I could make it down to New York was the final dress rehearsal. So, I worked in the hospital Thursday night until midnight, and eight hours later I was on a flight to LaGuardia.

I almost canceled at the last minute. Fatigue and inadequate sleep would have been easy scapegoats. But in reality, I think something else was tugging at me to stay home: I had become afraid of this opera. I knew that the piece ends with a realistic portrayal of an execution by lethal injection. As a physician, a scene of death by lethal injection represents the pinnacle of cognitive dissonance: all the accoutrements of modern medicine, being used to kill, instead of to heal or alleviate suffering. I didn’t want to see it. (And I’ve never seen the film version, nor read the original book by Sister Helen Prejean that inspired it.)

Capital punishment, set to sound.

I’m glad I went. Dead Man Walking is a deeply affecting and beautiful piece of art—and opera is an ideal medium to explore the philosophical challenges it poses. Jake’s score is richly layered and varied. But when the time comes, and we are forced to watch an execution on stage, the music stops. Wisely, Jake did not set the death penalty to music. Rather, he insightfully chose to confront us with the emptiness of silence.

As I watched the final scene unfold, I kept wondering: When did executions become a fucking medical procedure? What could be so counter-intuitive as that? It hurts to even think of my colleagues participating in something so barbaric—and medical societies are almost universally opposed to it.

Part of what disturbed me was the verisimilitude of the operatic moment. They wheeled in an anesthesia cart. They placed a tourniquet on the convict’s arm to help start an IV. They had a portable heart monitor which we watched go from sinus tachycardia—the heart rate of someone panicking—to the inevitable flatline of asystolic cardiac arrest.

One detail stung me. As in real life, when the medical assistant placed the IV, she wiped his arm with an alcohol swab. You know, to make sure they don’t cause an infection or anything. The absurdity of such a futile gesture begs the question: Just what is it anyone thinks we are doing here? Something civilized? Adhering to sterility does not—and cannot—sanitize.

When my colleague Atul Gawande asked a physician who had somehow ended up assisting in executions why he maintained sterile techniques during executions, his answer was telling: “Habit.”

The doctor probably didn’t realize it, but that’s a cop-out. The medicalization of executions is supposed to make us feel like we are being humane, rather than engaging in something deranged that reflects the most base of our lingering primitive instincts. And even doctors fall for it.

I don’t know when it happened, but at some point in my life, the death penalty became completely repulsive to me. In hindsight, it coincided with my growing interest in medicine. There’s no good method—not lethal injection, not hanging, not a gas chamber, not a firing squad, not an electric chair—because it is the whole idea that is nauseating. Our supposed preference for one method over another is nothing but a tell about how we really feel, but do not want to confront. The medicalization of capital punishment has fooled many people into looking away, and feeling okay about that.

If the methods themselves are not cruel and unusual, the whole ritualized enterprise almost certainly is. Years of uncertainty, appeals, changes in timing—all amount to a form of psychological water torture, a condition which some have called Death Row Syndrome. The irony is that only a justice system fair enough to permit an exhaustive legal process ensuring that reasoned appeals are heard and deliberated upon could cause such suffering. Critics don’t buy it; that’s self-induced cruelty, they argue. Well, what else are they supposed to do? Would we rather accept a system wherein the death penalty is carried out within minutes, hours, days, or even weeks of the sentence? I doubt it, especially when later DNA evidence has overturned wrongful convictions, to say nothing of the racial disparities here. If we are thoughtful enough to have a legal system to guard against capricious tyranny, why haven’t we realized the emotional damage it causes is as cruel as whatever weapon is ultimately wielded by the state when the appointed hour arrives?

In case you haven’t noticed, I am opposed to capital punishment. At least, I think I am. I can’t seem to summon anything but a fleeting pang of satisfaction when I think about Adolf Eichmann hanging from a rope in Ramla. But it’s all a matter of proximity, physical and emotional, I suppose. As a physician, I would have refused to have had anything to do with his killing, let alone that of some convict whose deeds came up well short of genocide. In fact, my ethics—and the Geneva Conventions, as it happens—say that if he had come into my ER, I would have attempted to save him. Yes, I loathe murderers. But more than that, I certainly would not ever like to become one.

Dead Man Walking with music by Jake Heggie, a libretto by Terrence McNally, and based on the book by Sister Helen Prejean, opens the Metropolitan Opera’s 2023-2024 season in New York City this Tuesday, September 26th and runs through October 21st.