Medical Examiner

Lethal Injections Are Crueler Than Most People Imagine. I’ve Seen the Evidence Firsthand.

Alabama is pausing the use of the execution method after two botched attempts, but physicians need to refuse to ever participate in making them possible.

An IV bag with a skull and crossbones on it is pictured against a stark background.
Photo illustration by Slate. Photo by OwenJCSmith/iStock/Getty Images Plus and Barks_japan/iStock/Getty Images Plus.

Lethal injection is not a medical act, but it impersonates one. The method of judicial execution works by shuttling medicines, repurposed as poison, directly into a vein via an intravenous catheter. Intravenous use is a ubiquitous method for drug and fluid delivery that most anyone might recognize, either by direct experience when sick or by observation in others when others are sick. According to the Eighth Amendment of the U.S. Constitution, punishment cannot be cruel, and when lethal injection causes death, the outward result can be extraordinarily mild and bloodless. I speak from experience. As a physician, I was invited by Georgia prisoner Marcus Wellons to watch his execution on June 17, 2014. Lethal injection is a highly curated event; even my medical trained eye could detect very little. Wellons died quietly and quickly.

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I’ve since served as an expert witness in court for countless lethal injection cases. My work on autopsy analyses of executed individuals reveals that lethal injection kills not quietly and peacefully, but instead by drowning the executed prisoner in their own blood. Death row prisoners know this. In 2018, I was a medical expert for the defense for prisoners facing execution in Tennessee. Three prisoners told me separately that they had selected to die by the electric chair over fear of death by lethal injection. Initially represented as cruelty-free, lethal injection has been outed as the perfect vehicle of anticipatory torture.

Lately, an inability to establish intravenous access has created a new form of terror. In Alabama, the two most recent lethal injection attempts failed, and the prisoners survived to be witnesses and report on their own torture. Gov. Kay Ivey issued a pause on lethal injections in order for the Department of Corrections to review what went wrong. We’re unlikely to see the end of lethal injections as a result. Instead, watch for “new and improved” lethal injections that eliminate the arms as a location for the IV—it will be the neck or genital region only, from now on. These changes will require further involvement of doctors, and they may spare prisoners—and the public—from bearing witness to a particular twist. But they will not make lethal injection inherently less cruel. “Improved” lethal injection will not be humane, or acceptable.

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No method of execution in the United States has ever been set aside as unlawful because of a constitutional violation. Instead, an ever-evolving public distaste for certain execution methods is what leads to technique turnover. In Discipline and Punish: The Birth of the Prison, French philosopher Michel Foucault contrasts the public execution by dismemberment of Robert-François Damiens, convicted of attempted regicide, with the rise of the modern penal system. In the modern prison, the point is to control the moment-to-moment lives of the prisoners with excruciating granularity. Foucault claims that the move away from public dismemberment was not evidence of a maturing attitude toward punishment. Instead, the spectacle of punishment was simply replaced by the tactical use of power and control through regulatory force.

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One might wonder why Alabama continues to tinker with lethal injection when it could just use another method. Execution by firing squad merely requires the ability to shoot a gun—a skill broadly represented in modern America—and gas execution just needs someone to open a pressure release valve. The fact that they are simple makes the cruelty evident. Lethal injection involves individuals with health care training, giving it a sheen of modernity, technological advancement, even sophistication. In 2019, the Alabama Department of Corrections released the sequence it follows for executions, including lethal injections, on the orders of a federal judge. In this document, tactical power and control are made glaringly evident. The protocol includes instructions like “details of the scheduled execution will be discussed to bring everyone up to date,” as though killing a human is like doing any other routine procedure.

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One might imagine bioethical principles of medical practice would guard against the use of medical knowledge for malevolence—how could a doctor participate in an act designed to harm? But the profession of medicine sits comfortably adjacent to power. Medical practice is hierarchical and is itself concerned with power and authority. Senior physicians are at the apex of health care and have profound power over subordinate physicians and over many others within the health care entity. For some, the power dynamic can be intoxicating to the self and toxic to others. Physicians are, in some respects, natural torturers. They are taught what is painful and to refine their empathy as a method to understand the pain of others. Unchecked, empathy can be weaponized, because when one understands pain, one knows how to inflict it on others. While many physicians, including some professional medical societies, object to participation in execution, other physicians willingly and enthusiastically participate.

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When Alabama struggled to establish an IV in prisoner Joe Nathan James in July, it appears to have resorted to a procedure known as a cutdown to locate the vein. I know this because I arranged and participated in a second autopsy of James and saw firsthand the telltale signs of the cutdown. In a document dated Nov. 8, 2022, from the Alabama Department of Forensic Sciences, the state autopsy performed on Joe Nathan James on July 29 described unexplained “evidence of injury” in the left arm that matched my own observation. In a cutdown, the skin is opened with a surgical blade to visualize a vein not otherwise identifiable. Such an act is not in the skill set of an average person and is likely beyond the capabilities of a nurse or an EMT—it requires the skill of a doctor. Cutdowns are rarely used now in a medical setting, as ultrasound—the use of sound waves transmitted through the skin and reflected—has replaced this procedure. A cutdown is within the skill set of an older and experienced doctor.

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The Alabama execution protocol allows for the use of a so-called “central line” when the execution team is unable to place an intravenous line in an arm or leg. How many times that team might try for the arm or leg before switching to a central line is unspecified. Recent lethal injection executions in Arizona and Texas both used central lines. Alabama has given itself permission to use a central line as well. A central line is when a catheter is placed in a vein located in the neck, chest, or groin. In this procedure, the needed vein can’t be seen or felt. The vein runs very close to an adjacent artery, and unlike the vein, the artery is a structure under considerable pressure. If the artery is accidentally penetrated by the needle, the pressure is enough to dramatically squirt blood under significant force. To locate this vein, one must be well versed in regional anatomy, including the possibility of anatomical variation. One must know lung anatomy so the needle does not puncture and accidentally collapse the lung. Such a complication is life-threatening. One must know the anatomy of the lower abdomen to avoid puncturing the bowels. As Alabama and other states include a central line as an option in lethal injection, the state is in essence demanding the presence of a doctor.

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It is in the interest of the state of Alabama to have no more executions as a spectacle of incompetence. Alabama will no longer risk failure. Instead of the setting aside of lethal injection, anticipate an escalation of the skills of the involved personnel and the quick use of a central line. Doctor-placed central lines for the purposes of lethal injection torture the mind as well as the body. The doctor is transformed from healer to executioner. It is the ultimate betrayal of trust. The profession of medicine could more unanimously object and this would come to a halt, but this has not been the case. State medical licensing boards, professional medical societies, and hospital credentialing bodies need to act with conviction, punishing doctors who help states execute. Otherwise, doctors will participate, as they always have. The current moratorium on executions in Alabama is not cause for celebration. Alabama is not standing down—it is reloading.

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