Using drugs for executions: What really happened in Ohio?

The death penalty has been in the news lately, what with a “botched” execution in Ohio, using a 2 drug method that Louisiana has also recently adopted for it’s administration of the death penalty.

These changes come on the heels of a new tactic by death penalty opponents: getting European countries to ban their pharmaceutical manufacturers from exporting drugs that may be used to execute people.  These bans were partially responsible for nationwide shortages of several anesthetic drugs a few years ago.

Long story short, propofol, the “Michael Jackson drug,” went into shortage due to the contamination of a major supplier, and a perfect storm of low prices (due it being a generic drug) and extreme difficulties in manufacturing it correctly and with sterility.  Sodium thiopental, the older back-up to propofol, came into demand.  Promptly thereafter, the manufacturer stopped selling it in the US due to it’s use in lethal injections, leading to a nationwide shortage of anesthetic drugs and the temporary importation of drugs from Canada.

In any case, because of chronic shortages and problems with vein access (more on this later), the traditional method that had been used: a three drug combo of sodium thiopental, pancuronium bromide, and potassium chloride has been abandoned in many states.

Let’s go back in time:  What did this three drug combo do?  It was originally developed by a Dr. Jay Chapman.  He observed that animals were killed more humanely than people (the firing squad and electric chair were the options in use at the time for executions in Oklahoma).  So, he developed a three drug protocol that has been widely adapted since.

The first drug is sodium thiopental, a barbiturate.  Barbiturates produce different effects at different doses, but in the dose used in lethal injections produces an anesthetic coma.  The patient has no awareness, and no consciousness of anything around them.  As the patient is in a state of deep anesthesia, the patient loses their brain stem reflexes, and stops breathing.  As the patient stops breathing however and O2 saturation drops, involuntary movements start taking place.  These are known as “agonal” movements.  Not because the patient is in agony — the term just refers to the movements of a patient when they are close to death (a heart that has suffered blocked artery and is dying is in an “agonal” rhythm, a patient who is dying experiences “agonal” breathing).  The patient is not conscious of these: think of people moving in their sleep.  On it’s own, sodium thopental is lethal due to the suppression of breathing — but it would take a long while.  The human body has reserves of oxygen, and the agonal movements may supply just enough air to prolong the execution.

To stop these agonal movements (which might be distressing to onlookers), the second drug is administered: pancuronium bromide, a non-depolarizing muscle relaxant (aka, a paralytic) — it completely stops all muscle movement.  This drug too can be lethal all on it’s own, but the sensation it would produce (think of feeling the need to breathe but not being able to move a muscle — until death) was deemed too cruel on its own.  Thus, it’s only given after the sodium thiopental takes away consciousness.  It’s really a bit redundant: the only function is to prevent onlookers from being alarmed at the dying, “agonal” movements.  And if given to an improperly anesthetized condemned inmate (due to dosing issues, vein issues, or a variety of reasons), it can result in a rather terrible way to die. But it would stop agonal breathing more completely and reliably than the sodium thiopental.  But even this isn’t what ultimately killed inmates executed under the protocol.

The two drugs would kill given enough time, but Dr. Chapman decided on a rapid final method: potassium chloride.  This drug produces rapid cardiac arrest by disrupting the electric balance of the heart.  If given on it’s own, it would produce brief, agonizing pain (the most painful heart attack you can imagine).  Hence why it’s given after the sodium thiopental puts the patient into an anesthetic coma.

As you can imagine, this is a hideously complicated protocol, with a few critical failure points.  The sodium thiopental may not produce an anesthesia effect if too small a dose is given.  This is extremely unlikely however, as a massive overdose of the drug is given to prevent just that occurrence.

More likely is this: venous access problems.  To give any of these drugs, intravenous access must be established — that is to say, a route to give fluids directly into the patient’s bloodstream.  IVs actually can be pretty difficult to establish — you have to get a line directly into a vein which might move or roll around, or be very small, or might break, etc.  The people establishing these lines are prison workers — who have probably never started an IV in their lives.  It is possible that they start two IVs — one in each arm.  One of these lines is good.  The other one isn’t — and instead goes through the vein or otherwise isn’t capable of delivering drugs.  A medical provider would recognize this instantly.  A prison worker probably not so much.  The bad IV is used for the sodium thiopental, the good IV is used for the pancuronium bromide, and the bad IV for the potassium chloride.  What would be the result?  The inmate would be paralyzed, and unable to tell anyone that the sodium thiopental didn’t work while they suffocated to death over the course of 5-10 minutes.

This outcome is considered inhumane, and thus many states have developed variations on this “traditional” approach.

Back to the present day.  Ohio’s new protocol used just two drugs: midazolam and hydromorphone.  These are two entirely different classes of drugs: a benzodiazepene and an opioid.  Why?  Because these drugs don’t need an IV.  Instead of prison workers poking around, looking for a vein, they can just inject the drugs into the muscle — like an epinephrine auto-injector for allergic reactions.  Plus, there was no paralytic — meaning that it would be impossible for the inmate to be aware but paralyzed and unable to say anything.  What’s the downside?  IM drugs’ absorption into the bloodstream takes longer and is more inconsistent — meaning it might take awhile to get to the dose needed to suppress breathing.

So what happened in the execution chamber?  Exactly what was expected.  The drugs kicked in, the patient lost consciousness, and proceeded to die due to oxygen deprivation.  Here’s the thing: he couldn’t have experienced any sensation at all.  Why?  Because consciousness is a higher order brain function than breathing.  For an inmate to “experience” pain, the inmate’s brain stem has to be functioning.  The only reason the inmate wouldn’t be breathing is if consciousness has already been suppressed.  If anything, the inmate ironically died having the high of his life.  Don’t believe me?  Ask an overdose victim.  Because really, that’s all this new protocol is: a massive overdose.

However, due to the slow absorption into the bloodstream and the agonal movements of the chest wall, some air exchange still went on for a while, some movement was witnessed, and the inmate died more slowly than if they had been paralyzed.  The inmate appeared to move around and struggle for 25 minutes — which led to a lot of people claiming it was botched when in reality what happened was exactly what was expected.

All the media excitement about a “botched” execution is just that: media excitement.  The method used in Ohio is probably as humane as it can get.

That said, there is another consideration: why use medical drugs in executions at all?  I commend Dr. Chapman for his intent: to execute inmates more humanely.  But his recent suggestion is right: the most rapid, painless, and reliable method to execute anyone is probably the guillotine.  We shouldn’t mix medicine and executions.

But, the real reason to oppose the death penalty isn’t the method.  After all, if we’re going to kill someone, do we really care about how much pain they might experience in the last few minutes or seconds of their life?  No, the real reason is because it is incredibly arbitrary and racist.  I believe in the death penalty in the abstract — I think killing a person is actually more merciful than locking them in a 6′ by 6′ box for 50 years.  But as currently applied, it is utterly ridiculous and demonstrably ineffective.

Vamsi Aribindi is a medical student who blogs at Follies of an Amateur Intellectual.

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  • Frank Lehman

    It all seemed like a reasonable and well thought presentation, until…..until at the very end when it says that the death penalty is racist. The death penalty is lots of things (maybe it is a good idea to have it–maybe it is not) but please do not ruin an otherwise good article by making such a blatant political statement.

    • John C. Key MD

      I agree with Doctor Lehman completely–but the stupid ending statement is not Mr. Arbindi’s fault–he’s just a product of the last few decades of our leftist educational system.

      • terragamo

        I am a 4th year medical student who also has learned about statistics. In our learning, we learned that we couldn’t just look at the statistics which make us happy and fashionable at a New Yorker convention.

        • ninguem

          Well, perhaps that is the problem.

          Mathematicians learn statistics.

          Medical students are being fed propaganda that’s CALLED statistics.

    • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

      With all due respect to Dr. Lehman and Dr. Key, my education taught me to understand statistics.

      In 1996 in Kentucky, 100% of death row inmates were on death row for killing a white individual. 0 were there for killing a black individual, despite the fact that over 1000 black people were murdered in Kentucky since the reinstatement of the death penalty.
      (Who Gets to Death Row, Kentucky Courier-Journal, Mar. 7, 1996)

      In an academic study, defendants who “looked black” were over twice as likely to be sentenced to death for the same crime as someone who didn’t.
      ( Eberhardt, Jennifer L.; Davies, P G.; Purdie-Vaughns, Valerie J.; and Johnson, Sheri Lynn, “Looking Deathworthy: Perceived Stereotypicality of Black Defendants Predicts Capital-Sentencing Outcomes (2006). Cornell Law Faculty Publications.Paper 41. http://scholarship.law.cornell.edu/lsrp_papers/41 )

      I am in favor of the death penalty- but only if all defendants are equally likely to face it, regardless of their skin color.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Yes, because mandatory minimums are not wreaking enough havoc on our legal system, which is incarcerating more people than anywhere else in the world, with zero success. Let’s now start indiscriminately murdering them, because two wrongs always make a right.
        Besides, who needs judges and juries. Maybe computers should be installed in court rooms instead, so the algorithms can impartially decide solely based on data, so those flawed humans don’t fail to actually convict whites of capital crimes just to get around the new law.
        This should work equally well in medicine. 100% evidence-based.

      • ninguem

        How about this statistic.

        Since capital punishment has been reinstated in 1976, there have been precisely three executions in Kentucky.

        Three.

        1. Harold McQueen – white The victim was white
        2. Edward Lee Larper – white The victim was white (parents). He asked to be executed, over life in prison.
        3. Marco Allen Chapman – white. The victims (small children) were white, murdered with the mother watching. Again, he asked to be executed, expressing remorse for the murders he admits doing.

        Since 1976 in the Commonwealth of Kentucky, 100% of the death row inmates in Kentucky who have actually been executed, have been white. 100% of the victims have been white.

        • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

          You still haven’t refuted my point- individuals who killed Caucasians were given the death penalty. Meanwhile, the people who killed 1000 African-Americans did not get the death penalty, suggesting higher penalties for individuals who kill whites compared to blacks. The disparity here is the race of the victims, not that of the perpetrators.

          • ninguem

            Your “point” is irrelevant. Death penalty without execution is life in prison.

            The people who actually got executed were white.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            I did in fact look it up- see the two sources I cited.

            They make different points: the first source explained how the race of the victim influences death sentences regardless of the race of the perpetrator. The majority of individuals murdered since the death penalty was reinstated up till 1996 were black. However, the only people sentenced to death were those that murdered white individuals.

            The second source demonstrated that the race of the defendant influences death sentences, regardless of the race of the victim.

            And I agree with you- life in prison is more inhumane than the death penalty. In this case, an ideal solution would be a system that gave an equal rate of death sentences to those that murdered Caucasians and those that murdered African-Americans.

  • ninguem

    “As you can imagine, this is a hideously complicated protocol……..”

    Nothing complicated at all, it is an induction of anesthesia, only with gross overdoses, deliberate of course, with potassium thrown in as a bolus, and no attempt at resuscitation for obvious reasons.

    The prisons treat prisoners with HIV, hepatitis, actually getting more and more elderly prisoners because of “three strikes” laws, etc., they are……..well……far more experienced than you are in that IV start.

    Not that’s saying much, you’re a medical student.

    • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

      Actually, prison medical staff is forbidden from participating in executions per ethical rules of both the AMA and the American Correctional Health Services Association. The people putting the IVs in and pushing the drugs have never done so before. The first few times it was done in Oklahoma, the prison warden mixed all three drugs before pushing them, causing a precipitate.

      • ninguem

        I can’t begin to tell you how little respect I have for any ethical rules of the American Medical Association and the ACHSA. It’s getting to the point where there are more medical student members of the AMA than paying members.

        If the prisons want incompetent people handling the executions, that’s their business, bring back the firing squad. The mechanics of the execution is as simple or complex as they choose to make it.

        • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

          The ethical rules of the AMA are incorporated into the policies of the Medical Board in most states. Thus, physicians and other medical professionals that assist in executions have their licences challenged by death penalty opponents, meaning that very few physicians participate in executions (this is the reason why California has been unable to resume executions- no physicians willing to supervise the act).

          • ninguem

            A lawsuit waiting to happen and a big smackdown for the Boards and Medical Associations and specialty boards, that is long coming.

            The Boards interfering with the physician acting in a lawful capacity on a condemned prisoner duly condemned and exhausted appeals.

            But participation in abortion is OK.

            People are entitled to their opinions on both abortion, on capital punishment (doing it at all, and the racial “fairness” of it), but the contradiction between the two is obvious.

            Same as the OB/GYN board claiming they have the authority to prohibit OB’s from treating males.

            It’s none of their business. Likely you’re not seeing it yet, if you’re in medical school, but the Boards have been overreaching for years. They need their hands slapped, if not amputated.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Heh, I know the boards have their problems, but I’m in favor of the devil we know rather than the devil we don’t. If the boards are abolished or become too toothless, we’ll be left with State Departments of Health and other government agencies overseeing doctors, and discipline handled by district attorneys looking to make a name for themselves. I shudder to think of the cash cow that licensing fees will represent then (not that doctors already aren’t being charged through the roof to support the general budget in certain states like Texas), or the general competence of the people overseeing the profession.

            Every time a some medical scandal happens, doctors will get an extra 4-10 hours of mandatory continuing education slapped on, and some poor scapegoat of a doctor will be charged with murder by the local DA, until we’re begging for the old system back.

          • ninguem

            You have a great future in administration.

            The Boards have spent decades deflecting criticism with the bogeyman of something worse.

            All they do is inflate their salaries to astronomical levels and exist as 99% of the bogeymen they claim will come if they didn’t exist.

          • guest

            Exactly. Wait until this young man finds out how extortive his medical board is.

  • guest

    And they judge others for living in ivory towers.