Lethal Injection Cocktail Can Be Used Despite Risk of Pain
Monday June 2, 2008
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The Kentucky case, Baze v. Rees, narrowly focused on the constitutionality of the three-drug method of lethal injection used — not the legality of the death penalty itself. The challenge, filed by death-row inmates Ralph Baze and Thomas Clyde Bowling Jr., argued unsuccessfully that the state’s procedure violated the Eighth Amendment of the Constitution, risking cruel and unusual punishment in the form of unnecessary pain and suffering for the inmate.
The three drugs used in Kentucky are the same three used by the federal government and in all other death penalty states (except Nebraska, which had used the electric chair until February, when the state’s Supreme Court ruled electrocution was cruel and unusual punishment). The Supreme Court ruling in the Baze case leaves the door open to future challenges, but challengers will have to show that a state’s process risks severe pain and that there also is an alternative method available.
While the specific written procedures and dosages for lethal injections may vary from state to state, all that use lethal injection employ the same drugs administered intravenously in the same order: first sodium thiopental, an ultra-short-acting barbiturate; next, pancuronium bromide, a neuromuscular blocking agent that paralyzes the voluntary muscles; and finally, potassium chloride, which stops the heart.
Most medical experts agree that when administered correctly and in the right dosage, this combination is effective and not painful. But those who have challenged the method argue that the procedures states may use – sometimes using technicians or orderlies or prison guards to administer the drugs — could lead to a person being inadequately anesthetized. Potassium chloride can cause an agonizing burning sensation, they say, but the paralyzing effect of the pancuronium bromide would make it impossible for the inmate to express any pain or suffering. And the paralyzing agent itself, if administered without adequate anesthetic, creates a feeling of suffocation as the person is unable to move the muscles necessary to breathe.
“Nobody disputes that if the three-drug formula works to perfection, inmates should be completely anesthetized and deeply unconscious at the time they’re paralyzed and killed by the potassium chloride,” says Ty Alper, associate director of the Death Penalty Clinic at the University of California Berkeley School of Law. Alper wrote a friend-of-the-court brief on behalf of the inmates in the Baze case. “But by paralyzing the inmate, it’s hard for anyone except someone who’s highly trained to know about anesthetic depth, to know whether the inmate is truly unconscious or not, so we don’t know how many lethal injection executions have been terribly botched.”
The questions are thorny for medical professionals, many of whom belong to national associations, such as the American Nurses Association and the American Medical Association, that have policies barring members from participating in executions on ethical grounds.
It is difficult to determine exactly how often nurses and physicians participate in executions because of the secrecy that sometimes surrounds the procedure. In many states, neither physicians nor nurses participate, although there is often a doctor standing by to confirm that death has occurred, says Richard Dieter, executive director of the Death Penalty Information Center in Washington, D.C. Some states, such as Illinois, forbid physician participation, while others, such as North Carolina, have mounted efforts — so far unsuccessfully — to require physician participation, he says.
It is safe to say, however, that some doctors and nurses are willing to participate in executions and may be called in when something goes wrong, Dieter says. In fact, Alper says nurses have participated in executions in some states, including California.
“It is impossible to tell because we don’t have information from many states, but far more doctors and far more nurses participate in executions than people realize,” Alper says.
Lisa Thiemann, CRNA, MNA, the acting senior director of professional practice for the American Association of Nurse Anesthetists, explains a few of the things that can go wrong with the three drugs. Because they are administered intravenously, there could be infiltration of IV fluid into surrounding tissue, which would prevent the medication from reaching the vascular system and could cause a delay in the drug’s action. Or the IV tubing could become disconnected and interrupt the delivery of medication. There could also be an incorrect calculation of the drug dosages needed to achieve the desired effect, or the drugs could be administered in the wrong order. Thiemann, whose organization does not take a position on capital punishment or on anesthesia professionals being involved in lethal injections, says it is a valid concern that the long duration of the effects of the pancuronium bromide might make it impossible to determine situations in which an inadequate dose of sodium thiopental was given and the patient was feeling pain. While she says that potassium chloride infusion can “sting and cause some vein irritation,” she declined to comment on whether the three-drug protocol is humane or whether there might be a more humane method available.
Some have suggested the current lethal injection protocol was originally chosen partly because it is distinct from the way animals are euthanized and because the paralytic agent offers the inmate some degree of dignity at the time of death, masking any involuntary movements that witnesses might find disturbing. Ironically, those who oppose the current method are now looking to the veterinary world for what they see as a more humane alternative: executing with a single overdose of a barbiturate, the method commonly favored to put down household pets.
The American Veterinary Medical Association (AMVA) has lengthy guidelines on euthanasia for animals, and the debate over lethal injection has become so politically charged that the AVMA recently decided to put a cautionary message on the cover of the guidelines, noting they are not intended for human lethal injection. That said, veterinarians do not often use paralytic agents “because we don’t need to,” says Dr. Gail Golab, PhD, DVM, director of animal welfare for the AVMA. The central issue, she says, is whether the individual subject to the procedure is unconscious before being paralyzed. “A lot of times, the problems with euthanasia are less about the approach than the problem that the people administering it aren’t trained correctly,” she says. “A lot of those approaches they want to limit are very humane when they’re administered correctly. The problem is when they’re not.”
The favored method for euthanizing pet animals is a large dose of pentobarbital, says Dr. John Dodam, past president of the American College of Veterinary Anesthesiologists and associate dean for academic affairs for the University of Missouri College of Veterinary Medicine. Neuromuscular blockers such as pancuronium bromide are typically not used and are considered unacceptable as a sole euthanizing agent for most situations, he says. “When you do use them, you take away your ability to assess responses,” he explains.
The Death Penalty Clinic’s Alper argues that the anesthetic-only procedure used on animals would make for a more humane method for humans because it doesn’t involve a painful drug or one that paralyzes and would be easier for those who lack significant medical training to administer. Veterinarians have subjected euthanasia procedures to considerable medical and scientific scrutiny, he says, “in stark contrast to the way lethal injection was developed for people.”
Dr. Ray Greek, M.D., a board certified anesthesiologist and science advisor to the National Anti-Vivisection Society, counters that the drugs used in lethal injection, if administered correctly, should be sufficient to ensure that an inmate is completely anesthetized. The focus of the debate on the drugs is misplaced, he argues. “I think the controversy should focus more on the human factor,” he says. “The drugs are foolproof.” In a hospital setting, caregivers can give patients a dose of an anesthetic, monitor his or her reactions, and then give him or her more if necessary. In prisons, on the other hand, Greek says, “you get one shot.”
Barbara Kirchheimer is a freelance writer. To comment, e-mail editorNTL@gannetthg.com.
