Who—and how—to kill are focus of US death penalty cases

Who—and how—to kill are focus of US death penalty cases

Questions about prisoners' mental competence and use of pancuronium bromide ignite recent controversy

Two recent US court cases are renewing the debate on who may be executed for crimes, and how executions are done in the 38 states that have the death penalty. In one instance, the Supreme Court declined to hear the case of a man whom officials want to treat with anti-psychotics so that he can be declared competent to be executed. The other case is that of a man sentenced to death in Tennessee who is challenging that state's use of pancuronium bromide, a non-depolarising muscle relaxant, in executions.

The Supreme Court case was brought by Charles Singleton, who stabbed a grocer to death during a robbery in Arkansas in 1979 and has been on death row since later that year. An appeals court ruled in February that Singleton could be medicated, which in general is his preference, and that his understanding of his impending execution was a side-effect. By declining on Oct 6 to hear the case, the Supreme Court upheld that decision and set the stage for Singleton's execution.

Michael Grodin, director of the medical ethics programme at Boston University School of Public Health, said he found the decision “very disturbing and problematic”. “Physicians should be in the business of caring for patients, not in the business of law enforcement”, Grodin said. “I think the real problem is that physicians shouldn't be involved in cases where there's going to be a death penalty involved unless that's taken off the table.”

The Supreme Court has previously ruled that the US Constitution's eighth amendment, forbidding “cruel and unusual punishment”, prohibits execution of those who could not understand that they were being executed. Many codes of ethics forbid doctors to medicate patients simply to make them understand they are being executed, although some doctors have said they would participate in capital punishment, disallowed by the American Medical Association (Ann Intern Med 2001; 135: 884-88). Other health-care providers might be asked to administer such drugs. But the American Nurses Association is “strongly opposed to nurse participation in capital punishment”, and a spokesperson for the US National Association of Emergency Medical Technicians said such involvement would be contrary to its oath and code of ethics.

Another case, that of Abu-Ali Abdur'Rahman, a Tennessee man who was found guilty of a 1986 murder, has put the spotlight on pancuronium bromide, the second of three chemicals used in lethal injection in Tennessee and about 30 other states. Sodium pentothal is typically used first to anaesthetise the prisoner, followed by pancuronium bromide, then by a lethal dose of potassium chloride. Abdur'Rahman's lawyers argued that if the sodium pentothal is ineffective, the prisoner would be paralysed by the pancuronium bromide and experience suffocation and a painful death by potassium chloride while awake but unable to express himself.

A Tennessee court agreed, but ruled that the method did not violate the Constitution's eighth amendment because the dose of sodium pentothal used in that state would be fatal. Tennessee had, however, banned pancuronium bromide's use to euthanise animals. “People have always thought that lethal injection was a painless way to die”, said Deborah Denno (Fordham University School of Law, New York), who has written extensively on methods of execution in the USA. Justice Antonin Scalia, a conservative member of the Supreme Court, wrote in a 1994 decision about a case involving the rape and murder of an 11-year-old girl, “How enviable a quiet death by lethal injection compared to that!”

But death penalty opponents say that the three-chemical method leads to frequent botched executions because untrained or poorly trained prison workers are often unable to find vessels suitable for venipuncture or simply don't understand how the drugs work.

The British Royal Commission on Capital Punishment in 1953 questioned the use of lethal injection for those reasons, 12 years before the UK abandoned executions. How pancuronium bromide became so widely used is somewhat of a mystery, although it likely dates back to Oklahoma's introduction of the chemical into its protocol in 1977 following advice from Stanley Deutsch, then a professor of anaesthesiology at the state's medical school. The method was then replicated in other states, and lethal injection is how most death-row inmates are executed.

The Lancet, Volume 362, Number 9392, 18 October 2003

http://www.thelancet.com/journals/lancet/article/PIIS014067360314617X/fulltext