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Lethal Injection, Midazolam and the USA

Martin Luther King said the death penalty adds deeper darkness to a night already devoid of stars. Most US citizens support capital punishment, as do a substantial chunk of the UK population.  Many will assume it’s skilled and humane, swift and silent, but they’d be wrong. King’s night is filled with the sound of screaming.

On May 26th 2017 Thomas Arthur was executed in Alabama by lethal injection, after 34 years on death row. He had asked for the firing squad. Beneath his terrible request lies terror, and a ghastly reality:

For years, US states executed using an anaesthetic, thiopental, to induce unconsciousness, a paralysing drug such as pancuronium, to stop muscular activity and thus avoid alarming the witnesses with any upsetting thrashing around, and potassium chloride, otherwise an incredibly painful drug to receive, to stop the heart. In 2011 thiopental’s manufacturer, after years of trying to stop this use of a drug manufactured for therapeutic purposes rather than state-licensed murder, simply ceased production. Gradually, supplies ran out. Attempts to obtain them from Europe were blocked by the European courts, and something new was needed.

The original protocol had been drawn up by an Oklahoma doctor in the 1970s – but who would design a new one, in the days of evidence based medicine? And is this the practice of medicine at all, anyway, or is it something else entirely?

After head-scratching, consensus amongst the executing states settled on another idea, the use of a sedative, midazolam. It’s not an anaesthetic, but it was widely available. There wasn’t any evidence that it would work, but it sedates so it seemed like a good idea. Oklahoma said they looked it up online.

Midazolam isn’t a painkiller, and many suspect it can’t mask pain, even in huge sedating  doses. It is not designed to cause unconsciousness, and there is no evidence based dose at which it is guaranteed to do so. Anyone already habituated to sedatives of addiction is likely to be pretty resistant to its effects. It is not an anaesthetic – it’s not designed to be one, it’s not tested as one, and it doesn’t work as one.

Its chequered execution history bears this out:

  • In Ohio in 2014 Dennis McGuire struggled on the execution table for 26 minutes before eventually dying.
  • In Arizona Joseph Wood took nearly two hours to die, requiring 15 injections of 50mg rather than one.
  • Clayton Lockett’s execution in Oklahoma was halted 33 minutes in as he spoke coherently and tried to get off the table. His i/v siting had been botched despite sixteen attempts by the paramedic and the doctor, who included an accidental femoral artery stab in his general mess-up, spraying blood everywhere, according to witnesses. His executioners, in almost incomprehensible irony, were discussing resuscitation when he finally died of a heart attack. His lawyer said it looked like torture. The UN High Commissioner for Human Rights called it cruel, inhuman and degrading. Clearly, it was a disaster. 17 US states still requires a doctor’s presence at execution, but there is no requirement for skill, or to be in current practice.

By 2016 drug companies had managed to find a legal way to block midazolam supplies to executioners.  In April 2017 Arkansas tried to execute eight men in ten days, before their last batch expired, and managed to execute four of them despite global outcry (and concerns for the psychological well-being of prison staff), but Alabama has a midazolam stockpile. Thomas Arthur, despite his please to be shot instead, was executed minutes before his death warrant expired, still challenging the humanity of the method. Robert Melson died the same way in the same jail twelve days later. He shook for 32 minutes before expiring.

The future looks still more brutal. Now out of suitable drugs, Utah has reinstated the firing squad with a doctor helpfully locating the heart for the marksmen (let’s hope they find one who knows where it is). Several states are legislating to reinstate the electric chair, and Oklahoma say they’ve heard from a company offering “pain-free and mistake-free gas chamber executions.” Seriously.

Some will always believe a horrible death appropriate for those convicted of inhuman acts, but one suspects that if the Land of the Free really thought it acceptable to torture people to death it would say so. Execution is not medical. Trying to make it look neat and medical using the trappings of medicine looks more like an unwillingness to look truth in the eye, for fear of seeing a Catch 22 reflected there: How can execution be skilled and humane, when no one with skill and humanity wants to be involved?

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