A 2024 Research Letter Suggests What a Botched Lethal Injection Might Feel Like
11 anesthesiologists volunteered to be chemically paralyzed but fully awake.
To the extent any drugs belong in lethal injection, paralytics have always been the most controversial inclusion.
The “classic” three-drug lethal injection cocktail, unused in the United States since 2011 due to drug availability issues, involved a sedative (sodium thiopental) to induce unconsciousness and potassium chloride, which in large doses will overload heart muscle’s ability to exchange sodium for potassium, the electrical exchange that makes it beat. The third drug, a paralytic (or neuromuscular blocking agent), was largely included out of ignorance: Oklahoma Chief Medical Examiner Jay Chapman, who wasn’t an anesthesiologist, based the formula on his experiences as a surgical patient. While a handful of states have abandoned the use of paralytics (seizing on “the vet option” for its supposedly easy logistics), the majority still use them. Ethics commentators have noted from the beginning that paralysis serves as little more than PR in executions; if the condemned can’t move, they can’t show signs of a botched execution, and thus it’s harder to critically evaluate an execution method with high public approval despite its real record.
A recent research letter in Anesthesiology, however, suggests that wide-awake paralysis is an even worse experience than previously known, and provide perhaps the best (proximate) glimpse into what it feels like during a botched lethal injection.
What Paralytics Do (and What They Don’t)
Paralytics fall into two broad classes (depolarizing and non-depolarizing); depolarizing paralytics, the predominant class in medical use—and near-exclusive in lethal injection—work by binding to the same receptor as the neurotransmitter acetylcholine1, preventing muscles from firing. This is vital for emergency conditions like trauma and surgery, where providers need to manage reflexive or semi-conscious attempts to “protect” the airway by resisting the tube2.
Paralytics, however, aren’t sedatives; while a paralyzed subject is unable to move, they’ll feel everything happening to them. The psychological risks of this are well-known, as described here by emergency physician Andrew Merelman:
You notice a pain in your throat and want to gag and vomit. You feel that you are breathing but cannot seem to control it yourself. The pain in your throat is worsening to the point where you feel like something is stuck in it. You try to reach toward your mouth but you can’t move at all. Helplessness and pain overcome you and primal fear sets in. You are more aware now than before intubation as the pain has cause you to become alert…Only after an hour do you regain the ability to breathe or move. You start to over-breathe the ventilator and set off alarms. You reach for your endotracheal tube and luckily a nurse stops you from pulling it. Only now are you given sedation and fall back into unawareness.
Dr. Merelman calls paralysis without sedation “a negligent act,“ and he’s too kind if anything; it’s grounds for revocation of your license. It’s even sent a Tennessee nurse to jail for manslaughter3.
What the Volunteers Described Is Even Worse Than We Imagined
There’s been plenty of literature on the effects of paralysis without sedation, mostly retelling non-expert patients’ subjective experiences. Where February’s research letter4 breaks new ground is in providing 11 volunteers to undergo the procedure, all anesthesiologists (the specialty that, in addition to having the most training hours, has the most experience with administering paralytics). The subjects were given one non-depolarizing (vecuronium, the most common paralytic in lethal injection) and one depolarizing paralytic (succinylcholine) and asked to recall their experiences.
“I honestly felt that I was going to die.”
Despite being more aware than anyone on the planet how effectively they could be managed in this situation, all participants recalled a “immediate, primeval“ panic. One described the feeling of losing one’s airway: “my tongue seemed to take up all of my throat … it felt like a very very small crack between tongue and pharynx. It was unnerving thinking it might close at any point.” All subjects felt short of breath despite bag-valve masks providing adequate ventilation. Those who attempted to breathe on their own felt an immediate sense of suffocation, as did four subjects who attempted to swallow.
As bad as these anesthesiologists make it sound, it’s worse if a lethal injection subject isn’t adequately sedated; as the letter notes, “None of these mitigating factors apply to the patient who awakens accidentally while paralyzed.“ The subjects describe ventilation as their saving grace, with nearly all of them demanded increases in the rate of artificial breathing despite knowing their oxygenation and rate were sufficient—lethal injection subjects don’t get either. Subjects of the states’ (unsanctioned) experiments also have no protection against feelings of suffocation should they swallow, with the added complication that the sedative used may induce salivation5.
The study might also provide a window into just how awful it is to die by potassium chloride, which is known to produce an unpleasant burning sensation in one-six-thousandth of a lethal injection dose. Trying to move during paralysis was described as “striking both in its unpleasantness, and its rapidity of onset, and it vanished almost as quickly once the attempted movement was ceased. Subjects were surprised to find they disliked the sensation so much they were not keen to try it again.” Condemned men like Oklahoma’s Clayton Lockett, meanwhile, attempt to rise from the table during their executions.
Our Best Window into the Condemned’s World
As anesthesiologist and death penalty researcher Joel Zivot has said, “The easiest pain to bear is someone else's.” It’s extremely difficult to determine, given both ethical research concerns and states’ reticence, exactly how wrong lethal injection can go. Studies like this, as limited as they are in replicating the conditions of lethal injection (and as little as they may intend to), provide an invaluable window into history’s most popular and most problematic execution method.
I recently found old critical care lecture notes wherein I wrote “acetylcholine=go“. I’m going to assume once again that’s enough neurology to get the point across.
For simplicity, “tube“ here refers to both an endotracheal tube (which enters the trachea) or a supraglottic airway (which sits above the esophagus); within the industry it usually refers exclusively to the former.
I’m oversimplifying the Radonda Vought case, which involves some what-was-she-thinking malpractice; nor am I endorsing her charges and conviction, which involve competing medical ethics concepts too complicated to rehash here.
A research letter is like a study, but has more relaxed criteria and isn’t peer-reviewed. The letter represents the subjective experiences of the volunteers, while objective criteria were measured in an earlier study.
Etomidate, as used by Florida, is known to, as is ketamine (proposed but not used); records are mixed to negative for most others.