J. Kent Garman
Humane Execution: An Oxymoron
It sounds better than hanging by the neck from a rope, getting shot, being fried electrically or gasping on toxic fumes. It’s called lethal injection, and it’s the method used almost exclusively in this country for state-mandated killings of convicts.
Killing and medicine have converged in ways they never have before. As caregivers and California residents, let’s look at this biological process, which has become the flash point for a larger debate on capital punishment.
When Oklahoma became the first state to adopt lethal injection in 1977, the “cocktail” of anesthestic drugs selected consisted of 2000 mg of sodium pentothal (a barbiturate sedative), 100 mg of pancuronium bromide (a paralytic agent), and 50 mg of potassium chloride (to stop the heart). These drugs are given intravenously in sequence. The doses of the first two drugs given are approximately 10 times the doses employed for an anesthetic induction. Other states adopted Oklahoma’s protocol, and this is now the method used in the U.S. almost exclusively. The initial dose of pentothal varies from 2000 mg to 6000 mg across various states. A few states still “offer” alternatives to the condemned such as hanging, firing squad, or cyanide gas. (In Washington State a few years ago, an inmate did choose hanging from a short menu, sending his embarrassed keepers to 19th-century manuals to learn how to do it).
Before we get further, I want to state that I am fervently opposed to the death penalty. The United Nations has called for a ban of capital punishment. The United States is currently the biggest user among only a handful of “civilized” democracies with legalized execution. Some states have already set a moratorium on capital punishment after documenting that innocent people were executed or condemned to die.
I believe executing human beings brutalizes the state, the judicial system, the individuals forced to actually perform the execution, and the public that allows it. It has never been shown to be an effective deterrent. Having said all this, I recognize that there are many people who disagree with me. In fact, a study published in the Archives of Internal Medicine (2000) by Farber showed that the majority of 482 physicians surveyed favored the death penalty. This is one of those un-winnable debates like abortion and assisted suicide.
In 2005, Koniaris et al published a paper in the Lancet that looked at post-mortem blood thiopental levels in 49 executed inmates in Arizona, Georgia, North Carolina, and South Carolina. (In fairness, this study has been criticized as flawed because of the paucity of data regarding post-mortem distribution of thiopental.) Nevertheless, the conclusion was that 43 percent of the inmates had blood thiopental concentrations consistent with possible consciousness. The authors then commented that this subset of inmates might have been fully aware and would have experienced “pain” from the additional drugs given. They also pointed out that the American Veterinary Medical Association specifically prohibits the use of neuromuscular paralytic agents for animal euthanasia because of the possibility of awareness of the animal under paralysis.
In California last month, condemned prisoner Michael A. Morales persuaded a federal judge, based on this paper - flawed science or not - and observations of previous “botched” executions, to craft an unprecedented ruling. The judge said that the state had two choices: first, have a qualified medical expert present in the execution chamber to certify that the prisoner was actually unconscious before the paralytic drug and potassium were injected. The second choice was to omit the paralytic agent and potassium and just use the barbiturate. He reasoned that these choices would ensure that the prisoner was not awake and suffering.
The state chose the first option and actually was able to recruit two anesthesiologists who agreed to be present during the execution to certify unconsciousness. However, an AMA policy states clearly that physicians should not have any involvement in executions. The policy even states that doctors shouldn’t pronounce death, because if the patient is not dead, the doctor would become complicit by pointing out that further drugs were needed to complete the job. (There are no penalties attached to this ethical statement.) In some other states, state-employed physicians do actually participate by mandate in executions. It should also be stated that there is no California law prohibiting physician participation in executions, so the Medical Board would not be involved.
The two anesthesiologists in California were not identified by the state. I do have a heavily redacted copy of a CV from one of the physicians involved. It shows that the physician is a chief of anesthesia, an assistant clinical professor in a volunteer faculty, a member of the California Society of Anesthesiologists, a delegate of the American Medical Association, and is board-certified in anesthesiology.
The Morales case sparked a spirited debate by physicians and various medical associations. The California Society of Anesthesiologists stated its adherence to the AMA’s no-participation ethical statement. The debate widened to include abortions and assisted suicide. Ethicists joined in to point out that circumstances were different. After all, a condemned prisoner is not required to provide informed consent, and the doctor-patient relationship with the death-watch physician is compromised at best
As a citizen-physician, I became involved in news interviews with CBS and ABC as a spokesperson for the California Society of Anesthesiologists. I was asked but could not give interviews to Fox, NBC, and CNN as well. I appeared on TV three times — short sound-bites extracted from 30 minute interviews.
Then before Mr. Morales was to die, the judge turned up the heat and ordered that the physicians present would have to decide if additional drugs were required to complete the execution. To their credit, the two anesthesiologists then bailed out at this mandate for direct involvement.
Next, the state executioners said they would increase the dosage of thiopental to 5000 mg and use only this drug for the execution, omitting the paralytic agent and potassium. The judge then said that the person injecting the drug had to be inside the execution chamber and had to be licensed by the state to inject intravenous medications. The list of those licensed to do so is short: physicians, nurses, veterinarians, dentists, paramedics, EMT’s, and a few others. The state was unable to find anyone willing to do this job because of ethical concerns. The execution was postponed indefinitely.
I was asked by one news anchor how the prisoner would die if only one drug were given. Fair enough, this is a medical issue. I explained that barbiturates alone would simply put the brain to sleep and probably stop it from sending signals to the body to continue respirations. If breathing stopped, the prisoner would slowly become hypoxic and cyanotic. The heart would stop later as a result of the hypoxia. Increased CO2 and hypoxia in the brain could restimulate breathing and some shallow respirations might continue long enough to allow the thiopental to redistribute out of the brain and awareness to return. I stated that the use of the paralytic agent and potassium to stop the heart was a much better method if they really wanted to kill the person. I also pointed out that the death with a barbiturate only could be quite gruesome with movement, cyanosis, convulsions, and gasping respirations.
Many people think (and hope) that this controversy will open a new national debate on the merits of the death penalty, perhaps leading to its abolition. Two laws have just been proposed in California: the first would prohibit physician participation in executions. The second would place a moratorium on the death penalty pending further study and political debate. It is perhaps time that the U.S join the rest of the civilized society who have stopped legalized state killing.
References available on request. And as always, I welcome your comments on this very timely topic that we as physicians, who often deal with death in other contexts, have special expertise we can apply as good citizens.
