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Killing me softly: rethinking lethal injection

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By Aidan O’Donnell


How hard is it to execute someone humanely? Much harder than you might think. In the United States, lethal injection is the commonest method. It is considered humane because it is painless, and the obvious violence and brutality inherent in alternative methods (electrocution, hanging, firing squad) is absent. But when convicted murderer Clayton Lockett was put to death by lethal injection in the evening of 29 April 2014 by the Oklahoma Department of Corrections, just about everything went wrong.

Executing someone humanely requires considerable skill and training. First, there needs to be skill in securing venous access. Some condemned prisoners have a history of intravenous drug use, which obliterates the superficial, easy-to-reach veins, necessitating the use of a deeper one such as the femoral or jugular. Lockett was examined by a phlebotomist—almost certainly not a doctor—who searched for a vein in his arms and legs, but without success. The phlebotomist considered Lockett’s neck, before resorting to the femoral vein in his groin.

Second, there needs to be skill in administration of lethal drugs. The traditional triad of drugs chosen for lethal injection incorporates several “safeguards”. The first drug, thiopental, is a general anaesthetic, intended to produce profound unconsciousness, rendering the victim unaware of any suffering. The second drug, pancuronium, paralyses the victim’s muscles, so that he would die of asphyxia in the absence of any further intervention. However, the third drug, potassium chloride, effectively stops the heart before this happens. All three drugs are given in substantial overdose, so that there is no likelihood of survival, and the dose of any single one would likely be lethal. When used as intended, the victim enters deep general anaesthesia before his life is extinguished, and the whole process takes about five minutes.

Thiopental and pancuronium are older drugs, no longer available in the United States. US manufacturers have refused to produce them for use in lethal injection, and European manufacturers have refused to supply them. This has forced authorities to use other drugs with similar properties in untested doses and combinations.

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Lockett was given 100mg of the sedative midazolam, intended to render him unconscious. Witnesses were warned that this execution might take longer than expected because midazolam acts more slowly than thiopental. Lockett appeared to be still conscious seven minutes later; nonetheless, three minutes after this, he was declared unconscious by a prison doctor. Vecuronium (a similar drug to pancuronium) was then administered to paralyse him, followed by potassium to stop his heart.

Journalist Katie Fretland, who was present at the execution, wrote that Lockett “lurched forward against his restraints, writhing and attempting to speak. He strained and struggled violently, his body twisting, and his head reaching up from the gurney” and uttered the word “Man”.

How can you tell if someone is unconscious? Though it is not clear what criteria the prison used to determine Lockett’s level of consciousness, the tool most widely used is the Glasgow Coma Scale (GCS). Developed in 1974 by Teasdale and Jennett, the GCS recognises something fundamental: consciousness is not a binary state, on or off. Instead, it is more like a dimmer switch, on a continuum from fully alert to profoundly unresponsive.

The GCS uses three simple observations: the subject’s best movement response, his best eye-opening response, and his best vocal response. A fully-conscious subject scores 15. Someone under general anaesthesia scores the minimum score of 3– one cannot score zero—and this is the score which I would expect Lockett to have after 100mg of midazolam. From the reports, we can infer that Lockett’s score was much higher; it was at least 8. It should never have been above 3.

The prison doctor determined that the intravenous line was not correctly located in Lockett’s vein, and that the injected drugs were not being delivered into his bloodstream, but instead into the tissues of his groin, where they would be absorbed into his system much more slowly.

Despite a decision to halt the execution attempt, Lockett was pronounced dead 43 minutes after the first administration of midazolam. It was widely reported that he died of a “heart attack”, but this is a very imprecise term. I surmise Lockett suffered a cardiac arrest, brought on by the gradual action of the lethal drugs. During those 43 minutes, Lockett was likely to be partly conscious, slowly suffocating as his muscles became too weak to breathe, and his heart was slowly poisoned by the potassium. How much of this he was aware of is impossible to estimate.

As an anaesthetic specialist, I am trained and skilful at establishing venous access in the most difficult patients. I am intimately familiar with all of the drugs which might reasonably be used, and I spend my professional life judging the level of consciousness of other people. I would seem to be an ideal person to perform judicial execution.

However, I never will. First, I consider judicial execution morally unacceptable. Second, it is profoundly unpalatable to me that the drugs I use for the relief of pain and suffering can be misused for execution. Third, I live in a country where execution is illegal. However, even if I lived in the United States, the American Medical Association explicitly and in detail forbids doctors to be involved (however tangentially) in judicial execution, leading me to question the involvement of doctors in Lockett’s execution.

Different authorities in the United States are executing prisoners using a variety of drugs in combinations and doses which are untested, and not subject to official approval. Of course, as soon as official approval for a particular regime is granted, suppliers will move to restrict the supply of those drugs for execution, and this cycle will begin again. Drain cleaner would work fine; will they go that far?

Lockett’s bungled execution should prompt us to consider some fundamental questions about lethal injection: Who should be involved? What training should they have? What drugs should they use? Where should they come from? And the most important question of all: isn’t it time the United States stopped this expensive and unreliable practice?

Aidan O’Donnell is a consultant anaesthetist and medical writer with a special interest in anaesthesia for childbirth. He graduated from Edinburgh in 1996 and trained in Scotland and New Zealand. He now lives and works in New Zealand. He was admitted as a Fellow of the Royal College of Anaesthetists in 2002 and a Fellow of the Australian and New Zealand College of Anaesthetists in 2011. Anaesthesia: A Very Short Introduction is his first book.

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Image credit: Lethal injection room, by the Californian State of Corrections and Rehabilitation. CC-PD-MARK by Wikimedia Commons.

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4 Responses to “Killing me softly: rethinking lethal injection”
  1. I respect you, your thoughts, and your profession. More importantly, I respect your views on “judicial execution as morally unacceptable.”

    Criminals need to be punished for their crimes. And ways of punishing them are not at all perfect.

    Still, justice needs to be served.

    Please allow me to say that you are doing the right thing.

    Thank you very much for the very informative article.

    AK

  2. Katie says:

    Interesting that drug manufactures restrict the use of their drugs for lethal injection.

  3. Bufford says:

    As a physician in Texas, the discussion of lethal injection is a frequent occurrence. I am, at times, truly amazed by the simplistic response people have to the death penalty in general, and lethal injection in particular. I have had the fact that people undergo successful anesthesia put up to me as a reason that lethal injection is a reasonable and even preferable method to execute. I counter that even in the most skilled hands, the induction of anesthesia is sometimes not a smooth seamless process. Indeed, I have had rarely had cases cancelled because venous access could not be successfully secured. if skilled anesthesiologists cannot always obtain venous access when they do this every day; how likely is it that the technicians employed by the prison system will always be able to gain access? After all, even in Texas, executions are not a daily event, limiting the experience of the technicians involved.
    With respect to the drugs involved, if the sole intent is to kill the prisoner, ultimately, there will be always be a drug or combination of drugs available. Florida is supposed to use Midazolam, reported as a dose of 500mg to induce the execution. A very commonly used medication, the pharmaceutical industry will have great difficulty restricting the availability even if they so choose.
    From a physician standpoint, however, I fear that there will be someone who will agree to help in executions, if indeed this has not already occurred. Only about 15% of physicians are in the AMA, and even fewer fully subscribe to all of the AMAs’ tenets.

  4. From a human rights standpoint, no execution can be “humane,” because the prolonged anticipation of an unnatural death is itself a form of psychological torture. Prisoners who were subjected to the ordeal of mock executions (where the victim is not physically harmed at all), and also to serious forms of physical abuse, have often found the anticipation of imminent violent death more psychologically devastating than physical pain and degradation.

    Of course, our worst criminals can and must be punished; and in Texas since 2005, as in every State of the U.S.A. retaining the death penalty and almost every abolitionist State as well, the sentence of life without parole (in the UK, a “whole life tariff”) serves this purpose.

    Probably the “least bad” lethal injection protocol in the U.S.A. was the “single drug” method using a massive overdose of a barbiturate such as sodium thiopental or sodium pentobarbital. The potential problems with venous access are still present, but at least this alternative (notably used by Ohio around 2009-2010, when these drugs were still available) avoids the potential horrors of conscious paralysis and suffocation with a paralytic, or the sensation of burning alive if potassium were to travel through the veins of a prisoner not in a deep plane of surgical anesthesia. Ultimately, there is no right way to do the wrong thing, and society’s resources would better be devoted to real solutions for preventing violent crimes and more reliably bringing offenders to justice.

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