A Doctor’s Guide to Botched Executions

lockett execution chamber
I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

Not for amateurs

Though lethal injection is supposed to be more humane than the electric chair or the gas chamber, often it doesn’t work as planned. Mr. Lockett died on April 29 after the injection of midazolam, vecuronium, and potassium chloride into his system. It is unclear from media reports how much of which drug he actually received. Apparently, prison staff had difficulty finding a vein.

The drugs were injected, they thought, into the large femoral vein in Mr. Lockett’s groin, which should have killed him within moments.

But witnesses reported that Mr. Lockett was still groaning and trying to breathe for over 40 minutes before he died. The medications probably were deposited into his muscles and soft tissues rather than entering the bloodstream directly. As they were slowly absorbed, they probably caused muscle weakness, air hunger, agitation, and gradual suffocation before Mr. Lockett’s heart finally stopped.

Lethal injection, to be done right, should be done by physicians who are experts in getting needles into veins, and in giving anesthesia drugs. Logically, anesthesiologists would be the first choice. A bipartisan panel of criminal justice experts in Washington just released a major study on the death penalty, and says, “The proper administration of anesthesia is crucial to the humane execution of an inmate.”

But the American Society of Anesthesiologists and the American Medical Association agree that a physician, “as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

I can’t imagine intentionally doing harm to a helpless person under my care, no matter how vicious a crime he might have committed, any more than I could harm one of my children. When a gunshot victim—usually a young man—is rushed to surgery, I don’t want to know if the police think he was an innocent victim or a shooter himself. My task is to take care of him, not to judge.

So if lethal injection is to continue, the task will fall to others, not to anesthesiologists. Some well-meaning people want to make the process better. They argue in favor of using a single anesthetic drug, such as thiopental, in a large enough dose to produce death without needing other drugs to paralyze breathing or stop the heart.

But that would still be practicing medicine. The drugs must be obtained under a physician’s prescriptive authority, and the technique of injecting them into a vein requires medical training even if it’s delegated to a nurse or a technician.

Other options?

No doubt some readers will think that I must be a bleeding-heart Los Angeles liberal. They would be wrong. I’m a Texas native, and earned the rank of major in the US Army Reserve. I know how to shoot a gun, and am not at all squeamish.

There’s no doubt in my mind that I would be capable of violence against anyone who physically threatened my family.

My purpose is not to argue for the abolition of the death penalty. The Constitution leaves that decision up to each state. My argument is that capital punishment should not involve either the misuse of medical techniques and drugs, or the practice of anesthesiology by people who are not qualified to do so.

Anyone who supports the death penalty shouldn’t flinch at considering other options, and I’m sure modern technology could come up with an electric chair far superior to the ones of the past.

If a needle is still preferred, I’m surprised no one has considered the option of air embolism. The injection of a large volume of air into the heart will stop the circulation very effectively, just like an air lock in your fuel line. The technique is quite simple; it involves no drugs and little teaching.

Find a large syringe and attach a long needle—three inches or so is best. Draw air into the syringe. Insert the needle under the breastbone in the direction of the left shoulder, aiming down at a 30-45 degree angle. When blood starts to fill the syringe, inject the air forcefully into the heart. Repeat if necessary. (For a practical demonstration of the injection technique, see the movie “Pulp Fiction”.)

Too gruesome? I thought it might be, but let’s face facts. No execution—taking the life of an unwilling person by force—can be truly humane.

Lethal injection has the highest failure rate of all methods of execution due to its technical complexity. Today it is often difficult to obtain the proper medications since many corporations don’t want to supply drugs for that purpose. No other method of execution attempts to hide behind white-coat respectability and pretend that it’s neither cruel nor gruesome.

No other method of execution dishonors the profession of medicine and the pledge to do no harm.

Perhaps life imprisonment without parole isn’t such a bad alternative.

Karen Sullivan Sibert, MD (@KarenSibertMD) is a practicing anesthesiologist  and associate professor of anesthesiology at a major medical center in Los Angeles. She writes at aPennedPoint, where this piece originally appeared.

11 replies »

  1. You don’t give anesthesia. You are a physician. CRNAs perform the anesthetic while you sit in the lounge surfing the internet and sipping coffee. Sheesh!

  2. > But that would still be practicing medicine.

    Positively not — it is abusing medical knowledge. Executioners who are not “bound by an indenture and oath according to the medical laws” ought not be given any medical knowledge to abuse. And classically, doctors swore they wouldn’t give it to them. Nurses shouldn’t give it to them either.

  3. Very well-written, and cogent article, and congrats to Dr. Sibert for her thoughtful analysis.

    However, as a lawyer/doctor guy, I would only add a few of the following caveats:

    1) I would use caution describing Clayton Lockett’s execution as necessarily “botched.” It may not have gone by the expectations of some, but it was 100% successful. The intent was for the state to execute Mr. Lockett, and he was, in fact, executed. He will not ever torture, murder, or demonize any innocent victims again. Additionally, the arbiter for what constitutes a “botched” execution is not really you or I, or the media, it is the 8th Amendment of the Constitution, which proscribes “cruel or unusual” punishments. Consider that our founding fathers lived in a world where prisoners had their entrails drawn out, or beheaded, or pulled in to pieces by horses, etc., and I doubt they would have considered going to sleep with an IV as violative of the 8th amendment- but I do suppose there is a “relativity” argument that can be made.

    (Also remember that the brief moratorium on execution in the US (Furman v. Georgia in 1972) had nothing to do with the MECHANISM of execution, rather, the Supreme Court had held that the states were not administering the death penalty equally based on race.

    2) The main issue with Lockett and others does not seem to be the ADMINISTRATION of the pharmacological agents, which by state law can be obtained by the Dept of Corrections without a physician ordering them. (This is done to protect the physician who works for the state or corrections dept from ethical or other attack – like claims of “malpractice”). Rather, the issue is the correct placement of venous access. It’s no surprise that many on death row have a hx of IV drug abuse, or similar pathology, making access sometimes difficult.

    Thus is seems what is needed is not expertise at “anesthesia,” but expertise at sufficient IV (or central access) placement. It’s pretty clear that nurses or other technical staff can accomplish this, witness the widespread use of “PICC line” staff in hospitals, using ultrasound, or other technology, to provide access. Plus, the benefit is that the patient will need the access for only a limited time.

    If no IV access can be obtained even by ultrasound, or using the “PICC line” nurse/tech, then perhaps the most accurate and easy mechanism is to use an intra-osseous access device. I’m sure this will sound horrific to some, and no doubt the ACLU and others will jump out of their pants to vilify it, but we use this mechanism in the ED on 90 year old grandmothers and coding infants, with almost zero complications and excellent results.

    3) Finally, our society has always used “cutting edge technology” (no pun actually intended – ok, maybe some) in executions. When electricity came into use, William Kemmler became the first person executed in the US by the “electric chair.” Hanging, firing squads, etc. were replaced by the gas chamber. This in turn was supplanted when post-WWII America viewed this as a bit too similar to the Nazi’s methods of the Holocaust. Now, we have a “Medicalization” of executions, and this understandably makes doctors (and some in the public) nervous, as Dr. Sibert accurately portrays, the “procedure” is pretty much exactly like having general anesthesia, without the patient waking up afterward.

    Paradoxically, the anti-death penalty crowd has been a bit stymied of late, since the overwhelming majority of lethal injection executions that have occurred in the US have gone off without a hitch, and are pretty clearly not a violation of “cruel and unusual.” This is exactly why they have changed their tactics and targeted the actual drug makers, which conveniently were almost all located OUTSIDE of the US, in countries WITHOUT a death penalty.

    Until the “Black Capsule” of M*A*S*H becomes a reality, then we will continue to struggle with a mechanism that is not violative of anyone’s definition of “cruel and unusual,” but remember that we have many in our country (and perhaps on this blog) who oppose the death penalty regardless, and would oppose the mechanism even if were waving of a magic wand . . .

  4. I will avoid taking either view on this and just mention that this was a great post, I enjoyed reading it from the point of view of someone who uses those same medications on a daily basis, but for other uses.

  5. What the inmate in Oklahoma did to his victim is enough for me to forever support the death penalty. However, to remove the so called practice of medicine from the process, why not a bullet to the back of the head? It takes no skill, is extremely effective and death occurs so quickly that the victim doesn’t suffer. No need to obtain drugs from Europe. We have plenty of lead here in the US of A.

  6. Thanks for pointing out that inmates have a Constitutional right to healthcare (along with Native Americans). It’s a useful reminder that the word “right” has a real meaning, which is often forgotten in the clamor for rights of all kinds, real and imagined.

  7. Bubba,

    I have to agree with you. This is horrible and the only way to not do it is to not do it. I don’t support the death penalty (a position I’ve come to over the years), and I find it particularly repugnant to perform it medically. That appears to me to just be an artifice. Dressing it up in a medical costume is an attempt to give it moral legitimacy by making it seem like something less grievous than what it is.

    I think Dr. Sibert is correct. If it’s a medical procedure, it ought to be done by a doctor, and if the medical profession refuses to cooperate, then it is up to the courts to protect convicted criminals from being butchered while they are being killed by ham handed employees who have no idea what they are doing.

  8. Crazy country. Dr. Kovorkian was prosecuted and convicted for 2nd degree murder for putting people to sleep who wanted to die. Consider the irony if he had been given the death penalty.

  9. Considering that death row inmates are one of the only segments of the U.S. population with a constitutional right to health care, this argument/dissection of the issue is spot on…

    If malpractice law were to be applied in Oklahoma, who would be responsible? The physician providing the prescription for the cocktail?

    While the case of Clayton Lockett is a sad, gruesome one, perhaps it will serve as a final straw push to demolish the practice at the state level…

    Not before Robert Campbell is executed in Texas this evening by an undisclosed sedative, unfortunately: http://www.theguardian.com/world/2014/may/12/texas-inmate-execution-lawyers-appeal-clayton-lockett.

  10. People have been killing other people since the beginning of time. There are many ways to do it; hanging, the firing squad, the guillotine, etc.

    It is not a “treatment” and why we need a doctor to do it escapes me.

  11. Horrible. The only humane way to do this is not to do it.

    Here’s a question for any health lawyers who may be out there – should a doctor who is involved in administering a lethal injection be subject to malpractice law?

    Hard to see why not. After all, were a physician to be involved in such a disasterous outcome treating a patient under normal circumstances they would almost certainly find themselves facing a huge lawsuit …