The execution by lethal injection, in its current formulation, was publicly presented on May 11, 1977 by an American doctor from the state of Oklahoma, Jay Chapman, as a more “humane” alternative to other types of executions, such as electrocution or hanging, and today is the most common form of execution in the United States.
Of the 22 judicial executions that occurred in 2019 in this country, 20 were by lethal injection. The first state that applied it was Texas, in 1982. In addition, it is applied in other countries, fundamentally the People’s Republic of China, although the protocol applied is not public.
The combination of three lethal drugs
Conventional execution protocols for lethal injection usually contemplate the consecutive administration of three drugs with lethal potential by themselves; This combination is intended to induce anesthesia first and then death from cardiorespiratory arrest.
Usually, the protocols contemplate taking two routes, one in each arm, and the administration of drugs, independently, in one of them, reserving the second for the hypothetical event that problems arise.
The drug delivery cannula is applied by a trained prison technician or officer (never by a physician), and an infusion pump for drug delivery is prepared in an adjacent room by another officer.
Sodium thiopental (3-5 gr.) Is administered first, in order to induce anesthesia and, therefore, loss of consciousness, then pancuronium bromide (40-100 mg), which causes paralysis of the musculature. of the respiratory system, and finally potassium chloride (100-160 mEq), which leads to cardiac arrest.
The infusion pump through which these drugs are administered is activated by an official or by a private citizen, and the drugs are automatically and sequentially applied. Typically, death occurs seven to ten minutes after the completion of drug administration, and must be certified by a medical professional.
Doctors absent from executions
The American Medical Association establishes, from an ethical perspective, that no doctor should participate in executions, in any way, except in certification of the death of the prisoner. However, these are professional recommendations that are not binding on physicians. In fact, in some states, such as Missouri and Georgia, some doctors have voluntarily participated in judicial executions.
What are the pharmacological effects of the three constituent compounds of the lethal injection?
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Sodium thiopental: Thiopental is a classic ultra-short-acting barbiturate, commonly known as “truth serum” for its disinhibitory effect, which is used primarily as an anesthetic inducer, causing loss of consciousness for up to 30 seconds after intravenous administration. But keep in mind that it can enhance the central depressant effect of opiates and alcohol, substances commonly consumed in prisons.
Furthermore, pancuronium can dilute thiopental, reducing its effects. Finally, there is great interindividual variability in metabolism and sensitivity to barbiturates, so its effects may be insufficient for some subjects, regardless of whether they are overdosed, as in the case of lethal injection.
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Pancuronium bromide: This drug is a competitive neuromuscular blocker, which antagonizes the action of acetylcholine on the motor plate of the neuromuscular junction, preventing contraction of muscle fibers, being widely used in surgical anesthesia as a muscle relaxant for endotracheal intubation. In overdose, like 100 mg in the case of lethal injection, muscle paralysis takes place between 15-30 seconds.
In some North American states, such as Florida, the convicted person is offered the possibility of taking diazepam (Valium) as a tranquilizer hours before the execution and this substance can modify the effects of pancuronium. Something very similar occurs with tobacco, widely consumed in prison population, which would require an adjustment of the dose of the blocker. With respect to electrolytes, pancuronium can increase the incidence of arrhythmias of the same. Finally, barbiturates can potentiate the effects of pancuronium in a dose-dependent manner, so a dose adjustment would also be necessary.
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Potassium chloride: Deadly potassium poisoning occurs by interfering with the electrical activity of the myocardium, reversing the cell gradient of this ion. This prolonged depolarization of muscle cells prevents their normal discharge capacity, stopping cardiac activity.
Symptoms of this intoxication include paresthesias in the extremities, muscle contractions and cramps, mental confusion, cardiac arrhythmias, leading to definitive cardiac arrest. Cardiac effects and acute painful symptoms at the injection site are especially relevant after intravascular administration, as is the case at hand. Vomiting, nausea, and diarrhea are also common.
An agonizing sensation of suffocation and burning and internal pain
In 2007, I had the privilege of participating in an already classic study with researchers from the University of Miami Miller School of Medicine, which analyzed data obtained from the stories of inmates executed in the states of North Carolina and California, along with interviews carried out with those attending the executions, as well as data on animal experimentation.
In veterinary surgery, the application of between 1.5 and 5 grams of thiopental may not be sufficient to induce anesthesia. In the practice of lethal injection, if anesthesia is not effective, the inmate would experience an agonizing sensation of suffocation and burning and internal pain, massive muscle spasms and finally death from cardiac arrest.
The results of the executions, together with the variable effect between species of different doses of thiopental, suggest that, in the usual practice of lethal injection, thiopental could not exert a fatal effect and be insufficient to induce long-lasting surgical anesthesia in the period. of execution. In fact, postmortem plasma thiopental concentrations were even lower than those used in surgical anesthesia in 88% of a sample of 49 inmates executed in Arizona, North Carolina, South Carolina, and Georgia.
To these factors must be added the fact that the prisoners, in this situation, are in a hyperadrenergic state, with great anxiety and excitement, which may require a higher dose of thiopental. Furthermore, the (real) pain experienced by the inmates would not be evident in the condemned, due to the paralyzing action of the pancuronium.
On the other hand, there was also evidence of executions in North Carolina, California, and Virginia indicating that the potassium chloride contained in the lethal injections did not actually induce immediate cardiac arrest, as previously postulated, but that electrocardiographic death occurred, in some cases, up to nine minutes after administration of this agent.
Our study concluded that lethal injection protocols do not cause a fatal effect through the intended mechanisms, indicating a failure in their design and implementation.
On the other hand, the fact that the administration of thiopental is not carried out by a professional has been associated, in several known cases, with serious application defects, taking up to 30 to 60 minutes to find an affordable route, including suspension. of an execution in Ohio, like the one of the defendant Romell Broom, in 2009, after 18 failed attempts.
The execution of Ángel Nieves: a 34-minute agony
If the effects of thiopental and potassium chloride are insufficient, some inmates may die from pancuronium-induced asphyxiation (evident even four minutes after administration of this drug at therapeutic doses), and under the painful sensation of internal burning caused by the potassium chloride. This is what could have happened in the controversial case of the execution in 2006 of Ángel Nieves Díaz in the Florida state prison, whose agony lasted 34 minutes, requiring the application of a second dose of the drugs.
Therefore, the hypothesis that lethal injection is a painless and peaceful method of execution is extremely questionable, and not only because of the evident defects in the application systems, but also because of the pharmacological scheme itself, which is potentially inadequate.
The American Constitution prohibits cruel punishment
The Eighth Amendment to the United States Constitution expressly prohibits cruel punishment, and the results of our study suggest that the lethal injection possibly violates this constitutional amendment.
Thanks to this research work, a moratorium on the application of this method of execution was achieved in 11 North American states, highlighting Florida. However, in the end, everything led to the design of a new lethal injection method in which only the barbituric agent is applied, to which the refusal of many pharmaceutical companies to supply their products for these practices has also undoubtedly contributed.
Lethal injection is not a “more humane” method
The first state to apply the single-drug protocol was Ohio in 2009. It involves the administration of five grams of thiopental sodium, and it has now been applied in eight North American states. However, it is known that overdose of this barbiturate has been associated with a marked anti-analgesic effect, which can increase the agony and suffering of prisoners undergoing lethal injection.
Thus, the idea that lethal injection is a “more humane” method than other enforcement procedures must be rejected. Moreover, it is no longer a matter of thinking about “more humane” protocols, an ethically reprehensible fact, but of openly proposing the definitive abolition of capital punishment, as an editorial in the magazine very well pointed out. The Lancet in relation to our work:
“Capital punishment is not only an atrocity, but also a stain on the reputation of the world’s most powerful democracy.”
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