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Execution Worthy of Man

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Contrary to popular misconception the trend toward the use of more humane methods for executing persons condemned to death is neither new nor unidirectional. It merely represents another of those frequent reversals of history, this time away from the ugly retrogression fostered by the Dark Ages. And we're not entirely free from it yet.

Among the many cruel means for execution in ancient Greece and Rome was the benevolent exception of the use of carbon monoxide (CO).29 This bit of compassion was irrelevant to the misguided fanaticism of the Middle Ages which sought to assuage outraged morality by even exceeding the Roman penchant for head-down crucifixion through the brutality of stoning, burning, flensing, and shredding humans to excruciating death. The incredible savagery began to abate with the introduction of a new contraption designed to facilitate the slaughter of the French Revolution. Despite its intent for an ostensibly "quick and painless" decapitation, the device named after the unfortunate Dr. Guillotin (who did not invent it but endorsed its use through naïve altruism) was to become the symbol of terrible grotesqueness.28 Almost a century later a commission of physicians in the U.S. designated electrocution to be more humane than lethal doses of chemicals such as chloroform, morphine, and even cyanide.9 However, the latter gained acceptance in the early 20th century. Finally, the drive for compassion culminated with the adoption by several states of lethal injection of Pentothal (thiopental, TP).


But let's not forget that hanging is still in use, and that any trend is a two-way affair. With understandable bias ours is claimed to be the most highly developed society in history. That may be less arguable only from a materialistic rather than from a philosophical, moral, or spiritual point of view. Short-sighted altruists blithely dismiss the overpowering fact that in a little over one generation this century has witnessed the two most devastating "world" wars in history, and the two most thoroughly planned and efficiently executed genocides. It can be a painful mistake to assume that brutal methods will never again be used for executions in civilized societies, and that capital punishment itself is headed irreversibly toward permanent oblivion. After all, it is one of those human inventions distilled from a complex mixture of social, political, economic, and religious factors which always change with time and defy accurate prognostication. There always have been, and most likely always will be, equally sincere and intelligent advocates for and against the death penalty. At any given time the majority argument usually prevails, as it has in the U.S. intermittently. In view of all this, the only rational action is to validate our vociferous claim to superior civility by insisting that at least in our time all condemned humans be put to death by the most humane means known.

And what would that be? Of all thus far conceived or used, only two stand out today as equal candidates: an ultra-fast acting sedative solution of TP injected intravenously as a lethal dose mixed with a couple of ameliorating chemicals to paralyze breathing and the heart of a dying person; and secondly, concentrated colorless, odorless, and tasteless carbon monoxide (CO) gas inhaled in lethal amounts. Minimal agony attendant death by either agent is verified by the experience of millions of patients who have undergone major surgery under anesthesia initially induced by the former, and by the strong inference that fatal poisoning by the latter is not enough to annoy even a sleeping subject. But which of the two is best overall?

A quantitative assessment is summarized in Table I. Hydrogen cyanide gas (HC) is included, since heretofore it was generally considered to be the optimal means. Because the three agents are being compared in connection with a distasteful purpose, a negative minus signs, the better or more advantageous. Maximal advantage is signified by zero. Complete objectivity is, of course, out of the question for this kind of arbitrary study, since evaluation of some points of necessity depends exclusively on common sense, experience, and subjective extrapolation from very indirect data. Obviously a truly scientific experimental design of the hallowed "double-blind" type involving a small, heterogeneous coterie of condemned human beings is not possible.

As far as logistics or ease of performance is concerned, TP requires the least amount and manipulation of materials, and the least effort in accommodating the subject. The only necessities are a syringe with attached needle and filled with the lethal solution, a flexible tourniquet, and a simple table or chair. CO would mandate use of a tight-fitting facial mask connected by suitable flexible tubing to a steel gas-storage cylinder, and a stretcher or cot for the recumbent subject. HC calls for an elaborate and very expensive air-tight chamber with a built-in chair under which the lethal chemical reaction produces the HC gas. For each of the three methods the ease of performance of execution is inversely proportional to the complexity of the above material requirements. For example, execution with HC requires the most materials and is the least convenient to perform.

Many of the current lethal injection laws stipulate the simultaneous injection of other chemicals to supplement the action of TP, such as muscle relaxants and cardiolplegics.9 This essentially superfluous medley is a result of the mistaken notion that the physical state of a body undergoing execution by TP is identical to that of a body undergoing induction of surgical anesthesia with TP. It is true that muscle relaxants are often, but not always, necessary to assure optimal tranquility of a lightly anesthetized surgical patient16, but that consideration is nullified by the extremely rapid and profound depressive effect of a lethal bolus of TP which would even negate the clinically dangerous laryngospasm of parasympathetic nervous imbalance known to accompany routine TP induction for surgery.17 The rapidity of cardiovascular collapse and ensuing death after lethal TP injection makes the use of KCl solution to stop the heart of no real

value. A massive intravenous dose of TP alone is enough.

Some opponents of capital punishment complain that TP for lethal injection represents misuse of an agent specifically designated as a medicament.23 But does this constitute an infraction beyond the accepted use of antibiotics or hormones in domesticated animal to fatten the yields (and profits) of the meat and poultry industries? In fairness the critics should also indict theriatricians who "put down" doomed animals with intravenous injections of sodium pentobarbital; solution26---surely not a "medical" purpose. And how about the use in humans of anesthetic agents for purely elective cosmetic surgery?26 Or to facilitate the "execution" (euphemistically called an abortion) of an unfortunate fetus which just happened to be the wrong sex? If the misguided critics still insist that such use in the latter examples is legitimate for the amelioration of psychological duress resulting from the questionable feminine concern over a less than attractive flat chest, or from the disappointing fruit of unbridled passion, would they dare insist that the use of the same ameliorating means for the indubitably real psychological burden of an individual facing total and meaningless personal extinction is any less legitimate? Hardly likely!

Intravenous TP is the most rapid acting of the three agents. An adequate dose will produce tranquil and complete unconsciousness well within 10-15 seconds.22 Observations during execution in the gas chamber reveal that as a rule the effects of HC become apparent within one minute, and death ensues in three to five minutes. I am not aware of any reported death due to direct inhalation of 100% CO concentration, but it is reasonable to assume that the time required for such an execution would at least equal the interval for HC. In any case, there can be no doubt about the significant difference in speed of effect between intravenous TP and the inhaled gases.

The only real drawback with TP executions is the necessity of a truly skilled and experienced phlebotomist to administer the injection. True morality, compassion, and common sense would demand that the procedure be entrusted to those, medical or lay, having the greatest competence, which in most instances means physicians themselves or their highly skilled technologists. Unfortunately authoritative and dictatorial medical organizations have denounced and prohibited physician participation in lethal injection4; and although they strongly and deceitfully deny such action to be unethical, they stop short of branding it a censurable offense. Their stance is ultimately indefensible, and only serves to calm the ambivalent emotionalism of those physicians who intimidate or even threaten with loss of licensure colleagues willing and extremely able to perform the injections.7 On the other hand, execution with HC or CO is less demanding of special skills and is within the capability of any normal layman.

Disadvantages are reversed when considering ease of performance. In addition to the necessity of restraining a subject in the gas chamber, special care is required in sealing it against leaks, in starting the lethal HC chemical reaction under the seated subject, and in evacuating the chamber of all traces of HC gas at the end of the procedure. Because TP is so fast, generally there really is no need for any restraints or special concern once the injection is completed. However, CO takes more time, and restraining straps or sheets sometimes would probably be necessary. Also, the integrity of the mechanical set-up of tank, tube, and mask would require close monitoring of the entire procedure, a factor of less concern if some kind of CO-chamber is devised and used.

Safety of the immediate environment must also be considered. TP is absolutely no threat to any person or thing, no matter how sloppily it's handled. CO, too, is relatively safe with reasonable alertness for possible leaks. Evidence from well-documented studies on workers in heavy vehicular traffic and in tunnels21 indicates that even small leaks of CO in a well-aerated room would not constitute a significant danger to life or health. This factor is not involved in the use of a well constructed chamber for the deadlier HC gas. Leaks of the latter can be detected by its tell-tale odor of bitter almonds, whereas CO is beyond detection by any human sense organ. TP is the unquestionable choice here.

The same is true from an aesthetic standpoint, that is, what an onlooker might observe during an execution. Reactions of the subjects could be guessed at fairly accurately from knowledge of the basic pharmacological properties of the three agents. Extensive laboratory and clinical experience with TP leaves no doubt about its superiority for the induction of a deep, coma-like state.22 On the other hand, inhalation of the deadly gases usually produces antecedent physical signs. Whereas individuals who regain consciousness after accidental CO intoxication while asleep may recall nothing other than the nothingness of dreamless sleep, others poisoned with CO while awake usually complain of mild dizziness and headache before lapsing into unconsciousness.21 In the HC gas chamber, inmates have been observed to gasp, twitch, writhe, and struggle. The lethal effects of HC were dramatically demonstrated to us in medical school. I recall vividly the violent convulsions of a rabbit about 45 seconds after having been given a lethal dose by gastric tube of a sodium cyanide solution,--and the cyanide effect is much faster as HC gas. In sharp contrast, years ago I witnessed the "putting-down" of a cancerous cat using intravenous and slower-acting pentobarbital solution. With eyes wide open, the animal almost imperceptibly went limp within four seconds, without a twitch, gasp or sigh.

In fairness, one minor observable advantage of the gases should be pointed out: the generally pleasing, almost life-like, even pinkish postmortem complexion in some light-skinned subjects. In the case of HC it is due to the engorgement of veins with bright red blood saturated with oxygen, which the poisoned tissue cells cannot utilize.1 A similar appearance after CO poisoning results from the very high concentration of postmortem cherry-red carboxyhemoglobin in vessels of the skin and mucous membranes.21 In live victims of CO that color is often obscured by the pronounced cyanosis and pallor of extreme anoxia, signs which also may characterize the less agreeable skin color after death by barbiturate overdose.

Physiological responses to predictable pharmacological actions engender objective states which are beyond measurement. The gases kill essentially by internal asphyxiation, rendering inhaled oxygen inaccessible to, or unusable by, cells of tissues and organs. In the red blood cells the ability of oxygen to combine with hemoglobin is 10 times that of CO, but dissociation of the former proceeds 2,200 times faster. Therefore the affinity of CO for hemoglobin is 220 times stronger than that of oxygen.21 Furthermore, CO inhibits the dissociation of oxyhemoglobin and thereby reduces accessibility to the body's cells of the available oxygen.21And only negligible amounts can be dissolved in plasma. The net result is a kind of extracellular asphyxiation of tissues. The lethal block is a step farther, in the cells proper in the case of HC which has a high affinity for any chemical constituent having trivalent iron (Fe II).2 Almost all the iron in hemoglobin is in the reduced (Fe I) form, therefore immune to the attack of HC and capable of delivering oxygen to cells. However, the key cytochrome oxidase enzymes which facilitate the use of oxygen for energy production within the mitochondria of cells contain Fe II and are rapidly inactivated by HC to stop all energy reactions through otherwise intact mechanisms.2 This is intracellular asphyxiation.

HC really acts in a more complicated two-step process by first becoming attached to protein (albumin) before passing on to bind with the cytochrome oxydases.28 Because most of the data on the binding has been obtained from in-vitro laboratory experiments, they may not correlate with what actually takes place in a living body.28 HC also binds readily with other crucial enzymes containing molybdenum, zinc, and copper to broaden and further complicate its role in the mechanism of death.

In the final analysis, the symptoms caused by massive doses of HC or CO are those of hypoxia. The weakness and dizziness due to high concentrations of CO mentioned earlier may, on occasion, not occur.21 Carboxyhemoglobin concentration of 30-50% leads to peripheral dilation of vessels and to faster heart and respiratory rates. Intermittent convulsions may ensue when the concentration reaches 50-60%, followed by severely depressed heart and lung function at 60-70%, and inevitable death when it surpasses 70%.21

HC is especially dangerous, because lethal amounts are very rapidly absorbed into the blood stream when inhaled.2 Both the cardiovascular (CV) and central nervous (CNS) systems are especially sensitive to HC, the brain exquisitely so.28 A concentration of only 0.2-0.3 mg of HC per liter of inspired air (or 200-300 ppm) will kill rapidly by asphyxia due to poisoning of the CNS and its bulbar respiratory center.1 A massive dose usually produces so-called apoplectic death during which the victim convulses and cries out loudly before falling unconscious.2 For a brief period all electrical activity in the brain disappears, but very soon reappears with markedly depressed amplitude. The heart also shows depressed amplitude on the electrocardiograph (ECG), but it keeps beating after the brain finally becomes electrically "silent."28

From a subjective standpoint, TP is by far superior. It is one of the "ultra-fast- acting" barbiturate drugs which in relatively low doses act as hypnotics in producing a pleasant state of drowsiness.8 In increasingly larger doses they become sedatives which put subjects into a state resembling normal sleep, followed by deep anesthesia, then toxic coma, and finally death.15 Speed and duration of action of barbiturates are directly proportional to the degree of their lipid solubility. TP is 11 times more soluble than secobarbital of the merely "fast-acting" group.15A single intravenous TP dose of 3.5-4.0 mg per kilogram of body weight brings on unconsciousness in 10 seconds, and a brief sub-lethal dose, 90% of the TP is removed from the blood as it passes through highly vascular organs such as brain, heart, and liver.8 Due to minimal dissociation and to extensive plasma binding, only negligible amounts of TP are excreted by the kidneys. Its high solubility/partition coefficient ratio enables TP to cross the blood-brain barrier quickly and easily either way. The major part of the dose received by the brain is very soon redistributed via the blood stream to other less vascular tissues like muscle, to end up in the storage of avascular fatty deposits which thereby permit early recovery from a single sub-lethal dose.8 Constriction of vessels in the brain and the heart tends to delay this sequence and to prolong depression of those organs.22 The larger the initial dose of TP, the higher its plasma and brain concentrations at which consciousness returns (accounting for so-called acute tolerance.)8 Therefore, a lethal dose must be big enough to cause metabolic inactivation, mainly in the liver, less in the brain, and not at all in muscle, at a rate of 10-15% per hour, too slow to be of consequence in this regard.22 In view of all its other advantages, TP is the ideal agent as far as potential biological damage is concerned. Despite its potent pharmacological action, there is no evidence that a single lethal intravenous dose of TP, competently administered, will result in identifiable cellular or tissue injury. However, although TP itself is a weak acid, a 2.5% solution of its sodium salt is quite alkaline (pH 10) and can be a severe irritant if handled carelessly.12 Anyone responsible for injection of the lethal dose must have the utmost skill, and this represents the only criterion on which TP falls short of the gases as the best means of execution. Leakage of TP into subcutaneous tissues, or its accidental injection into an artery causes excruciating pain.12 Only in the hands of those less experienced and less well-trained than physicians would it be reasonable to expect the possibility of incompetence transforming this otherwise most humane execution into one of the cruelest. Despite their emotional reticence, there is no justifiable reason for physicians to refuse to perform the requisite flawless injections,19 especially when permitted do so.9

The anoxia resulting from the concentrations of HC and CO high enough to induce unconsciousness will necessarily result in tissue damage. This is especially true for brain and heart which are very vulnerable to oxygen deprivation. In cases of death from CO poisoning almost all organs reveal small foci of hemorrhage and necrosis.21 Changes in the brain caused by HC predominate in the white matter, consisting of demyelinization and more frequently of frank necrosis. These are considered to be a direct result of histotoxic anoxia rather than merely a secondary consequence of edema or altered neuronal function.28

This egregious advantage of TP is of extraordinary importance at a time when organ transplantation is almost routine surgical practice, and when the demand for organs will hopelessly outstrip supply for the foreseeable future.24 In striving to impart a modicum of positive significance to otherwise meaningless impending death, many condemned men plead to be allowed to donate their healthy organs during the process of execution by the conventional anesthetized surgical procedure.3,6,10,13,20 Currently there is an incipient campaign in the U.S. aimed at motivating state legislatures to modify their death penalty laws accordingly18,--to enable transplant teams to prepare comfortably for, and leisurely carry out, the life-saving procedures for the culling of robust organs from sturdy and often young adult bodies which must by law be destroyed, instead of having to depend upon strictly fortuitous organ procurement from "brain-dead" donors whose body parts may not have escaped the subtle ravages of fatal disease or trauma. In at least one state such a bill was actually drafted5, but antipathetic pressure from medical and correctional authorities forced its withdrawal before the scheduled committee hearing I had planned to attend.25

TP rightly belongs at the top of any list of desirable means for executing human beings. All its other superb features are capped by offering the only hope of transforming a totally negative death into a positive, truly priceless life-gift, setting the stage for a miraculous and hitherto impossible exchange of life and death.

Table I

Criteria CO HC TP

Materials -- ---- -

Cost -- ---- -

Speed ---- ----

Personnel - - ----

Performance -- --- -

Environment -- ---- 0

Objective Effects -- ---- -

Subjective Effects -- --- -

Biological Damage --- --- 0

TOTAL -20 -30


1. Arena JM: Cyanide. In Haddad IM, Winchester JF: Clinical Management of

Poisoning and Drug Overdose. WB Saunders Co., Philadelphia, 1983, 744-47.

2. Arena, JM: Poisoning, 4th ed., Chas. C. Thomas, Springfield, IL, 1979, 153-4.

3. Bishop A: Personal letter to author, Apr 1984.

4. Bolsen B: Strange bedfellows: death penalty and medicine. JAMA 248:1982, 518-9.

5. California Senate Bill No. 1968, 16 Feb 1984.

6. Carey J: Personal letter to author, Mar 1984.

7. Carrell B: Execution controversy faces physician. AMA News, 21 Jan 1983, 37.

8. Churchill-Davidson HC: A Practice of Anesthesia. WB Saunders, Philadelphia, 1979, 746-770.

9. Curran WJ, Casscells W: The ethics of participation in capital punishment by

intravenous drug injection. NEJM 302:1980, 226-30.

10. Davis F: Personal letter to author, Jan 1984.

11. Devlin MM: Execution by lethal injection and the role of the physician. JAMA 248,1982, 3031.

12. Dornette WHL: Legal Aspects of Anesthesia. FA Davis, Philadelphia, 1972, 303-9.

13. Evans J: A condemned man's last wish: organ donation and a "meaningful" death.

Hastings Center Report, Feb 1979, 16.

14. Gold AH: Mammary prostheses, in: Rubin LR: Biomaterials in Reconstructive

Surgery, CV Mosby, St Louis, 1983, 552-63.

15. Goth A: Medical Pharmacology, 10th ed. CV Mosby, St. Louis, 1981, 303-11.

16. Greene NM: Anesthesia, in: Schwartz SI, ed.: Principles of Surgery, 3rd ed.: McGraw

Hill, NY, 1979, 482-6.

17. Guerra F: Thiopental forever after, in: Aldrete JA, Stanley TH ,eds.: Trends in

Intravenous Anesthesia. Yearbook Med. Publ., 1980, 143-51.

18. Kevorkian J: Capital punishment or capital gain, J. Crim. Law, Criminol., Pol. Sci., 50: 1959, 50-1.

19. Kevorkian J: Medicine, ethics, and execution by lethal injection, Med Law, 4:1985, 307-313.

20. Kevorkian J: Personal interviews with three condemned men on death row in San

Quentin, CA, April 1984.

21. Klassen CD: Nonmetallic environmental intoxicants, in: Goodman & Gilman:

The Pharmacological Basis of Therapeutics. Macmillan, NY, 6th ed., 1980, 1641-3.

22. Kortilla K: Pharmacokinetics of intravenous nonnarcotic anesthetics, in: Aldrete JA,

Stanley TH,eds.:Trends in Intravenous Anesthesia.Yearbook Med. Pub.1980,13-21.

23. Kristovich S: Quoted in "Appeals Court puts lethal injection on hold", AMA News,

20 Oct 1983, 14.

24. Overcast JD, Evans RW, Bowen LE, et al: Problems in the identification of potential

organ donors. JAMA:251, 1984, 1559-62.

25. Pitts K: Letter to author, 20 Apr 1984.

26. Scott WN, Ray PM: Euthanasia, in: UFAW Handbook on the Care and Management

of Laboratory Animals. 5th ed., Churchill Livingstone, NY, 1976, 168.

27.Weiner DB: The real Dr. Guillotin. JAMA, 220:1972,.

28. Way JL: Cyanide intoxication and its method of antagonism. Ann Rev Pharmacol

Toxicol 24:1984, 451-81.

29; Youmans WB, Siebens AA: Respiration, in: Brobeck JR, ed.: Best & Taylor's

Phisiological Basis of Medical Practice, Williams & Wilkins, Baltimore, 9th ed.,

1973, 6

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