Saturday, May 3, 2014

It's tough killing somebody when you really want to.

When I like to impress people about my job, I tell them that I have enough drugs in my anaesthetic cart to kill somebody several times over.  The last person I told this to said, "Thanks for not doing that."

This is why I read with interest and quite a bit of disgust about the series of botched executions in the US.

As a disclaimer I oppose all killing including by the state.  There is no question that what murderers have done is beyond reprehensible.  I feel that killing somebody years or decades after the actual event lowers our society to a place lower than the murderer.  As a teenager I read Truman Capote's "In Cold Blood".  The theme of the book was that while what the two murderers did was wrong, so was their execution many years later.  That's what I think Capote was getting at, he could have just been trying sell a lot of books.  There are some murderers for whom I wouldn't lose a lot of sleep seeing them executed but it is a question of degree and how heinous does a crime have to be before deciding to execute somebody.

Canada has not to its credit executed anybody since 1962 and abolished the death penalty in 1976 replacing it with life with no parole for 25 years for first degree murder.  Between 1962 and 1976 many murderers were sentenced to death, the government let them sweat while their appeals were exhausted, then commuted the death sentence to life imprisonment.  Prior to 1962, Canada had an automatic death sentence for murder and strung people up with great gusto.  The reason for relaxing the death penalty originally was not out of concern that it was wrong but rather that there was concern that juries were acquitting defendants rather than see them face the death penalty.  Canada started sentencing people to 25 years before parole 38 years ago which means that there are a significant number of people convicted of first degree murder walking the streets in Canada.

Periodically one of our right wing politicians brings up bringing back the death penalty.  The common theme is, "but we won't hang people anymore, we will just execute them by lethal injection."

So while large percentages of the American and Canadian population support the death penalty, their support is hinged on the perception that that actual execution  is humane and most importantly it is done out of sight.

Our forebears on the other hand treated executions differently.  They were painful and  long, usually occurring  within hours to weeks of the actual sentence.  They were also for the most part done in public.  There were also no appeals.

As society changed fewer crimes were punishable by death, executions were moved indoors, viewed by only a few witnesses and replaced by methods thought to be more humane.  Methods like the electric chair, the gas chamber and lately lethal injection were all felt to be more humane. (Actually Thomas Edison invented the electric chair to demonstrate how dangerous AC electricity was; Edison favoured DC current.) Appeals were added to make sure the judge and jury actually got it right.  And along the line, most countries and quite a few US states banned the death penalty.

About 30 years ago when some US states started contemplating lethal injection, I suspect most anaesthesiologists thought very hard about just how much drug it would take to kill somebody and what combination would they use.  I suspect some anaesthesiologists were asked formally or informally what they would recommend.  The combination of pentothal, pancuronium and potassium was arrived at.  I am still not sure what doses they used.  Pentothal on its own as many anaesthesiologists have found out is lethal on its own, however the pancuronium and potassium provide the coup de grace.

This seemed to work quite well until pentothal was no longer available in the US (or for that matter Canada).  As I have blogged in the past, pentothal was a perfectly good drug, not as good as propofol still a drug a lot of us would still like to have the option of using.  This caused a problem for executioners in the US because the only source of pentothal is from the EU, all of whose governments have banned capital punishment are not enthusiastic about supplying a drug whose only purpose is to kill people.  Pentobarb widely used in euthanizing animals has been considered but it is not approved for use in humans (it might kill them?) plus nobody knows what dose is lethal or even amnestic in humans.

This lead to an attempt to get propofol which apparently is no longer manufactured in the US with almost disastrous results as the EU threatened to cut off the supply to the US until the supplier begged the state which had obtained the propofol thru underhanded methods to return it.  Propofol which is more cardiostable and less of the respiratory depressant than pentothal might not even be that good a drug.

Therefore I gather midazolam which is still made in the US has been used in at least two botched executions, one execution in combination with hydromorphone.   The touted advantage of the the midazolam/ hydromorphone combination is that it can be given IM if venous access is a problem.  Of course IM injection is unpredictable especially in someone who is peripherally shutdown because they are after all about to die plus to give a lethal dose you would have to inject large volumes.  Combinations of benzos and narcotics are as we all know frequently lethal when you actually aren't trying to kill somebody but apparently work less well when you are trying to.

But it would seem that as soon as it was apparent that getting a good execution cocktail was no longer easy, that state legislatures would just say, "look we've tried as hard as we can to find a pleasant way to kill people but we just can't so why don't we just get rid of this death penalty thing and lock them up for life without parole."   Aside from the fact that the death penalty isn't a deterrent (murderers either don't expect to get caught or don't care if they get caught) and the fact that by conservative estimate 1/25 persons on death row is actually innocent, would this make sense?

Lost in this whole discussion is why the US with a population of 317 million has to import drugs?  If this leads to anaesthetic drugs once more being manufactured in North America and we can start to forget about shortages or impending shortages I just might not be that opposed to capital punishment. 


Anonymous said...

There are so many possible options it's hard to believe they could botch an execution. What about IO access for difficult IVs? What about mask nitrous oxide followed by volatile (e.g. isoflurane) at very high concentrations? Midazolam 100mg or higher plus an opioid at a very high dose should work too, even through a tiny IV (no pain).

Bleeding Heart said...

Intraosseous is painful requires special equipment and training.

Executing with volatile would be very difficult. Not sure whether you, Anonmymous are an anaesthesiologist but gas inductions in adults especially uncooperate adults are very difficult aside from having the watch the patient struggle with the mask, they may develop airway obstruction and laryngospasm. The only beneficiaries if we started executing with volatile would be those anaethesiologists who like regional anaesthesia because a significant number of patients would now be afraid to have volatile anaesthetics.

100 mg of midzolam is 20 cc definitely requiring IV access. Benzodiazepines do not on their own cause apnea, you would need to add a second or third agent.

You can spend a lot of time thinking of innovative ways of killing people or you can just lock them up for life and actually save money by avoiding the expensive appeals.