Not Like the Others, Part I: How Lethal Injection Is Nothing Like Assisted Suicide

The comparisons are natural, but the similarities end at the superficial.

A medical volunteer preparing a syringe. [Hannibal Hanschke/Reuters]

The work of ending lethal injection has, since its early-century heyday, not gone that well. The effort to reveal the cruelty involved in it, however, has seen success, and with it two fairly natural questions: isn’t this the same thing we do in either of two procedures, assisted suicide or pet euthanasia? This and next week, we’ll contrast lethal injection with these two procedures, beginning with assisted suicide.

Assisted suicide (also known, among several other names, as Medical Aid in Dying and voluntary euthanasia) involves many of the same drugs, in most cases delivered the same way, and yet the difference in results couldn’t be more stark: deaths by lethal injection can take up to three hours and show signs of suffering in as many as 80% of cases, while doctors in assisted suicide are dealing with the problem of it working too quickly.

Like any discussion of how and whom we choose to kill, assisted suicide has its own controversies, which get more than adequate coverage in many other corners of the Internet. The Project takes no position on assisted suicide other than to note that it is, as practiced, a legitimate medical procedure ripe for comparison to the unsanctioned human experiment that is lethal injection.

Brief Histories of Lethal Injection & Assisted Suicide

While the philosophical tradition surrounding euthanasia is at least as old as Socrates, modern efforts toward what would become voluntary euthanasia began at the turn of the century. Noting both morphine’s intended effect of killing pain and its side effect of fatally depressing the respiratory drive, “incurable sufferers“ and their caregivers began to advocate for the right to die peacefully rather than prolong their agony. While medical associations abhorred the idea and public support for “mercy killing“ nosedived following the revelation of Nazi Germany’s Aktion T4 (whose similarities to the contemporary American death penalty I’ve noted before), activists and physicians began developing means of delivering painless deaths. By the time physician-assisted suicide was legalized in Oregon in 1997, a significant body of work—surreptitiously but consensually developed—already existed for carrying it out.

Lethal injection, by contrast, began in conjecture. As state legislatures prepared new sentencing language to comply with requirements set by the Supreme Court in 1972’s Furman v. Georgia, one Oklahoma lawmaker—personally opposed to capital punishment but too politically vulnerable make it public—sought to assuage his conscience by adding an amendment about a “humane“ method to the new capital sentencing language the state’s legislature crafted. He sought advice on creating such a method from the state’s Chief Medical Examiner, who suggested a cocktail of surgical drugs despite no experience in toxicology or anesthesiology. Oklahoma’s cocktail became law with only a cursory review from an anesthesiologist and was copied nearly word-for-word by other states; despite obvious evidence it doesn’t work, changes to this formula since then have come only from decreased drug availability.

Patient Evaluation & Protocol Selection

These vastly different histories show up perhaps most notably in how medical examinations are conducted for each procedure. According to the Practice Standard for Medical Assistance in Dying written by the College of Physicians and Surgeons of British Columbia¹, two “medical assessors” (both a physician or nurse practitioner), independently of one another, must certify that the patient has met numerous qualifying conditions intended to act against safeguards. One of these assessors takes on the role of “assessor-prescriber,“ developing a protocol reviewed by the other assessor in concert with the patient to decide on an acceptable risk profile.

Lethal injection, justly hampered by the medical community’s objections, involves far less care taken by people of significantly less expertise. The lethal injection protocol by which all Florida’s executions are conducted bears the signature of Secretary of Corrections Ricky Dixon, whose medical knowledge is unknown beyond a bachelor’s degree in criminal justice. A death row inmate’s “limited“ final medical examination, to look for “medical issues that could potentially interfere with the proper administration of the lethal injection process,“ is conducted by a provider with as little as one semester of education. The thoroughness of examinations like these is questionable at best, Alabama’s, for instance, failed to reveal that a diagnosis well-known to constrict veins would be a problem in the two-and-a-half-hour failed attempt to execute Doyle Hamm.

Drug Selection & Preparation in MAiD vs. Lethal Injection

Though the ideas are superficially similar, the protocols for legal voluntary euthanasia also differ wildly in their implementation. The at-home IV protocol designed by British Columbia physicians involves a four-drug procedure designed to alleviate suffering, not to ensure death: midazolam eases patient anxiety, while lidocaine dulls the occasional burning sensation known to be caused by the primary sedative, the short-acting sedative propofol. Somewhat similar to lethal injection, a small dose of a paralytic (rocuronium bromide) is included due to commonly stated patient fears, but in a comparatively small dose and only after a sedative coma is assured by direct observation of four signs. All of these chemicals are dispensed from the pharmacist directly to the physician or nurse practitioner performing the procedure.

By comparison, Florida’s subjects receive 100mg of etomidate, a similarly short-acting sedative but in far less supply than the British Columbia protocol’s stock of propofol, whose producer, quality, and date of manufacture are all state secrets. The “execution team warden,” whose qualifications are simply “experience, training and good moral character,“ determines “after consultation“ that the inmate is unconscious before ordering the administration of more than double the rocuronium dose (500 mg) and potassium acetate, which ultimately kills the patient by interfering with the heart’s electrical conductivity. Even though potassium infusions are also known to burn intensely, Florida’s choice of sedative offers no pain relief.²

Also Not Medicine: Nitrogen Hypoxia Executions

As Alabama prepared to administer the first nitrogen hypoxia execution earlier this year, observers pointed out the similarly superficial commonalities with the Sarco pod, a euthanasia device that displaces the oxygen in an open area surrounding the patient until they pass away peacefully. After inspecting Alabama’s facilities, Sarco pod developer Dr. Philip Nitschke noted that the use of a mask rather than an open chamber meant that airtightness wouldn’t be assured and incomplete cerebral hypoxia (a brain-damaging but not fatal lack of oxygen) “cannot be excluded.“ While the sample size is too small to draw definitive conclusions, his fears appear to have been borne out.

The message in either case appears to be clear: the criminal justice system must either respect the general refusal of the medical community to collaborate on executions or lower its expectations of medical-grade results. With disheartening frequency, they appear to have chosen the latter.

1. British Columbia’s and Florida’s protocols were chosen for their thoroughness and relatively recent development, respectively, and for both countries’ lack of access to sodium thiopental, a common drug in Dutch voluntary euthanasia and an original component of lethal injection.

2. Missouri drew up (but never used) a propofol-based single-drug protocol accounting for the burning sensation with one-quarter the dose of lidocaine as the British Columbia protocol against double the sedative dose.