Lethal injection perverts the ethics of practicing medicine

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 U.S. 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 S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.  She blogs at A Penned Point

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  • NewMexicoRam

    A guillotine seems better, and quicker, to me.

    • querywoman

      I read an account of the last criminal guillotined in France that included a commented that it’s the calmest way to go.
      Remember, Dr. Guillotine invented it, but similar stuff had been used before.
      Makes sense that a sharp, falling blade would be quick and painless.

      • ninguem

        I must point out a few facts.

        The doctor’s name was Joseph-Ignace Guillotin.

        Not Dr. Guillotine.

        And the guillotine was actually invented by a French surgeon and physiologist by the name of Antoine Louis.


        Those familiar with anatomy may know the manubrium-sternal angle, known as the “Angle of Louis”.

        The execution device became associated with Dr. Guillotin, who in fact was against the death penalty.

        Fortunately, the device was not named after Dr. Louis.

        Think of the carnage.

        All the Brits who ask to use the loo, with disastrous misunderstanding.

        • querywoman

          I didn’t think he had an “e” on his last name, but I didn’t bother to look it up.
          I know Dr. G was horrified at the slaughter for which it was used.

        • guest

          Fascinating, thank you for sharing this.

  • guest

    The amusing thing is there have been report after report about inhumane conditions at prisons across the country. Didn’t they go on a hunger strike at Pelican Bay in protest? In TX there have been reports of prisons with no AC in the middle of the Texas summer with cells reaching 110 degrees inside. Similar conditions reported in Louisiana.

    But yes, it is capital punishment that is uncivilized. LWOP is way more humane, right?

    • DeceasedMD1

      There was a book written about that called the Crime in Punishment”. the title says it all.

      • guest

        Will check it out, thanks. I’ve been fascinated by our deeply flawed criminal justice system. I won’t deny that when I read about some of these inmates’ crimes I think they should die for what they’ve done. That said, I am well aware of the flaws in our justice system and am not certain it is competent to decide who lives or who dies.

        • DeceasedMD1

          it was written by Karl Menninger if you are interested. Although these are heinous crimes, if you notice, there is no rehab available in prison systems so even for petty crimes or misdemeanors.there is no way out for most.
          Pretty cruel. the majority of the severely mentally ill who have petty misdemeanors due to their mental illness. are in prison since there are few psychiatric beds.

  • querywoman

    Ha! Topic is making me sick. But, before leaving it, I’ll point out that the misuse of the drug combo highlights that medicines can be abused. These are strong substances with potential for harm as well as good.

    Brutal criminals are a regrettable fact of life. Society has always struggled with what to do with the worst.

    • DoubtfulGuest

      I’m nearly hurling right along with you, qw. I don’t know what to think. I’ve always been fairly anti-death penalty, but I can see the argument that it can be more of a “personal purity” issue, not wanting to get their own hands dirty, but then what do you do when that sociopath escapes and kills another kid? How is that humane? Or the conditions in prisons, I knew nothing about it.

      For me, the main arguments against it have been “too flawed to fix” (killing people who turn out to be innocent) and the odd sort of cheerful bloodthirstiness exhibited by many pro-death penalty types. The enjoyment is scary. If it’s a serious discussion about dangerous criminals who cannot be stopped any other way, but we’re not happy about it, then I might be on board. I really need to learn more about it.

      • querywoman

        Gag! When I research why people are on death row in Texas, I see there are a lot of violent, horrid people there.
        I do believe a Cameron Todd Willingham was innocent, but Gov. Perry doesn’t agree.
        I am a liberal, but both Govs. Bush and Perry got a lot of flack for the executions in Texas. Neither man was the judge or jury for any of the Texas death row cases. Sad that one person gets the flack for a state system.
        Both Govs. Bush and Perry maintained the status quo, respected the laws of their state.
        The death penalty is a hard issue!

  • ninguem

    How about the California-style gas chamber, but with a halogenated inhaled anesthetic agent?

    Perhaps going to an anoxic atmosphere to ensure death.

    No need for IV access.

    • DoubtfulGuest

      Yes, and to make it even more like being prepped for surgery, there could be a radio playing “adult contemporary” hits while the prison guard chirps “Now you’re going to smell something like PER-fume, okaaaay?”

    • querywoman

      The gas chamber is not perfect either. Supposedly every method tried has a risk of failure, except a falling blade.
      They have seen a few heads “talk” after death but it’s assumed it’s just autonomous reaction.
      You’re the doctor. You can speculate on these things better than I.
      The IV drug method “sanitizes” the process, makes it seem like a medical procedure, which it is not.
      The few times I had surgery, the anesthesia knocked me out. I never remembered the surgeries.

  • querywoman

    Doctors assisted the church torturers in the Inquisition. I never understand why Nazis had doctors in the concentration camps.

  • querywoman

    Wow! Tennessee has resurrected the electric chair! Electrocution is not a medical procedure.
    Lethal injection is a medical procedure, and no medical procedure is risk-free!

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