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(Sub)Lethal Injection, Again…
The topic of lethal injection lends itself to analysis from numerous perspectives. I approach it as a reluctant and ambivalent opponent of the death penalty. That view derives from two overriding principles: one, the state (federal or otherwise) is not the owner of citizens’ lives and ought not have the power to extinguish them; two, the state — demonstrably incompetent to deliver mail, control national borders, or even conduct credible elections — is not competent to do so.
Having said that, I only hope to impart to Ricochet members the actual medical facts surrounding this controversy. The media are way off the mark in what passes for “reporting” on this topic. Whatever one’s opinions regarding the death penalty or the methods used, actual facts are helpful. I have no agenda here to persuade anyone of anything. As I said, my own opinion is highly ambivalent.
I do not want to address, here, the moral issues related to lethal injection. A separate post might well address the topic of how much suffering is desirable or permissible in conducting executions of individuals who have taken others’ lives, often brutally. Morality aside, the current legal standard for “cruel and unusual” permits various methods, provided that mishaps are not foreseeable. Therein lies the problem — both legal and practical — with lethal injection.
At first blush, one might think that relatively simple, mechanical means of execution like hanging, electrocution, gas, or firing squad are reliable and without foreseeable mishaps. Unfortunately, experience shows this to not be the case. One example: after a volley of high-powered rifle fire in Utah, the condemned was still alive and the firing squad had no more cartridges at hand. There are examples of bungling with all methods. You may read of them should you so desire. The inescapable inference from such knowledge is that, in the hands of the state’s functionaries (and given the overall record of state competence in most of its endeavors), any method of execution will foreseeably go awry. Adding the biological and technical complexities of lethal injection makes mishaps not a risk, but a near certainty, especially as such executions are presently conducted (i.e. with technical personnel starting the IVs).
The media, either through incompetence or, more likely, in pursuit of an anti-death penalty agenda, universally focus on the drugs used for lethal injection. The drugs are not the problem. They are all suitable for the purpose. The problem, rather, is venous access — the inability of the state’s functionaries to start a proper IV. Subcutaneous (under the skin, but not in a vein) injection of sedative/hypnotic medications like the ones used in Arizona will, eventually, cause unconsciousness, —but it may take a looonnng time. In the present instance, two hours elapsed before death ensued. Presumably Arizona also used a second drug to cause muscle paralysis. This prevents breathing and death results from hypoxia. Given intravenously, the agents used will reliably cause first deep unconsciousness and then death, in that order, in 10 minutes or so. Some states give potassium chloride as the third component. This results in immediate cardiac arrest. Injected subcutaneously, all bets are off as to the sequence of events.
Midazolam, used by Arizona and Ohio, is poorly absorbed subcutaneously but will cause sedation first and then unconsciousness — slowly. Muscle relaxants, on the other hand, are absorbed more rapidly and initial muscle weakness will progress to complete paralysis (again, over some time). Potassium chloride causes an excruciating burning sensation when injected subcutaneously. In this most recent circumstance — a failed IV and no potassium chloride given — it is most likely that the individual was sedated but not necessarily unconscious, and experienced muscle weakness and increasing air hunger. It would be a cruelly effective method of torture.
As an anesthesiologist, I have given literally hundreds of “lethal injections” of exactly the same type used by Arizona. Every anesthetic is actually a lethal injection, because the drugs promptly stop respiration. The patients would die but for the fact that we “rescue” them by breathing for them. The media is currently hyping the use of midazolam (a benzodaizepine of which Valium is the best-known example) instead of thiopental, a barbiturate (Pentothal is the best-known brand). Now, barbiturates are generally far more lethal than benzodiazepines when used alone because they are much stronger respiratory depressants (they are used in this manner, orally, in those jurisdictions that allow assisted suicide). No state relies on either midazolam or thiopental alone to cause death. That is why a paralytic agent and or potassium is given following unconsciousness.
Midazolam, particularly in the large doses used, will reliably induce profound unconsciousness in every instance, provided it is actually given intravenously. Anything done to the individual subsequently will result in no conscious suffering, whether it is paralyzing the muscles or stopping the heart with potassium. Again, this method is reliably effective in causing death with no conscious suffering, provided the drugs are delivered intravenously.
The problem with all the “unsuccessful” lethal injections to date has been failure to properly place an intravenous catheter. Terms like “the vein collapsed” or “the vein blew” are euphemisms used to cover up the fact that the individual starting the IV has failed and won’t admit it. Usually, EMTs start IVs for lethal injection. Sometimes, failure is quite understandable, as with former IV drug abusers (who are likely overrepresented on death row) or patients who have had extensive chemotherapy, their veins having all undergone sclerosis. Such individuals no longer have any peripheral (easily accessible) veins. When this kind of individual needs an IV for medical procedures, medical personnel — usually physicians — must start a central IV using internal jugular, subclavian, or femoral veins. Such procedures require only local anesthesia and are not painful when skillfully done. They do, however, carry serious (but uncommon) risks of complication. This skill must be regularly practiced to me maintained.
In order to meet the legal standard of foreseeability necessary to avoid being categorized as cruel and unusual punishment, lethal injection — particularly obtaining venous access — would have to be performed by physicians. Only physicians can reliably obtain IV access in all condemned individuals. Such an act, should an individual physician agree to it (surely, some would be willing to do so — but likely not one whose practice regularly involves starting central IV lines … trust me on this), would result in expulsion from every medical association. While membership is such organizations is not essential for licensure, such a physician would become a pariah, deemed unethical.
The state, in its wisdom, could undoubtedly employ a cadre of physicians to plausibly undertake this task. I doubt they would be very skilled in the necessary procedures, however, as they would be otherwise unemployable and these techniques, as already stated, require regular practice in order to be reliable.
We already employ the legal fiction that traditional execution methods have no foreseeable mishaps. The same fiction could, of course, be applied to lethal injection, should the state decide that it requires employment of physician executioners (who are likely to be as incompetent as their employers) in order to at least purport to meet the Constitutional standard as to cruel and unusual punishment. We already live in a society where “bureaucratic truth” or legal fictions are at odds with reality. Speaking for myself, I prefer to not go down the path of calling upon our healers to also become our executioners. We have enough of this tension between law and reality as it is. It simply isn’t worth it.
It occurs to me that it might be be a step toward a more honest society (where laws better reflect reality) were we to return to public execution by one of the traditional methods. Do we really want to sanitize and medicalize state killing? I have no doubt the death penalty would be far more effective as a general deterrent were we to return to the old ways. It would also clearly show citizens the actual results of some of their representatives’ choices.
Published in General
So then we return to hanging. Yes I know hanging can be screwed up but most of the recent (and famous) examples of hangings gone wrong have probably had more to do with malice on the part of the executioner than technical problems (I am thinking of the Nazi leaders after Nuremberg or the hanging of Saddam Hussein and some of his top officials).
Also good luck about this not turning into a philosophical debate. I tried that once with a technical question about using seized narcotics for lethal injections………..I never really did get an answer for that.
Would that really work? Aren’t siezed narcotics often cut with all sorts of other agents? There would be no way to determine a proper lethal does. I guess you could take the drugs and distill them down to some known quantity but that just seems like too much effort. Furthermore what if you fail to capture enough drugs?
Mechanical means of killing are probably the most full proof and least technical to administer. There are the traditional methods of course (hanging and shooting), but you can also just pith the criminals by driving a metal cylinder into the base of the skull destroying the brain stem and hypothalamus. No way anyone is living through that and death would be as close to instantaneous as possible. It would also be painless.
Didn’t they used to have an officer with a pistol and plenty of cartridges who was tasked to quickly intervene if the firing squad was ineffective?
“I approach it as a reluctant and ambivalent opponent of the death penalty. That view derives from two overriding principles: one, the state (federal or otherwise) is not the owner of citizens’ lives and ought not have the power to extinguish them”
Did the criminals own the lives that they took, or destroyed? I think you may want to re-think your argument.
As a former police officer I could care less if prison inmates eat steak and consume a quart of ice cream every night or have access to heroin when they are behind bars. As long as they are not released back into society I’m okay with that. If governors of the states would agree to give up the power to pardon or to commute life without parole sentences I would say abolish the death penalty. I have no problem that if new evidence comes to light on a persons guilt or innocence that a court hearing could be used to present that evidence and if someone is found not guilty by that new evidence they should be released.
In light of the fact of stories about botched drug executions and coming from Oregon where “assisted suicide” or state sponsored suicide is legal I wonder how many people take enough drugs to put down a herd of elephants and promptly vomit them back out of their bodies and have to start the process all over again. I ask this question in all seriousness and perhaps an anesthesiologist could answer my question.
A bullet in the back of the head, repeat as necessary, is all that is needed. Works for the Chinese.
If we’re going to execute people at all, why must we rely on drugs rather than mechanical means for execution?
Personally, I’m not sure why a swift and highly reliable (even if not 100%) method of execution is cruel or unusual, even without anesthetic. But let’s say everyone else disagrees with me and believes prisoners should be anesthetized before execution. Why can’t the prisoner be anesthetized first, then killed by mechanical means? Why must drugs (rather than, say, pithing, shooting, or beheading) be used to cause death?
Why not, for example, give the prisoner a subcutaneous shot of sedatives in his cell, then let him sit there till he gets sufficiently anesthetized, and then use mechanical means to execute him?
Oral administration is very different from IV. Nausea and vomiting is indeed a problem with barbiturates. I’m not sure how they deal with it, as I have no experience with oral administration. My best guess is that they pretreat the subjects with a serotonin 5-HT3 receptor antagonist like Zofran, which is quite effective in preventing drug-induced nausea & vomiting. It is widely used to prevent the problem with anesthesia or chemotherapy.
But not 100% reliable if not administered by a doctor? That seems to be what westman is saying.
If so, then means uglier than but equally reliable to physician-assisted execution by drugs would be more reliable than non-physician-assisted execution by drugs.
Much confusion results from law enforcement referring to most all illegal drugs as “narcotics.” Understanding is further hampered by the fact that in medicine, “narcotics” commonly refers to narcotic analgesics (opioids, like morphine), and to compound that, the term narcosis means stupor or unconsciousness. Surprisingly, narcotic analgesics, like morphine, heroin or fentanyl are not very good at inducing sleep or unconsciousness – rather feelings of euphoria. I recall as a resident, I was trying to induce anesthesia in a young Marfan Syndrome patient with an aortic dissection with morphine. After 200 mg (a huge dose), he had stopped breathing spontaneously from respiratory depression, but was awake and would breathe when I told him to.
In other words, we might not know what seized “narcotics” are and even if we did, they are not likely to induce unconsciousness. Needed for unconsciousness are sedative/hypnotic drugs (barbiturates/benzos) and they represent a small minority of the drugs which are abused.
Starting an IV is pretty fundamental. If the IVs for lethal injection are done by the same EMTs who may be called upon to save your life after an accident, should we assume they are equally incompetent in those circumstances? Is it not possible to determine after an IV has been inserted if it is indeed in the vein? (I seem to recall such a check after my cardiac event in 2005.) If you need a reliable IV, why not use one of the big veins rather than one in the arm?
Yes, fundamental, but not rarely, problematic with variables requiring ongoing judgment, depending on what it is being used for. A drip using only gravity may work fine in a small vein, but using it for large, rapid blood infusions may cause it to rupture. Similarly with drugs if large volumes are injected under too much pressure.
As to EMT competence, I’m sure most are, though the ones I have encountered have not been the most humble folks I have met – the kind who admit limits or errors.
Using large (central) veins would be preferable, but requires a physician, not an EMT.
Yes. Most reliable and “esthetic” = physician performed lethal injection
Next most reliable = mechanical means, which have been (so far) found to pass Constitutional muster.
Least reliable with, IMO, most foreseeable chance of mishaps and thus most likely to be found unconstitutional = lethal injection as it is now being done without physicians.
Not certain, but in some states, at least, I think the condemned were offered oral sedatives prior to execution.
Some clarification-
Some states use two drug cocktail – sedative/hypnotic plus muscle paralytic, pancuronium (Pavulon)
Some states use three drug cocktail – sedative/hypnotic plus muscle paralytic plus potassium chloride. The KCl is not a paralytic of skeletal muscle. It causes uncoordinated depolarization of the membranes of cardiac muscle resulting in ventricular fibrillation (a state in which the heart pumps no blood) or cardiac standstill. Either results in brain death in about 3 minutes.
Also useful to know that starting a central IV line requires cooperation of the subject. While one can immobilize an arm, it would be difficult or impossible to restrain someone enough to do this.
Five minutes with the victim’s family should do the trick.
The manner in which we now conduct executions has become muddled into some form of moral purity to assuage conduction of same. In all a fools errand at best.
The current system might be replaced with a simple massive overdose of Morphine, clean and simple.
The death penalty seems to have lost its sting as it were as a threat to the commission of crimes.
My Draconian self would like to see the National Razor adopted here. Sounds grossly uncivilized, yet that in and of itself may have been were we have become too kind and gutless.
That was my mothers take –
Midazolam gets absorbed from the nasal cavity pretty rapidly. Would a nebulized solution of Midazolam be absorbed via massive surface area in the lungs? Alcohol nebulization provides a rapid increase in BAL and can quickly lead to unconsciousness. I bet the same would apply to Midazolam. Ditto Fentanyl. In ER we have many case reports of idiots inhaling burning fentanyl patches and suffering a rapid fatal overdose, not to mention the Moscow Theater Hostage event where Russian security forces used fentanyl gas in a rescue attempt.. A combination of the two aerosolized with a chaser of Succinylcholine IM should work. If any respiratory drive resurfaced it would quickly be suppressed.
Alternately, put a CPAP mask on the individual. Start him on Nitrox. Once unconscious lean out the oxygen and deliver pure Nitrogen. Won’t look pretty, but then again anyone getting a death penalty actually carried out is bad bad bad .
I was wondering about the fentanyl gas. Nitrogen asphyxiation too.
Then bill the estate (or family) for the price of the bullet.
I was thinking the exact same thing. Wasn’t the guillotine developed to make executions humane? France even kept it as the national method of executions until they abolished the death penalty in 1981.
Who is in?
But I agree we shouldn’t sanitize execution, and when we have to confront the reality of what we do, that we will be more judicious in its application.
There has to be a death penalty available for consideration, to meet the requirements of providing justice.
Some level of unconsciousness could indeed be achieved with mucosal absorption of midazolam. It is difficult, however, to kill someone with benzos alone (The joke in med school was that the only way to kill someone with them is to run them over with the truck delivering them).
You are headed in the direction I have thought about. Fentanyl gas or nebulizer particles would likely work. The only wrinkle, as you surmise with the idea of a CPAP mask is upper airway obstruction preventing ongoing inhalation of sufficient fentanyl, which would draw out the process. It would work, but would have some of the elements of unsightliness now being complained of.
My best guess as to a painless, “esthetic” death goes like this: large does of oral/IM sedative beforehand. Restrain thoroughly. Place anesthetic rebreathing mask over nose/mouth. Induce general anesthesia by inhalation of desflurane or sevo. Oral airway prn (easy to do). Up the dose to lethal. Completely painless, quick. Tidy, but still sanitized.
Fentanyl gas might work, but the “helpers” would need access to the subject’s upper airway. With deep unconsciousness , the upper airway becomes blocked (like with sleep apnea) and slows down the inhalation process. This can be overcome by slipping a plastic device called an oral airway (or a nasal airway if mouth won’t open). An alternative cause of death with fentanyl is by chest wall rigidity, unique with this agent. Large rapid doses of fentanyl by any route of administration cause chest wall rigidity and can lead to quick death from hypoxia. Not likely to be pleasant to watch.
With inhalation induction of general anesthesia with potent inhalational agents (halothane, ethrane, desflurane, sevoflurane), a mask is placed over the nose and mouth. The mask is connected to a rebreathing circuit which absorbs exhaled CO2. The subject becomes unconscious in 1 – 2 minutes. An oral airway prevents airway obstruction. The gases are lethal at about twice the usual concentrations and it is easy to supply a multiple of that. Death ensues in minutes from myocardial depression during deep unconsciousness.
Guillotine is likely quicker & slicker. I believe it was once demonstrated by eye blinking (agreed to by the condemned before the head was lopped off) that there are 15 – 20 seconds of consciousness before brain death after the head has been lopped off. Not a pleasant thought!
Who did this spoof?
The ‘occasional mishap’ happens, but I bet not as often as the occasional mishap of a prisoner escaping or killing another inmate. Or a guard.
I vote for mechanical and fast, with as little chance of pain as possible. A gas to put them to sleep maybe.