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Issues Surrounding Lethal Injection as a Means of Capital Punishment

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Abstract

Lethal injection as a method of state-sanctioned capital punishment was initially proposed in the United States in 1977 and used for the first time in 1982. Most lethal injection protocols use a sequential drug combination of sodium thiopental, pancuronium bromide, and potassium chloride. Lethal injection was originally introduced as a more humane form of execution compared with existing mechanical methods such as electrocution, toxic gassing, hanging, or firing squad. Lethal injection has not, however, been without controversy. Several states are considering whether lethal injection meets constitutional scrutiny forbidding cruel and unusual punishment. Recently in the case of Ralph Baze and Thomas C. Bowling, Petitioners, v John D. Rees, Commissioner, Kentucky Department of Corrections et al, the United States Supreme Court upheld the constitutionality of the lethal injection protocol as carried out in the Commonwealth of Kentucky. Most of the debate has surrounded the dosing and procedures used in lethal injection and whether the drug combinations and measures for administering the drugs truly produce a timely, pain-free, and fail-safe death. Many have also raised issues regarding the "medicalization" of execution and the ethics of health care professionals' participation in any part of the lethal injection process. As a result of all these issues, the future of lethal injection as a means of execution in the United States is under significant scrutiny. Outcomes of ongoing legislative and judicial reviews might result in cessation of lethal injection in totality or in alterations involving specific drug combinations or administration procedures.
Issues Surrounding Lethal Injection as a Means of
Capital Punishment
Frank Romanelli, Pharm.D., M.P.H., Tyler Whisman, Pharm.D., and Joseph L. Fink, III, B.S., J.D.
Lethal injection as a method of state-sanctioned capital punishment was
initially proposed in the United States in 1977 and used for the first time in
1982. Most lethal injection protocols use a sequential drug combination of
sodium thiopental, pancuronium bromide, and potassium chloride. Lethal
injection was originally introduced as a more humane form of execution
compared with existing mechanical methods such as electrocution, toxic
gassing, hanging, or firing squad. Lethal injection has not, however, been
without controversy. Several states are considering whether lethal injection
meets constitutional scrutiny forbidding cruel and unusual punishment.
Recently in the case of Ralph Baze and Thomas C. Bowling, Petitioners, v John
D. Rees, Commissioner, Kentucky Department of Corrections et al, the United
States Supreme Court upheld the constitutionality of the lethal injection
protocol as carried out in the Commonwealth of Kentucky. Most of the
debate has surrounded the dosing and procedures used in lethal injection and
whether the drug combinations and measures for administering the drugs
truly produce a timely, pain-free, and fail-safe death. Many have also raised
issues regarding the “medicalization” of execution and the ethics of health
care professionals’ participation in any part of the lethal injection process. As
a result of all these issues, the future of lethal injection as a means of
execution in the United States is under significant scrutiny. Outcomes of
ongoing legislative and judicial reviews might result in cessation of lethal
injection in totality or in alterations involving specific drug combinations or
administration procedures.
Key Words: lethal injection, ethics, execution, capital punishment.
(Pharmacotherapy 2008;28(12):1429–1436)
Historically, capital punishment has been
accomplished by a variety of means, including
hanging, firing squad, toxic gassing, and
electrocution.1Toxic gassing involves the use of
cyanide pellets and sulfuric acid. Death usually
results in approximately 30 minutes. Hanging
results in death by severe spinal injury and/or
asphyxiation that results from a drop using a
rope of calculated length. Firing squad takes
place in a well-lit area where the condemned
individual is usually restrained and seated in a
chair designed to capture blood and other bodily
fluids. A white cloth circle is usually placed over
the condemned person’s heart while firing squad
members take aim approximately 20 feet from
the target. Electrocution usually involves an oak-
based chair with an electrical current delivered
cyclically from electrodes placed on the scalp and
right calf. The cycle is repeated if death does not
occur after the initial current is delivered.
When introduced, execution by electrocution
was considered more humane than other physical
methods of death including hanging.2Recently,
lethal injection has become the most commonly
From the Department of Pharmacy Practice and Science,
College of Pharmacy, University of Kentucky, Lexington,
Kentucky (Drs. Romanelli and Fink); and Eli Lilly and
Company, Indianapolis, Indiana (Dr. Whisman).
Address reprint requests to Frank Romanelli, Pharm.D.,
M.P.H., BCPS, University of Kentucky College of Pharmacy, 725
Rose Street, Lexington, KY 40536; e-mail: Froma2@uky.edu.
PHARMACOTHERAPY Volume 28, Number 12, 2008
used method of judicially authorized execution
in the United States.1, 3–6 The popularity of lethal
injection as a means of execution is supported by
a belief that it is a mo re huma n e m e t hod
compared with other options.3–7 Every execution
conducted in the United States in 2005 involved
lethal injection.4Despite its widespread use,
lethal injection is not without controversy. Many
have questioned whether lethal injection truly
invokes a death that is not considered cruel and
unusual punishment as proscribed by the eighth
amendment of the U.S. Constitution.8Recently,
the U.S. Supreme Court heard arguments in this
regard in the case of Ralph Baze and Thomas C.
Bowling, Petitioners, v John D. Rees, Commissioner,
Kentucky Department of Corrections, et al.9In a
spring 2008 rul i n g , t h e Court upheld the
constitutionality of the protocol used by the
Commonwealth of Kentucky. This case is not,
however, expected to completely settle the many
issues that surround the use of lethal injection.
The medical community continues to debate the
ethics surrounding a “medicalized” method of
execution that involves drug administration, as
well as potential roles for health care profes-
sionals in the process.3, 6, 10–12
Lethal Injection Protocols
The concept of lethal injection was first described
in 1888 by a New York physician who proposed
it as a cheaper and more humane method of
death.1 3, 14 The British Royal Commission on
Capital Punishment subsequently considered
lethal injection in the early 1950s but rejected
the concept after pressure from the British
Medical Association.13, 14 In 1977, the Oklahoma
State Medical Examiner, Dr. Jay Chapman,
proposed a “new” and “more humane” lethal
injection procedure, which would become known
as the Chapman Protocol.5 , 7 The Chapman
Protocol outlined an execution process that
involved placement of an intravenous line into
the prisoner’s arm with an infusion of saline, with
subsequent infusion of an ultra–short-acting
barbiturate in combination with a chemical
paralytic. These drugs were selected in part to
replicate the procedures followed in most
anesthetic regimens for general surgery, with the
caveat of using exaggerated doses. The protocol
was approved by the Oklahoma legislature and
was quickly adopted by almost every U.S. state,
with Texas being the first to use the method in
1982.5–7
Today, most states follow a standard protocol
that typically involves fastening the condemned
prisoner to an execution table, with subsequent
insertion of two intravenous cannulas (one in
each arm).1, 5–7 Insertion of the lines involves sterile
equipment and a standard aseptic technique to
avoid infection. These precautions are followed
in the event the execution process is halted for
any reason, and the prisoner receives a stay. One
cannula serves as the delivery route for the lethal
chemicals while the other serves as a backup.
The drug delivery line is connected to a dispensing
device that is housed in a separate room. The
prisoner is also connected to a continuous electro-
cardiogram monitor. After placement of the
intravenous line, saline infusions are commenced
in both arms. Subsequently, and in succession,
three potentially lethal compounds are delivered.
In most states, the following drugs are adminis-
tered in sequential order: sodium thiopental,
pancuronium bromide, and potassium chloride.
Various details involving execution protocols
differ from state to state. For example, state law
dictates the specific officials involved in both the
declaration and certification of death. Typically,
this involves the prison warden and/or a physician,
co roner, or medic a l examiner.1, 5 –7 Vari o us
professional or nonprofessional staff are also
involved in gaining venous access, ordering the
necessary drugs and supplies, loading drugs into
the delivery device, and activating the delivery
machine.
Sp ecific de tails regard ing letha l injecti on
protocols used by various states are usually
maintained in confidentiality to protect those
involved in the execution process. Subsequent to
a Supreme Court order surrounding the case of
Baze v Rees, the Kentucky protocol was disclosed
in April 2008.9The Kentucky protocol begins
with thiopental 3 g (increased from 2 g in 2004),
followed by pancuronium bromide 50 mg and
then potassium chloride 240 mEq. The injection
of each agent is followed by a saline flush
(reported in official court documents as a dose of
25 mg) in order to minimiz e t h e r i s k of
precipitation from drug contact. The protocol
involves the use of certified phlebotomists and
emergency medical technicians for the purposes
of gaining intravenous access and also requires
the warden and deputy warden to confirm a loss
of consciousness after the initial thiopental dose.
Should prison officials determine that conscious-
ness has not been lost within 60 seconds, a
second dose of thiopental is administered through
another p reset i n t r a v e n o us l ine before the
commencement of the pancuronium infusion.
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LETHAL INJECTION Romanelli et al
Each drug component of the lethal injection
protocol has a theoretical purpose. Sodium
thiopental is an ultra–short-acting barbiturate
commonly used in the induction of anesthesia
and, in some instances, medical coma.15 , 16
Thiopental does not produce analgesic effects.15
The standard induction dose of thiopental is 3–5
mg/kg (210–350 mg for a 70-kg adult).8For the
purposes of lethal injection, doses typically range
from 3–5 g.1, 5–8 Doses in this range are expected
to induce unconsciousness in approximately 10
seconds. Thiopental pharmacokinetics are
biphasic with rapid (30 sec) drug distribution
into the central nervous system and subsequent
redistribution to the periphery within 520
minutes.8Of note, during the redistribution
phase, central nervous system concentrations
may decrease to 5–10% of the total dose, thus
potentially compromising anesthesia.8, 17 The
exaggerated dose of the thiopental alone used in
the lethal injection has the potential to cause
death from profound respiratory depression
and/or vascular collapse.
Pancuronium bromide is a nondepolarizing
neuromuscular blocker that inhibits skeletal
muscle and diaphragmatic activity, also without
analgesic effects.1, 7, 18 The typical surgical dose of
pancuronium is 0.2 mg/kg (14 mg for a 70-kg
adult). For the purposes of lethal injection, a
typical dose is 50–100 mg.1, 7 Paralysis usually
results i n 1530 sec onds, wit h death be ing
possible as a result of loss of respiratory drive.
Pancuronium will prevent movement and
fasciculations of any kind. These effects may
make the process more tolerable for those serving
as executioners and/or witnesses.
Po tassiu m chlori de is inte nded to in hibit
cardiac electrical conduction with eventual
asystole.1Standard replacement protocols for
intravenous potassium involve doses of 10–20
mEq/hour with sufficient time for intracellular
redistribution of the electrolyte. Most lethal
injection protocols involve a potassium bolus
dose of approximately 100 mEq.1, 7, 8
Because of requirements for venous access,
lethal injection has been associated with greatest
time spent in the death chamber before the
pronouncement of death (mean ± SD 29 ± 16.4
min).1Some state protocols also authorize the
administration of preexecution doses of anxiolytic
agents (e.g., benzodiazepines).1, 5–7
Controversies
Since 1977, lethal injection has been accepted
as a more humane method o f e x e c u tion
compared with more traditional approaches to
capital punishment (e.g., electrocution). Lethal
injection has n o t b e e n w ithout critic i s m ,
however. Many have described the process as
having “critical deficiencies.”19 These deficien-
cies may include unreliable screening of potential
members of the execution team, the lack of
substantive training and supervision of staff, poor
record keeping, and poorly designed execution
facilities.9, 19
Recently, several prisoners and professionals
have challenged the legality of various protocols
used for lethal injection. As previously mentioned,
the U.S. Supreme Court ruled in the spring of
2008 that in the case of Baze v Rees , lethal
injection as carried out by the Commonwealth of
Kentucky met constitutional scrutiny.9In this
case, the petitioners (Baze et al) themselves
conceded that if c a r r i ed out properly, the
Kentucky lethal injection protocol would likely
result in a humane death. However, Baze et al
argued that the protocol was in violation of the
eighth amendme n t b e c a use the protocol
introduces the risk of “significant pain.” The
petitioners asked the Court to evaluate the risk of
pain and the feasibility of protocols that might
eliminate such risk. Baze et al proposed an
alternative protocol that would involve the adminis-
tration of a single agent (either a megadose of
sodium thiopen t a l o r a n other appropriate
barbiturate) rather than the three agents used in
the Kentucky protocol (sodium thiopental,
pancuronium bromide, potassium chloride). The
plaintiffs acknowledged that the protocol changes
they were suggesting were scantly described and
not based on sound clinical experience or study.
Most of the evidence associated with single-drug
protocols is garnered from veterinary medicine.
The plaintiffs also argued that the Kentucky
protoco l lacked a “s ystematic” approach to
monitoring and assessing the depth of anesthesia,
and as such, the prisoner might be subjected to
unnecessary pain. As stated previously, the Court
upheld the Kentucky protocol, ruling that the
Commonwealth of Kentucky did appear to have
sufficient safeguards in place to prevent unneces-
sary pain and finding that the protocol proposed
by the plaintiffs was untested in humans.
Opponents of lethal injection argue that most
U.S. protocols do not ensure adequate anesthesia,
particularly given the biphasic pharmacokinetic
profile of thiopental.16, 17 In addition, arguments
have been made that under standard procedures,
thiopental is used only for induction of
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PHARMACOTHERAPY Volume 28, Number 12, 2008
anesthesia and not for maintenance and that the
rapid and subsequent administration of
pancuronium may actually dilute the bolus dose
of thiopental administered.16 Other criticisms
include the use of a standard dose of thiopental
as opposed to weight-based dosing, which is
considered the standard of care in anesthesia.
Opponents argue that the use of a standard dose
may result in underdosing certain prisoners,
particularly if they are obese.7Assuming that
prisoners are approximately the same weight
across jurisdictions, thiopental doses in various
states would range from 10–45 mg/kg.7The
recommended weight-based doses of thiopental
for clinical induction of anesthesia range from
3–7 mg/kg.15, 17 Thus, in an average prisoner,
thiopental doses may approximate the upper
le vel of standard dosing, particular ly if the
condemned person is obese. The median lethal
dose for thiopental has been reported in various
animal models to range from 35 mg/kg (rabbits)
to 91 mg/kg (mice).20
As previously stated, thiopental is also known
to redistribute from the central nervous system
into the periphery after initial induction dosing.
This redistribution phase might result in an
unpredictable reduction or loss of anesthesia
even in the presence of the megadoses used in
lethal injection. Opponents argue that the mean
du r ation to death f o r most lethal i n j ection
pro c edures is 710 minutes a n d t h a t t he
megadoses of thiopental used could wear off in
such a short period of time.7In most cases of
lethal injection, no medical assessment of
anesthesia depth is completed; rather, anesthesia
is assumed. One group of researchers collected
49 postmortem toxicology reports from lethal
injections in Arizona, Georgia, North Carolina,
and South Carolina in an attempt to characterize
serum thiopental levels.8Protocols from these
states specify the use of a 2-g dose of thiopental
as part of the lethal injection process. Serum
thiopental concentrations that were collected on
the same or next day after execution ranged from
trace amounts to a maximum of 370 mg/L.
Duration and rate of drug administration were
no t a v ailable from any state, and t h erefore
modeling to predict central nervous system
thiopental concentrations could not be conducted.
The researchers in this study concluded that
despite relatively similar drug dosing protocols,
individual prisoners had variable drug levels at
postmortem examination. These variations
might be explained by administration techniques,
individual variabilities (e.g., weight), and/or
thiopental pharmacokinetics. Regardless of the
reason for the variations, it is possible that at
least some of the executed prisoners might have
had serum thiope n t a l l evels that were
inconsistent with a surgical plane of anesthesia.
The data from this report must be interpreted
carefully as they may be limited by the fact that
samples were not drawn immediately after death
occurred or from similar anatomic sites, thus
making extrapolation difficult. In most instances,
samples were obtained at least 12 hours after
death. This lag time may make any correlations
between serum levels and clinical status difficult
to interpret, particularly since thiopental is
known to rapidly redistribute after infusion.
Another population that might be recalcitrant
to standard barbiturate doses is those with a
history of ill i c i t d r ug use.8Among these
pri s o n e r s, tachyphylaxis is a conc e r n a s i s
difficulty in acquiring suitable venous access for
drug delivery. S o m e l e v e l o f re s i s t ance to
thiopental might also occur in all condemned
prisoners due to their likely hyperadrenergic and
anxious state.8Opponents also cite the lack of
pro f essional expe rti s e a m o ng employees
designated to carry out lethal injection protocols
as an insurmoun t a b l e p o tential risk. 1,6
Inadequate intravenous access may result in
suboptimal dosing of any or all of the drugs
involved and can result in additional pain if
chemicals are inadvertently infused extravas-
cularly. This was the case in the December 2006
Florida execution of Angel Diaz.2 1 Mr. Diaz
remained alive 35 minutes after completion of
the lethal injection protocol. Subsequently,
second doses of each drug were administered,
with resultant death. An autopsy revealed 30-cm
chemical burns in both antecubital fossae that
were likely the result of misplaced infusion lines,
wh i ch caused th e d rug doses to b e i nfused
extravascula r l y a n d n ot intravenou s l y.
Pancuronium is the only agent in lethal injection
protocols that may be administered subcu-
taneously and in this case might have resulted in
chemical asphyxiation.18 As a result, th e n
Governor Jeb Bush immediately suspended all
executions in Fl o r i d a a nd appointed a
commiss ion to consider “ the humanity an d
constitutionality of lethal injection.”21
Other criticisms have included the potential for
drug precipitation. Thiopental and pancuronium
are solubilized at remarkably different pH values
and are known to be physically incompatible.22
Precipitation may especially be a concern since
most execution chambers are designed so that
1432
LETHAL INJECTION Romanelli et al
the drug delivery device is at a distance from the
prisoner in order to protect the anonymity of the
executioner and execution team that activates the
apparatus. This distance requires a lengthy
infusion line, which might exacerbate the risk of
drug contact time and precipitation. The length
of the line might also cause unintended
mechanical interruptions in drug delivery. Of
note, the execution protocol used by the
Commonwealth of Kentucky stipulates that a
saline flu s h b e u s e d a f t e r i n f u s i o n o f b o t h
thiopental and pancuronium. It is unclear how
many other states formally require that such a
procedure be followed.
Other mechanical causes of drug disruption are
also possible. In a Missouri case, a condemned
prisoner did not lose consciousness after the
infusion of thiopental; it was later recognized
that the straps used on the execution table were
acting as a tourniquet preventing drug flow.
Sub s e q uently, a Missouri ju d g e ordere d a l l
executions by lethal injection to be halted unless
a board-certified anesthesiologist was present to
ensure that anesthesia was present.23 Consistent
with guidelines issued by the American
Association of Anesthesiologists, none of the 298
board-certified anesthesiologists in Missouri were
willing to comply with this request.3, 24
Regardless of the cause, absence of anesthesia
would produce significant anxiety as a result of
chemical paralysis and impending suffocation, as
well as considerable pain from the infusion of
concentrated potassium chloride.1The presence
of pain and anxiety would go unnoticed
secondary to the prisoner’s paralytic state and the
lack of any requirements for the assessment of
depth of anesthesia.15, 16 Opponents argue that
current lethal injection protocols are cosmetic
and designed to cast an appearance of a serene
and comfortable death rather than to actually
produce one.7Proponents of lethal injection
often cite the fact that opponents have not
proposed any alternative regimens that are “more
humane,” and that the essential debate is not
over lethal injection itself but is actually over the
legality of capital punishment, which the U.S.
Supreme Court has already deemed constitutional.1, 9
Ethical Issues
Several ethical issues involving lethal injection
and the medical community have been raised.
Because lethal injection involves drugs and other
health-related equipment and procedures, various
health care professionals have been engaged in
the processes surrounding lethal injection. This
medicalization of state-sanctioned execution has
raised many concerns for the medical commu-
nity.3, 6, 1 0–14, 23 Physicians are often involved in
execution processes at a minimum to certify
death.1, 3, 6 A significant co n c e r n a mong
physicians is that the medicalization of execution
might result in greater roles for physicians and
other medical professionals, including but not
limited to the provision of intravenous access,
the compoundin g o f t h e l e thal drugs, and
delivery of those drugs. Both the American
Nurses Association and the American Medical
Association (AMA) oppose member participation
in most every component of capital punishment
by any means.1 4, 25 The AMA has on several
occasions reiterated its position that physicians
should play no role of any kind in the execution
process except for certifying death after it has
been declared by another person.25 Similarly,
many medical licensing boards have threatened
physicians who participate in executions with
di s ciplinary ac t ion includin g revocat i on of
licenses. The medical board of North Carolina
adopted a policy of disciplining physicians who
either verball y o r p h y s ically assist e d w i t h
execution. This pol icy was c hallenged and
overturned in a North Carolina court ruling that
deemed assisting with execution was not consistent
with practicing medicine, therefore leaving the
medical board with no jurisdiction.6
Many physicians who choose to participate in
lethal injection do so based on the premise that
they are acting on the prisoner’s behalf to ensure
that death is timely, comfortable, and incident
free.26 In this way, lethal injection is likened to
euthanasia, with the exception that the prisoner
has no right to refuse. In addition, so m e
physicians and other health care professionals
may hold the opinion that lethal injection is both
morally legitimate and more humane than other
forms of capital punishment.2 6 Others have
argued that participation in lethal injection is a
civic duty.3, 6, 10, 11, 12 Similar arguments were
made by Nazi physicians during the Nuremberg
trials.4 , 27 C linicians may f i n d t h e mselves
constrained by both perceptions of a duty to
serve society and a responsibility to an individual
patient. Likewise, clinicians may hold personal
opinions of capital punishm e n t a n d l e t h al
injection that might not mirror professional
opinions. The AMA and most licensing boards
have reiterated that the medical professions are
based on sustaining life and not ending it, and
therefore any participation in the process may be
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PHARMACOTHERAPY Volume 28, Number 12, 2008
viewed as contradictory to ethical practice.14, 25
Some have argued that even in cases where the
prisoners might themselves autonomously
consent to death by execution, it would be
unethical for a physician to participate simply
because the ultimate goal of execution is to harm
the “patient.”10 The induction of harm in this
instance would be incompatible with the proper
ends of medicine.
One group of authors randomly surveyed a
cross section of 1000 U.S. physicians by regular
mail regarding their willingness to participate in
10 aspects of lethal injection (eight of which are
disall owed by the AMA).26 Respo nses were
recorded on a Likert scale. Associations between
willingness to perform various aspects of lethal
injection and demographics were compared by
using 2tests, whereas binomial regression was
used to determine which associated variables
were significant. Of the 1000 surveys mailed,
962 were deliverable, and 413 were returned for a
response rate of 41%. Of these respondents,
approximately two thirds were AMA members.
Forty-one percent of respondents indicated they
would perform at lea s t o n e o f the AMA
disallowed actions, whereas 25% reported they
would perform five or more actions. A perceived
duty to society (p<0.001), approval of the death
penalty (p<0.001), and approval of assisted
suicide (p<0.015) were all correlated with a
willingness to perform disallowed functions. Of
interest, only 3% of all respondents were aware of
AMA guidelines regarding lethal injection. The
authors concluded that, in general, physicians in
this sample were willing to take part in various
aspects of lethal injection. This might, however,
have been influe n c e d b y t he fact that few
physicians were aware of AMA ethical standards
in this area.
Lethal injection as carried out by most U.S.
states does not meet generally accepted standards
fo r euthan asia as ca rried out in animal s by
veterinarians. The American Veterinary Medical
Association (AVMA) guidelines on euthanasia
address most every aspect of euthanasia proce-
dures including drugs, tools, and personnel.28 In
euthanasia protocols, the AVMA and several
states prohibit the use of neuromuscular blockers
because of the risk of unrecognized conscious-
ness. The AVMA furthermore specifies that
individuals carrying out euthanasia must be
trained and knowledgeable in administering and
assessing anesthesia. In terms of veterinary
euthanasia, record keeping and research are
considered essential in maintaining humane and
rigorous protocols that withstand scrutiny. In
contrast, the use of neuromuscular blockade as a
component of human euthanasia protocols in the
Netherlands seems common. In one report,
among a cohort of 535 cases of physician-assisted
euthanasia, 367 involved the administration of a
neuromuscular blocker.29 Of these 535 cases,
complications or technical problems were reported
in approximately 9%, and the median time to
death was 10 minutes (range 30 sec–7 days).
The time-to-death and complication data in this
report were n ot stratified i n terms of those
individuals who did or did not receive neuro-
muscular blockade. Regardless, data garnered
from euthanasia protocols that are common in
certain nations may provide some evidence-based
information that can contribute to the design of
more effective and potentially less controversial
humane lethal injection protocols.
Despite the fact that lethal injection involves
drug administration, relatively little has been
documented regarding pharmacist participation
in any aspect of protocols and/or procedures.
Several potent i a l a v e nues for pharma c i s t
participation in lethal injection exist including
drug acquisition, admixt u re, and deli v e r y.
Pharmacists might also be involved in providing
expertise regarding the selection of individual
agents that might be used in lethal injection,
including aspects of dosing, compatibility, and
effect ive delivery. In many ins tances, state
requirements for confidentiality make it difficult
to determine exactly what persons are involved
in lethal injection protocols. In 2000, judicial
documents revealed that at least at one time the
state of Florida mandated that “while the inmate
is being prepared, a pharmacist will prepare the
lethal substances.30 In 1983, the Arkansas
legislature passed a bill making lethal injection
the preferred method of execution in that state.
The legislation also required officials at the
University of Arkansas College of Pharmacy to
serve as consultants in the design of the lethal
cocktail to be used. After protests from the
college faculty, this requirement was deleted from
the law.29 In terms of drug procurement, most
states’ priso n s y s t e ms are authorized to
ci rcumve n t pharmacy ser vi c e s and direc t ly
acquire the necessary lethal substances and
su pplies from wh olesal ers.3, 11, 30 In a 1985
resolution, the American Pharmacists Association
opposed the use of the term “drug” to describe
the chemicals used in lethal injection and
asserted that the association opposes any laws or
re g u lations that ma n d a t e o r pro h ibit the
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LETHAL INJECTION Romanelli et al
participation of pharmacists in the process of
execution by lethal injection.31
Conclusion
Despite the recent Supreme Court ruling, lethal
injection as a means of state-sanctioned
execution is likely to remain an area of intense
debate. Greater scrutiny of individual state
pro t ocols is probable. C oncern regarding
existing and potential protocols is due to the lack
of research and data in this area. Since lethal
injection was first used in the United States, few
states have allow e d o u t side monitoring o f
executions and fewer have recorded any data.
Although much of the secrecy surrounding lethal
injection is intended to protect executioners, the
lack of data makes current and future protocols
difficult to examine and scrutinize.
Information that would be critical to gather
regarding drug administration includes dose as
well as rate and duration of administration. The
volume and extent of saline flushes used should
also be recorded. Officials should also consider
gathering postmortem serum drug levels
immediately on certification of death. These data
could be used in co n c e r t w i t h eyewitn e s s
monitoring to better understand the process and
clinical effects surrounding lethal injection. This
information, if needed, could be used by expert
panels to refine protocols while employing better
trained prison officials. For clinicians, however,
this may invoke a conundrum where medical
expertise is at least initially required in order to
make future processes less “medically intensive.”
It is important to no t e t h a t f ew, if any,
modifications have been made to most lethal
injection protocols since 1982, and that within
that time frame several new drugs and drug
classes have been introduced. Refining lethal
injection protocols to incorporate the use of
these newer agents or a reevaluation of older
agents might serve as solutions to at least some of
the deficiencies in current protocols. Consideration
might also be given to the weight-based dosing of
at least the thiopental component of most lethal
injection protocols.
As the debate regarding lethal injection
continues, penal systems, at a minimum, should
be encouraged to ensure the proper training and
practice of officials authorized to carry out these
procedures. Whether the penal system can
devise and administer lethal injection protocols
that meet constitutional requirements without
the assistance of health care professionals may be
a core determinant in the future use of this
modality of capital punishment.
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... Legal and ethical debates surrounding lethal injection involve perceptions that some critical deficiencies in protocols may produce significant pain and suffering; therefore, the process may fail to meet constitutional scrutiny in terms of the eighth amendment. 1 Capital punishment consistently has been an ideological and political debate in the United States, but with the advent of methods involving the administration of drugs, this issue increasingly has raised pertinent clinical issues. [1][2][3] Some have proposed that through the administration of drugs and use of other clinically related paraphernalia (eg, needles, syringes, gurneys), justice officials effectively have ''medicalized'' capital punishment. ...
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... However, it does not produce any analgesic effect. 44,45 Since the salt form of the drug is administered intravenously, the solubility has not been an issue for bolus injections. Although this drug was widely used for lethal injection in the past, this drug is no longer available in the United States. ...
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ABSTRACT Several independent elements have recently combined to thrust United States capital punishment into a chaos. Corrections officials and policy makers have attempted to "humanize" capital punishment by evolving into a chemical execution process, and soften the outward appearance. Foreign policies have interrupted chemical protocols by banning key ingredients. These disruptions are spawning new theories of legal challenges in capital punishment. This is a critical time for stakeholders and all members of a civilized society to pause and reflect on the role of capital punishment.
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Our last chapter focused on time-honored ethical standards for ethics at the end of life. We now turn to some much more controversial concerns: assisted suicide and pharmacist participation in lethal injection.
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This Note traces the history of the lethal injection drug shortage and its impact on how states carry out the death penalty. Though this topic has received much attention in recent years, relatively little attention has been paid to the D.C. Circuit's decision in Cook v. FDA, which exacerbated the shortage. In Cook, the D.C. Circuit enjoined the FDA from exercising its enforcement discretion to allow the importation of sodium thiopental, the primary anesthetic used by states in lethal injection executions. This decision is significant because it effectively required the FDA to ban the importation of sodium thiopental, forcing states to find other ways to carry out executions. Many states have turned to new drugs and manufacturers, while others have returned to past methods of execution. However, states' use of alternative drugs and manufacturers has had disastrous consequences, and the return to old methods of execution constitutes an unacceptable regression towards inhumane and barbaric punishment. Thus, this Note argues that states should make every effort to obtain sodium thiopental. Potential avenues to obtain the drug include adhering to the FDA's regulations or litigating against the FDA's regulations. Renewed access to sodium thiopental will resolve many of the problems plaguing the administration of lethal injection.
Palliative sedation evolved from within the practice of palliative medicine and has become adopted by other areas of medicine, such as within intensive care practice. Clinician's usually come across this practice for dying patients who are foregoing or having life support terminated. A number of intolerable and intractable symptom burdens can occur during the end of life period that may require the use of palliative sedation. Furthermore, when patients receive palliative sedation, the continued use of hydration and nutrition becomes an issue of consideration and there are contentious bioethical issues involved in using or withholding these life-sustaining provisions. A general understanding of biomedical ethics helps prevent abuse in the practice of palliative sedation. Various sedative drugs can be employed in the provision of palliative sedation that can produce any desired effect, from light sedation to complete unconsciousness. Although there are some similarities in the pharmacotherapy of palliative sedation, euthanasia, physician-assisted suicide, and lethal injection, there is a difference in how the drugs are administered with each practice. There are some published guidelines about how palliative sedation should be practiced, but currently there is not any universally accepted standard of practice.
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n this study we identified the precipitate formed when pancuronium bromide (pH 3.9) and sodium thiopentone (pH 10.6) are combined in vitro. A precipitate formed when sufficient pancuronium was added to thiopentone to decrease the pH below 9,25. The precipitate was isolated, redissolved in alkaline solution and identified as thiopentone using ultraviolet spectrophotometry. Pancuronium was soluble in water in the pH range of 2.0 to 12.0, whereas thiopentone was soluble in water only at a pH greater than 9.90. We conclude that thiopentone precipitates when combined with pancuronium because of a pH-dependent decrease in the solubility of thiopentone, rather than a chemical interaction.
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A mathematical analysis of the factors affecting thiopental redistribution in the human body after a single intravenous injection of the drug has been devised and presented. Concentration ratios of thiopental predicted mathematically were compared with those obtained by the direct measurement of concentrations in human blood and fat. Real and theoretical results agreed closely. According to the mathematical analysis, and also according to measurements made in man, the central nervous system attained a peak concentration of thiopental slightly less than I minute after intravenous injection of the drug. Five minutes later only half this concentration was present, and IO to 20 minutes after this, only one tenth remained. The rate at which fat concentrated thiopental was too slow to explain the rate at which the central nervous system was depleted. Instead, the lean body tissues rapidly took up most of the thiopental which the brain lost. The lean tissues thus appeared primarily responsible for depleting the central nervous system of the anesthetic. These findings suggest that fat plays a smaller role in limiting the duration of thiopental narcosis than has been supposed; conversely, the mass of the body and the rate at which its tissues are perfused with blood appear more important than has been recognized.
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Background: It has been found that physicians condone colleague involvement in capital punishment. Physicians' own willingness to participate has not been explored. Objective: To examine physicians' willingness to be involved in cases of capital punishment. Design: Survey exploring physicians' willingness to participate in 10 aspects of capital punishment by lethal injection, 8 of which are disallowed by the American Medical Association. Setting: United States. Participants: 1000 randomly selected practicing physicians. Measurements: Questions assessing willingness to be involved in and attitudes toward capital punishment. Results: 41% of respondents indicated that they would perform at least one action disallowed by the American Medical Association; 25% would perform five or more disallowed actions. Perceived duty to society (P < 0.001), approval of the death penalty (P< 0.001), and approval of assisted suicide (P = 0.015) correlated with increased willingness to perform disallowed actions. Only 3% of respondents knew of any guidelines on this issue. Conclusions: Despite medical society policies, many physicians would be willing to be involved in the execution of adults. The medical profession needs to be better informed about the ethical issues involved in physician participation in capital punishment.
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The time of onset and degree of neuromuscular blockade (NMB) in 80 anaesthetized patients, following either a single bolus injection of pancuronium 0.95 mg kg-1, atracurium 0.53 mg kg-1 or vecuronium 0.07 mg kg-1, or divided doses of pancuronium 0.15 mg kg-1, atracurium 0.07 mg kg-1 or vecuronium 0.01 mg kg-1 administered 3 min or 5 min before the second dose of pancuronium 0.08 mg kg-1, atracurium 0.46 mg kg-1 or vecuronium 0.06 mg kg-1, were determined and compared to the same parameters measured following succinylcholine administration (1 mg kg-1). The time to maximum NMB (100%) following the administration of succinylcholine was 58.1 +/- 5.3 s, whereas the time to maximum NMB (100%) following a single bolus injection of either pancuronium, atracurium or vecuronium was 130.6 +/- 22.2, 93.0 +/- 6.4, 127.5 +/- 13.0 s, respectively. These values for time to maximum NMB are significantly longer than the time required for succinylcholine to achieve maximal blockade. The time to attain maximum NMB following divided doses of pancuronium, atracurium or vecuronium separated by 3 min decreased significantly to 77.9 +/- 4.3, 77.5 +/- 7.6, 89.0 +/- 8.6 s, respectively. However, when the two doses of drug were separated by 5 min, only small, non-significant further decreases occurred in the time required to achieve maximum blockade. Although the time to maximum NMB following divided doses of pancuronium, atracurium or vecuronium is significantly longer than that for succinylcholine, divided dosing significantly decreases the time required to reach maximal NMB.
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