THE ELECTRIC CHAIR AND ANESTHESIOLOGY

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

What do the electric chair and anesthesiology have in common? The pertinent Venn diagram includes capital punishment, death by lethal injection, electrocution, and anesthesiology ethics. Anesthesiologists inject intravenous drugs to keep people alive during surgery. No anesthesiologist would be involved in lethal injection procedures or in recommending methods for killing another human being. Lethal injection requires someone to administer anesthetic medications in high concentrations without supporting breathing or cardiac function. On August 15, 2019 the state of Tennessee executed Steven West by electrocution for raping a 15-year-old girl and then killing both her and her mother in 1986. 

When given the option of lethal injection or the electric chair, West chose the chair. Uncertainties regarding current lethal injection drug regimens may have played a part in a recent inmate execution via the electric chair. Let’s look at the issues.

lethal injection table

Capital punishment by lethal injection is a relatively recent development. In 1982 Texas became the first state in the United States to use lethal injection to carry out capital punishment. The three intravenous drugs usually involved in lethal injection were (1) sodium thiopental, a barbiturate drug that induces sleep, (2) pancuronium, a drug that paralyzes all muscles, making movement and breathing impossible, and (3) potassium chloride, a drug that induces ventricular fibrillation of the heart, causing cardiac arrest.  

A barrier to lethal injection arose in January 2011 asHospira Corporation, the sole manufacturer of sodium thiopental, announced that they would stop manufacturing the drug. Hospira had planned to shift production of thiopental from the United States to Italy, but theEuropean Union also banned the export of thiopental for use in lethal injection.

Several death-row inmates have brought courtroom challenges claiming lethal injection violated the ban on “cruel and unusual punishment” found in the Eighth Amendment to the United States Constitution. There are drug regimen factors and technical factors regarding lethal injection problems. Regarding drug regimen factors, alternative sedative drugs such as midazolam, fentanyl, Valium, or hydromorphone have been considered to replace sodium thiopental, but there have been legal challenges as to whether inmates are indeed unconscious under these newer lethal injection recipes. The potential of cruel and unusual punishment can occur if the sedative combination does not reliably induce sleep, so that the individual to be executed is awake and aware when the paralyzing drug freezes all muscular activity. About ten years ago I was contacted by the Deputy Attorney General of a Southern state, who asked me if I would testify that a massive overdose of a single-drug intravenous anesthetic would reliably render an individual unconscious and anesthetized. The Deputy AG sent me the position paper authored by the opposition’s expert for the abolitionist argument. That paper was a massive treatise authored by an MD-PhD anesthesiologist-pharmacologist. The paper was approximately 80 pages long with hundreds of references. The abolitionist movement against capital punishment is strong. I declined to testify in support of the state’s lethal injection protocol. 

There are also technical factors involved with intravenous injection. A 100-fold overdose of a sedative should render an inmate asleep, correct? Not necessarily. What if the intravenous catheter or needle is incorrectly positioned, and the drug does not enter the vein in a reliable fashion? Is this a possibility? It is. If the catheter is not inserted by a trained medical professional it’s possible that the catheter will be outside of the vein, and the intended medications will spill into the soft tissues of the arm. The intended site of action of intravenous anesthetic drugs is the brain. To reach the brain the drug must be correctly delivered into a vein. Cases in which failure to establish or maintain intravenous access have led to executions lasting up to 90 minutes before the execution was complete. Thus the role of a medical professional to insert the intravenous catheter and administer the lethal injection is critical. The dilemma is that medical professionals are trained to save lives, not to execute people. The Hippocratic Oath clearly states that physicians must “do no harm” to their patients.

The American Medical Association states, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

The American Society of Anesthesiologists states, “Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine . . . The American Society of Anesthesiologists continues to agree with the position of the American Medical Association on physician involvement in capital punishment. The American Society of Anesthesiologists strongly discourages participation by anesthesiologists in executions.”

The American Nurses Association states, “The American Nurses Association is strongly opposed to nurse participation in capital punishment. Participation in executions is viewed as contrary to the fundamental goals and ethical traditions of the profession.”

Without a trained medical professional to administer the intravenous catheter and inject the drugs in a reliable fashion, the practice of lethal injection has stalled in the State of California. Since 2006 there have been no death penalty executions by lethal injection in the state of California. In February 2006, U.S. District Court Judge Jeremy D. Fogel blocked the execution of a convicted murderer because of concerns that if the three-drug lethal injection combination was administered incorrectly it could lead to suffering for the condemned, and potential cruel and unusual punishment. This led to a moratorium of capital punishment in California, as the state was unable to obtain the services of a licensed medical professional to carry out an execution. There are currently over 700 inmates on death row in California.

Death by electrocution reentered the news this month. In the electrocution method, the condemned inmate is strapped to a wooden chair and high levels of electric current are passed through electrodes attached to the head and one leg. Lethal injection has been considered a more humane method of capital punishment than the electric chair. Tennessee provided inmates with a choice of the electric chair or lethal injection, and inmate Steven West chose the electric chair. Will electrocution replace lethal injection as the most common form of capital punishment in the United States? There is no current trend to support this. In 2018 there were 23 capital punishment executions by lethal injection, and only 2 by the electric chair. In 2019 there have been 10 capital punishment executions by lethal injection, and only one by electrocution.

Challenges to lethal injection are ongoing, and are in the domain of lawyers and courtrooms. If current lethal injection methods are ruled cruel and inhumane or if they are ruled unconstitutional, and states cling to the goal of capital punishment, we may see more headlines like this month’s electric chair execution from Tennessee. 

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION https://wordpress.com/post/theanesthesiaconsultant.com/2738

APRIL 2014 LETHAL INJECTION IN OKLAHOMA – AN ANESTHESIOLOGIST’S VIEW

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Lethal injection using fentanyl occurred for the first time in the death penalty execution of Carey Dean Moore in Nebraska August 14th, 2018.

lethal-injection-0000-1503512440

Per CBS News, “The Nebraska drug protocol called for an initial IV dose of diazepam, commonly known as Valium, to render the inmate unconscious, followed by the powerful synthetic opioid fentanyl, then cisatracurium besylate to induce paralysis and stop the inmate from breathing and potassium chloride to stop the heart.

Diazepam and cisatracurium also had never been used in executions before.”

From an anesthesiologist’s point of view:

  1. Valium (diazepam), an antianxiety drug, is seldom used in current surgical anesthesia practice, as it has been replaced by Versed (midazolam), which has a faster onset and causes less stinging on intravenous injection.
  2. Fentanyl, a powerful morphine-type narcotic, given in very high doses, brings on sedation, respiratory depression, and unconsciousness. The combination of Valium and high doses of fentanyl (typically 100 micrograms per kilogram) was the standard anesthetic used for open heart surgery in the 1980s. High doses of fentanyl can cause chest wall rigidity, which would add to any agonal respiratory efforts during a lethal injection, hence the necessity of a muscle relaxant (see below).
  3. Cisatracurium, a muscle relaxant or paralyzing drug, blocks all muscle movement and breathing. The paralyzing drug is used to both stop respiration and to eliminated any writhing and agonal movements during the dying movements.
  4. Potassium chloride, in high concentrations, causes the heart to fibrillate and cease beating.

Beginning in the 1970s, initial lethal injection recipes in the United States included 1) sodium thiopental (a barbiturate) to induce sleep, 2) pancuronium (a muscle relaxant) to paralyze the individual, and 3) potassium chloride to fibrillate the heart. In the 1970s-1990s, thiopental and pancuronium were commonly used anesthetic drugs. (In recent decades, propofol has replaced thiopental as the hypnotic of choice for general anesthesia for surgery, and the drugs rocuronium and vecuronium have replaced pancuronium as muscle relaxants for surgery.)

The European Union banned the export of thiopental for lethal injection in 2011, and a search for available alternate sedatives and intravenous anesthetics ensued. By 2016, more than twenty American and European pharmaceutical manufacturers had blocked the sale of their drugs for use in lethal injections, effectively making most FDA-approved unavailable for any potential lethal execution drug.1

This use of fentanyl, diazepam, and cisatracurium in Nebraska is the latest chapter in the recipe for lethal injection story. Stay tuned to see whether the manufacturers of these drugs choose to ban their sale for use in capital punishment.

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

Note: As a physician who took the Hippocratic Oath to never harm patients, I neither approve of nor would assist in any way in the lethal injection of a prisoner.

 

References:

  1. Eckholm, Erik “Pfizer Blocks the Use of Its Drugs in Executions”The New York Times. May 16, 2016.

 

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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