May 24, 2014 at 5:38 PM

That's a timely question, as botched executions have been in the news lately. Death penalty states started death by lethal injection as a humane alternative to hanging, firing squad, electric chair, or a gas chamber. In theory, lethal injection might be more humane, but in practice, not so much. Some state laws initially required a physician to oversee the process, and tried to recruit physicians, and specifically anesthesiologists (like me) for the task. But physicians swear an oath to “first do no harm”, and state laws were changed when no doctors signed up for the job.

The technical aspects of lethal injection can be hard to overcome. First, secure access to a vein must be established. In a hardened prison population of IV drug users, finding an unspoiled vein can be next to impossible. And to be absolutely sure of a humane execution, you really need to access two veins, in case one fails, a frequent occurrence. Next, you have to choose your drugs carefully. Again, the high use of sedative and narcotic drugs in the prison population makes many inmates highly resistant to depressants. So at the least, we’re talking massive drug doses for a sure-fire execution.

The order and rate of drug administration is also a variable to contend with. The usual three drug cocktail approach uses a sedative to render the person unaware, a muscle relaxant to immobilize, and a potassium infusion to stop the heart. Here you run into a moral dilemma, and a PR nightmare if you have witnesses. If you give the muscle relaxant first, you can have an awake, terrified, but paralyzed inmate. So you have an execution that’s pretty for the press, but cruel and inhumane. If you give the sedative first, (as was done using midazolam in the recent botched execution that’s been in the news) you can have a sedated, unaware inmate that reacts violently until the relaxant kicks in. So you can have a humane execution that’s very ugly for the press, and appears to be very inhumane. If you give the potassium infusion before adequate sedation, it burns like fire.

Now if all these issues were not enough, drug companies often refuse to provide drugs for use in executions. This may be for reasons of religious or political objections to the death penalty, or because of the fear of negative PR that will impact drug sales. Another factor in drug shortages may be drug company fear of lawsuits from civil liberties groups and family members for pain and suffering.

Here’s a summary of what can go wrong:
No venous access, poor venous access, lost venous access.
Too low a drug dose/too slow drug administration/drug resistance.
Drugs not available/inadequate supply.
Paralysis before sedation/inmate terrorized/press happy.
Sedation before paralysis/inmate happy/press terrified.
Potassium infusion before effective sedation/burns like fire.

And lets not forget that DNA analysis of old evidence has uncovered many an innocent person on death row. The ultimate botched execution is the wrongful execution of an innocent person.

H.S. Clark, MD

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