Life and Death Row: Execution by lethal injection, How it kills

The lethal injection has been the primary means of executing condemned Americans for decades - but its use remains controversial

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What is the Lethal Injection?

Lethal injection, method of executing condemned prisoners through the administration of one or more chemicals that induce death.
Condemned inmates are restrained prior to receiving the lethal injection
Condemned inmates are restrained prior to receiving the lethal injection.

The drug midazolam – a sedative used by several states to cause unconsciousness – has proved so controversial that, in 2017, Alabama inmate Thomas D Arthur asked to be executed by firing squad. Arthur lodged an appeal with the Supreme Court to postpone his execution on the basis that midazolam, one of the drugs in Alabama’s three-drug lethal injection combination, could contribute to ‘prolonged torture’. The Supreme Court denied the appeal, and Arthur was executed (by lethal injection) in May 2017.

The controversy around midazolam became particularly heated at the time of Arkansas’s ‘mass executions’ in April 2017.

In Arkansas, the lethal injection comprises three chemicals: midazolam, to sedate; vecuronium bromide, to paralyse the muscles; and potassium chloride, to stop the heart.

Each of these is delivered at a dose that could theoretically kill the inmate; however, each drug has drawbacks. A cocktail of all three is used to mitigate the other drugs’ disadvantages.

At the time of execution, the inmate is strapped to a gurney, and IV tubes are inserted into both arms.

The Arkansas procedure uses two IV sites. This is partly to protect against ‘vein failure’. Vein failure was cited as the reason behind the ‘botched’ execution of Clayton Lockett in Oklahoma in 2014, which reportedly took 43 minutes as Lockett ‘thrashed on the gurney, writhing and groaning’.

Midazolam is the first of thre...
Midazolam is the first of three drugs in the Arkansas lethal injection procedure.

It was only later that the department director revealed that the single vein into which the drugs were being administered had ‘blown’.

The first drug given to the inmate is midazolam, a sedative, which is administered to render the inmate unconscious and prevent them from feeling any suffering.

Midazolam is a benzodiazepine. At low doses it has an anti-anxiety effect. At around 10mg, it knocks the inmate unconscious. On death row in Arkansas, the dose is 500mg.

The drug travels up the arm via the bloodstream to the brain. Within seconds, the inmate starts to black out.

It has been alleged, however, that some inmates who received midazolam have appeared to regain consciousness mid-execution.

During the 2014 execution of Dennis McGuire in Ohio, which used a combination of 10mg midazolam and 40mg hydromorphone, McGuire was seen ‘gasping’ for air for 10 to 13 minutes of the 24-minute execution. There were reportedly similar scenes during the execution of Joseph Wood in Arizona.

Following McGuire’s execution, Ohio raised its dosage to 50mg of each drug for executions.

An Associated Press reporter who witnessed the execution of Kenneth Williams in Arkansas in April 2017 reported that Williams lurched and convulsed 20 times after the injection of midazolam. According to the reporter, about three minutes into the execution, Williams’ body jerked forward “in a series of what seemed like involuntary movements,” lurching violently against the leather restraint across his chest.

Dr Joel Zivot, an associate professor of anesthesiology and surgery at Atlanta’s Emory University, said: “It was either a seizure that was predictable based upon Mr Williams’ co-existing medical conditions, or partial paralysis in an execution where the protocol itself was not followed. Or, more to the point, even if the protocol was followed, the protocol was fundamentally flawed.”

100mg of Vecuronium Bromide is...
100mg of vecuronium bromide is administered to paralyse muscles

Williams’ attorneys and the American Civil Liberties Union of Arkansas called for an independent investigation. Arkansas’s governor, Asa Hutchinson, dismissed the calls.

“I think it’s totally unjustified,” he said. “You don’t call for an independent investigation unless there’s some reason for it. Last night, one of the goals was there not be any indications of pain by the inmate, and that’s what I believe is the case.”

Separately, in a 2015 legal challenge brought by several death row inmates in Oklahoma, numerous experts testified that midazolam has no pain-relieving properties, and does not produce the deep, coma-like state of unconsciousness necessary to relieve suffering.

Placing the inmate in a state of deep unconsciousness is critical because the effects of the other drugs used in the lethal injection are believed to be extremely unpleasant.

Once the inmate is confirmed unconscious, 100mg vecuronium bromide is administered into their other arm.

Vecuronium bromide is used clinically in anaesthesia to paralyse the muscles – causing them to relax – so that surgery can be performed.

Unsedated, the inmate would feel the paralysis spread limb by limb. As the lung muscles are paralysed, the inmate would struggle to breathe. If conscious at this stage, “you’d feel you were suffocating,” Dr Stephen Morley, a forensic toxicologist at Leicester Royal Infirmary, told BBC Three.

Potassium chloride disrupts the balance of potassium ions in the heart.Potassium chloride disrupts the balance of potassium ions in the heart.

At this stage, the inmate should be fully unconscious and no longer breathing. However, their heart may still be beating as it isn’t affected by vecuronium bromide in the same way.

To stop the heart, potassium chloride is administered directly after the vecuronium bromide. Without proper sedation, this stage would be extremely painful. The feeling has been likened to ‘liquid fire’ entering veins and snaking towards the heart.

If the inmate is not fully paralysed, their muscles will also spasm uncontrollably, causing them to buck on the gurney, according to Dr Morley. This is because potassium sends signals to every muscle in the body to contract.

When the potassium reaches the inmate’s heart, it disrupts the delicate balance of sodium and potassium ions that keep the heart beating. The inmate’s heart would begin beating irregularly – and then stop.

If the procedure goes according to plan, the inmate should be dead less than 10 minutes after the first drug enters their system.

If there is a problem injecting the drugs, such as a blown vein or drugs being accidentally injected into muscle – or if the inmate regains consciousness – the procedure is stopped, the curtain for observers is closed, and staff work to restore the infusion site.

Is the Lethal Injection really not painful?

Substantial evidence suggests that botched lethal injections can inflict on the prisoner unnecessary pain and indignity, and media-witnessed injections have shown a significant pattern of mishaps—particularly in Texas, where lethal injection has been administered most frequently.

For example, prisoners can suffer if they do not have suitable veins or if they receive an inadequate dosage of sodium thiopental (in which case they might regain consciousness and sensation while being injected with the two other chemicals). In such a scenario (or through a mix-up of the drug sequence), a prisoner might feel excruciating pain but not be able to show it because he is paralyzed by the pancuronium bromide.

A study of state lethal-injection protocols showed that such failures can be linked to vague lethal-injection statutes, uninformed prison personnel and executioners (who typically are not medically trained, because doctors are normally precluded from participating in executions), and skeletal or inaccurate directions that reveal errors and ignorance about the procedure.

In two separate cases in 2004 and 2006, the U.S. Supreme Court ruled on the constitutionality of certain procedural aspects of lethal injection under the U.S. Constitution’s Eighth Amendment prohibition of cruel and unusual punishments. In response to mounting criticism of the three-drug combination by lower courts, in 2007 the Supreme Court agreed to decide whether Kentucky’s administration of its particular three-drug protocol violated the Eighth Amendment.

In a 7–2 plurality ruling (Baze v. Rees [2008]), the court upheld the constitutionality of the protocol, determining that it did not pose a “substantial” or “objectively intolerable” risk of “serious harm” to prisoners. The court also concluded that a proposed alternative method of execution, consisting solely of a large dose of sodium thiopental, was unacceptable.

Baze, however, did not quell lethal-injection litigation. As two justices and some legal commentators noted, the plurality’s vague and limited analysis did not definitively resolve the constitutional issue, because many critical questions were not addressed. Indeed, within months of the Baze decision, lawyers once again began to challenge the use of the three-drug protocol on the basis of a range of associated issues.

Following Baze, other developments arguably increased the risks of prisoners suffering during lethal injections. They included the adoption by states of entirely untested single-drug protocols using only sodium thiopental, as well as a shortage of sodium thiopental after production of the drug was halted by its sole U.S. manufacturer, Hospira, Inc., in 2011.

The shortage led prison officials to purchase the drug from companies in foreign countries, where a lack of government or industrial controls increased the risk that the drug obtained would be impure, expired, or for other reasons ineffective at rendering prisoners unconscious during execution.

Some states replaced sodium thiopental with pentobarbital, which had not previously been used for executions, prompting concerns that prisoners on death row were being subjected to continuous execution experiments.

At the time of the Baze decision, all states that conducted lethal injections incorporated sodium thiopental into their three-drug protocols. Continuous protocol shifting among the states after Baze, however, eventually resulted in four distinct protocols, which differed with respect to the number and kinds of drugs used (some used three drugs and some just one; some used sodium thiopental and some pentobarbital).

The division and instability in lethal-injection drug regimens, which had never existed before, suggested to some scholars and policy makers that some states might try to bring other drugs into the lethal-injection mix.

Meanwhile, the accumulation of constitutional challenges to the method led some states to abolish the death penalty altogether, as did New Jersey in 2007 and Connecticut in 2012.

Lethal injection has also been used in other countries. For example, there is evidence to suggest that China, which may have executed hundreds of prisoners with lethal injection, has used the same three-drug regimen originally adopted in Oklahoma.

The prevention of unnecessary suffering is a major part of lethal injection protocol, according to the Arkansas Lethal Injection Procedure document, which states (in capital letters): “EVERY EFFORT WILL BE EXTENDED TO THE CONDEMNED INMATE TO ENSURE THAT NO UNNECESSARY PAIN OR SUFFERING IS INFLICTED BY THE IV PROCEDURE.”


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