The US government and 27 states reserve the death penalty for those deemed the worst of the worst. Convicted of particularly heinous crimes, inmates are typically put to death after their appeals run out, often a yearslong process that regularly reaches the US Supreme Court – which has found lethal injection constitutional and not a violation of Eighth Amendment protections against cruel and unusual punishment.
Even so, workplace ethics dictate medical professionals “should have no part in this charade,” the American Medical Association wrote in a 2018 brief to the US Supreme Court in the case of the planned lethal injection of Missouri death row inmate Russell Bucklew. “Society wants to delude itself into a belief that capital punishment no longer represents a weighted moral choice, but is now somehow scientific – nearly antiseptic,” the group wrote. “This delusion, however, cheapens life and makes its extinction easier.”
In a common lethal injection protocol, a trio of chemicals is administered in three steps: First, an anesthetic renders an inmate unconscious; then a second drug paralyzes them; and finally, a third stops their heart.
Since losing access in 2009 to the anesthetic sodium thiopental — European pharmaceutical firms banned it in executions and the sole US producer stopped making it — some states have used pentobarbital in a single-drug protocol to execute death row inmates, while others have adopted midazolam as the three-drug method’s anesthetic.
Midazolam, however, has become the focus of lawsuits by inmates who claim it’s not effective at inducing unconsciousness, potentially exposing them to pain caused by the other 2 drugs. Indeed, those can have a highly painful effect, even in clinical settings — and they’re used in much larger doses for an execution, experts told CNN.
So far, courts have ruled midazolam sufficiently shields inmates from pain and does not violate the Constitution. And US Supreme Court Justice Neil Gorsuch last year in denying 1 death penalty appeal ruled the Eighth Amendment “does not guarantee a prisoner a painless death.”
Perhaps nowhere has midazolam’s use been as heavily litigated as in Oklahoma, the 1st jurisdiction in the world to adopt lethal injection — in 1977 — as its preferred execution method and the state that’s carried out more executions per capita than any other.
Here’s what happens in Oklahoma during a typical three-drug lethal injection of anyone who weighs less than 500 pounds, according to state documents — confirmed by a corrections spokesperson who declined further comment — and medical experts who spoke to CNN.
The inmate is secured and monitored in the execution room.
The inmate is strip-searched, then secured with upper and lower restraints to the execution table by the restraint team. The team then moves the inmate into the execution room and attaches leads from an electrocardiograph to the inmate’s chest. Staff leaders in a separate room observe the inmate with the help of a high-resolution camera and monitor, along with a microphone. The restraint team leaves the room.
PHASE I: SEDATION
The 1st drug, intended to render the inmate unconscious, is injected.
An IV team enters the execution chamber. IV team members locate 2 veins and place 2 catheters — a primary and a backup — into the inmate’s body.
The catheters are connected through a hole in a wall to the observation room into a medication-delivery device known as a manifold. Nine syringes, each filled with 1 of the 3 drugs used to execute the inmate or saline, are attached to the manifold for delivery.
The first 2 have green labels and contain midazolam, intended to make the inmate unconscious; the 3rd, with a black label, contains a saline solution to flush the midazolam out of the IV line.
A prison official reads the name of the 1st drug out loud. The contents of the 1st syringe are pushed in, then the 2nd, then the last.
PHASE I: SEDATION
The syringes are large — 60 milliliters — and it could take up to 1 to 2 minutes to inject each, according to documents from Glossip v. Chandler, a 2022 federal lawsuit challenging Oklahoma’s execution protocol.
Prisoners in Oklahoma are given 500 mg from the two syringes, plus 60 mL of saline solution.
What the National Institutes of Health and others say:
When used as anesthesia before surgery, the National Institutes of Health recommends no more than 5 mg of midazolam for a healthy adult under 60 years old to reduce anxiety and allow them to fall asleep. A Covid-19 vaccine is typically administered in a 1 mL, 3 mL or 5 mL syringe, according to the American Society of Health-System Pharmacists.
PHASE I: SEDATION
Officials perform a consciousness check.
5 minutes pass. A member of the IV team performs a consciousness check on the inmate — which could include a sternum rub and a pupil check, according to court records from Glossip v. Chandler — while officials in the observation room keep watch.
The IV team leader informs the director of the Corrections Department that the inmate appears unconscious, and if there are no problems that would require the execution to stop or revisit previous steps, the execution proceeds to the next phase.
What experts say:
Given the size of the anesthetic dose, a pulmonary edema — in which fluid starts to fill the lungs — likely has been triggered, according to a study by Dr. Joel Zivot, an anesthesiologist and professor at Emory University in Atlanta who has served in the past as a medical expert for the defense of prisoners facing execution; Zivot’s study examined the autopsy reports of 43 inmates killed in eight states. Of 28 killed using midazolam, 23, or 82%, showed signs of pulmonary edema, the study shows.
If the inmate is not fully unconscious, the fluid entering their lungs would make them feel like they’re drowning, Zivot told CNN.
However, a 500-mg dose of midazolam is adequate to render an inmate unconscious, said Dr. Ervin Yen, a retired anesthesiologist who has testified as an expert witness for the state of Oklahoma and has witnessed several executions. While some autopsies of inmates killed by lethal injection have indicated pulmonary edema, the condition would have begun after they lost consciousness and “is not causing them discomfort,” he said.
PHASE II: IMMOBILIZATION
The prison staff administers 2 syringes-worth of the 2nd drug, the paralytic, followed by saline in a 3rd syringe.
This chemical, such as vecuronium bromide, is intended to paralyze the inmate for the rest of the execution.
The 2 syringes with the paralytic are labeled yellow; the one with saline is labeled black.
PHASE II: IMMOBILIZATION
Over the course of the execution, an inmate is given 100 mg of a paralyzing drug like vecuronium bromide, plus a 3rd syringe filled with saline solution.
What the NIH says:
A steroid, vecuronium bromide is used during general anesthesia to help get and keep a tube down a patient’s throat so they can breathe and to help them relax. An initial dose of 0.08 to 0.1 mg/kg is enough to paralyze a human body for roughly 25 to 30 minutes, according to the NIH. At that rate, a 5.4- to 6.8-mg dose would be enough to leave a 150-pound person unable to move.
PHASE II: IMMOBILIZATION
What experts say:
Vecuronium bromide “paralyzes every muscle in the body, so there’s no way someone could communicate distress,” said Dr. Jonathan Groner, a professor of surgery at The Ohio State University and a pediatric surgeon at Nationwide Children’s Hospital, who stressed the views he gave CNN were not reflections of those institutions.
Yen agreed but stressed he believed the inmate would be unconscious: “They don’t give the vecuronium bromide until the health care person does a consciousness check.”
At this point in the process, a tear ran down the face of Gilbert Postelle during his 2022 execution at the Oklahoma State Penitentiary, witnesses said. "This was tearing that, in my opinion, … would be a sign of extreme stress,” said Dr. Gail Van Norman, an anesthesiology professor at the University of Washington who witnessed the execution.
Tears indicate a person might be inadequately anesthetized and may happen in a person who is paralyzed and in pain or suffocating, according to testimony from Dr. Mark Heath, an anesthesiology professor at Columbia University, in Baze v. Rees, a state lawsuit challenging Kentucky’s execution protocol.
PHASE II: IMMOBILIZATION
A minute or two passes before the director orders staff to proceed, according to one recent Oklahoma execution log.
What experts say:
This dose of vecuronium bromide alone would cause death by asphyxiation, experts said: The paralysis of the diaphragm means the inmate would not be able to breathe.
PHASE III: TERMINATION
The 3rd drug, which stops the heart, is injected.
2 of the final syringes are filled with potassium chloride and labeled red on the manifold, and the final is filled with saline and marked black.
Potassium chloride is normally given by doctors to treat low levels of potassium in the blood, which helps the heart and kidneys. At a high enough dosage, it will stop the heart instead — and sometimes is used to do exactly that for heart surgeries that cannot be performed while the heart is still beating, Groner and Yen told CNN.
PHASE III: TERMINATION
The IV team leader reads aloud that the inmate will get a dose of 240 milliequivalents (mEq) of potassium chloride, plus 60 mL of saline solution, then administers those doses.
What the NIH says:
A clinical IV dose of potassium chloride ranges from 10 mEq per hour to 40 mEq per liter of water.
PHASE III: TERMINATION
What experts say:
Potassium chloride is painful when injected or administered in an IV, experts said. “It feels like your arm’s on fire,” Groner told CNN, and the inmate could feel that pain if they are not fully unconscious, Zivot indicated.
That pain is amplified by the dosage and speed at which the chemical is given to the inmate, Yen testified for the state in the Glossip v. Chandler case.
PHASE III: TERMINATION
Once that much potassium reaches the inmate’s heart, it induces cardiac arrest. This can happen as quickly as within 30 to 60 seconds of injection, said Van Norman, who’s examined the heart monitor readings of inmates in lethal injection court cases.
The prisoner’s heart monitor soon flatlines.
The inmate’s time of death is logged.
The IV team leader checks the inmate. The director or designee announces the inmate is dead.
An official closes curtains to the observation room.
It’s important to note the process does not always unfold as outlined: Oklahoma in recent years has carried out a number of executions critics have deemed botched — a broad term used to describe any execution that deviates from a prescribed protocol, including those in which the inmate is alleged to have suffered inordinately.
In 2014, for example, a case report reveals Clayton Lockett writhed and moaned during his execution by lethal injection. He had an apparent heart attack 43 minutes after being administered the 1st injection, according to state documents and witnesses. And in 2021, John Grant convulsed and vomited on the gurney after he was injected with the 1st drug, witnesses said.
Among the execution methods — including hanging, a firing squad and the electric chair — used to punish some of American history’s most monstrous crimes, lethal injection has become the primary method. It’s come to pass, the American Medical Association wrote in its 2018 brief to the US Supreme Court, “as the result of this country’s century long march from hanging toward the overt imitation of medical practice in state sponsored execution protocols -- always in search of the most ‘humane’ way to kill.”
Yet, the Hippocratic oath after centuries still includes this vow, the brief notes: “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.”
And a broad band of field experts – also including the American College of Correctional Physicians, the American Society of Anesthesiologists and the World Medical Association – asserts it is “unethical for physicians to participate in capital punishment,” according to the American Medical Association.
For Groner, lethal injection – as the medical group wrote to the high court – is, in fact, a “charade,” he said. “It’s the veneer of medical respectability that’s been used to make it palatable.”
Source: CNN, Staff, November 29, 2023
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