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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
These musings reinforce my main point. There exist medical means to ensure a quick painless death. They all require some ongoing medical judgment, although the inhalation methods require less expert technical actions. EMT’s can reliably place oral or nasal airways to overcome upper airway obstruction. Maybe physicians aren’t required to act in every case with this method. Nonetheless, it would require a physician’s knowledge and design of the process to make it reliable.
Perhaps I have given away too much, but I surmise my revelations on Ricochet are unlikely to be read by anyone in officialdom (other than the NSA). I can only hope they do not share it with departments of correction which carry out executions. Remember we were told that 9/11 was allowed to take place through a failure of imagination. I suspect that failure is epidemic among all parts of the ruling apparatus, so my musings are unlikely to surface and be employed.
It may be that some failures result from too much pressure at the injection site. States employ some cockamamie automatic injection machine designed by an obscure engineer. If injections are too rapid, they may rupture veins with these publicized results.
I dunno if anybody’s mentioned it yet, but it’s nearly impossible to botch a guillotine execution.
The purpose of lethal injection is to mitigate the trauma experienced by the executioners. The practice has nothing to do with the comfort of the condemned.
Perhaps the notion that no physical suffering occurs also assuages the conscience of the citizenry. In Glass vs. Louisiana, Justices Brennan and Marshall dissented from the court’s refusal to grant certiorari. Had the case been accepted, the court would have reviewed the issue of whether or not electrocution represented cruel and unusual punishment. Written opinions dissenting from refusal to grant cert are most unusual. The justices, as advocates of “the living Constitution,” cited “evolving standards of decency” and described just what happens during the process. They said it was the modern technological equivalent of burning someone at the stake.
Mostly, the results of lawmaking are diffuse and analysis spun into meaninglessness. I tried to suggest that public executions or actual knowledge of what they are like, would confront citizens with the unadulterated reality of their representatives choices in this matter. Knowing that mechanical means of execution are horrible to witness, death penalty proponents sought to sanitize and medicalize the process in order to make it more acceptable to the public.
“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”
Is this really true? I thought doctors were prohibited from euthanasia as a medical prescription for a patient. But that does not mean that doctors are uniformly prohibited from killing people in other circumstances, merely because they are doctors. Self-defense and executions are not medical prescriptions for a patient.
Yes, traditional methods of execution are clearly more humane than injections, as is becoming more and more clear. Firing squad would seem to be the most humane. It is certainly the one I would choose if I had to. Injection wouldn’t even be on the list. The reason traditional methods are not used is not because they are less humane, but because they seem brutal or backwards. In other words, the sensibilities of those who sentence the condemned, and not treating the condemned humanely, are the most important.
The Onion.
It is indeed true that participation in state-sanctioned killing is universally regarded as unethical in the medical profession. The fact that the physician is not prescribing it is not controlling. The act of participation beyond merely pronouncing death will result in expulsion for all medical societies.
As to the conclusion that traditional methods are more humane from the point of view of the condemned, I can’t concur. Examples of problems with lethal injection have been sensationalized. Most actually go off without a hitch. You can easily find many descriptions of various horrors which have occurred with other methods. Properly done, death by lethal injection feels identical to induction of general anesthesia. Falling asleep in that setting is rather gentle (some even experience a pleasurable “rush”) and completely painless.
The story continues to unfold. According to the most recent media reports, Arizona did not use either a muscle relaxant to stop respiration or potassium to stop the heart. They used midazolam for unconsciousness and hydromorphone, an opioid to depress (but not promptly stop) respiration. This combination is lethal, but would foreseeably take a longer time than previously-used cocktails. Once again, the result of state decision making and incompetent state functionaries is on full display.
Public policy decision making – who makes critical decisions, the factual basis on which they are made, the competence of those who carry them out – has much wider application than on this specific, emotional and visible issue. Here, the poor results of our dysfunctional political process and tortured administrative process are obvious. It continues to astound me that results of progressive policies remain immune to poor empirical results. Would that this microcosmic example would prove instructive to voters, who can’t seem to see beyond the latest round of pie-in-the-sky promises from power-hungry lawmakers.
Oh brother. Any vet knows better. What idiots decided on that cocktail?
There’s a thought…sign everyone on death row up for VA care and let the government neglect them to death.
What about large animal tranquilizers? When I was reading up on the relative strength of pain killers I leaned about Carfentanil which is 1,000 times stronger than Fentanyl. People die just touching Fentanyl, Carfentanil is scary dangerous stuff.
Interesting thought. Fentanyl is only supplied commercially as a solution of 50 micrograms/cc. Beyond illicitly-produced fentanyl, it is never seen in solid form, but if it were, it would be dangerous, at least if applied to mucous membranes. I know zero about carfentanyl. It seems like merely putting it in someone’s mouth in solid form would be lethal. How quickly, I don’t know, but I am fairly certain that the state would somehow screw it up.
Again, one of the main points I am hoping to illustrate is the lack of competence of government officials. If they can’e even execute prisoners reliably in a humane fashion (assuming that is not an oxymoron), why on Earth should they be trusted to run virtually every aspect of our lives? Remember, these are the people who will be running the health care system from now on (unless they are brought over from the post office).
I’d find the AMA’s fainting couch act more tolerable if they also expelled abortionists. As it is, the professional association can perform medically and anatomically impossible acts upon itself for all I care. Nonetheless, I concur with keeping doctors out of the execution business. Execution is a governmental and juridical act. At the present time, medicine is not.
As a police act, though, it should be carried out in dignified and traditionally symbolic ways. Execution is not only for balancing the scales of justice and sating the community’s anger, but also for squaring the condemned with society. It is, ultimately, good for the condemned’s soul, to make right with the world. As such, he should be allowed to die in a way that dignifies himself -making an apology, as it were.
Lethal injection is a poor method -being rendered unconscious deprives the condemned of the ability to make a good end. Beheading and gassing would work, but are not our tradition (and have the stench of Jacobinism). Burning is medieval and monarchal. That leaves hanging and firing squad. I’d reserve the firing squad for soldiers, but I’m not that picky.
In addition to your statement, I’ve always thought of the death penalty as an act to remove from society someone who was too dangerous to be allowed to live.
In the US – the UK uses their health service to administer their death penalty – they just don’t impose it for criminal acts.
The more complex the execution mechanism, the more likely the state will screw up. I like the redundancy of the firing squad. Use 13 men with 12 bullets. Pick 2 or 3 key points on the chest. Death would be fast and certain.
You may be able to, for quality assurance purposes, pre-code the bullets to ensure that anyone off target is removed from future firing squads.