There But For The Grace of God Go I: Botched and "Successful" Executions (State Ordered Homicide)

This blog is called status iatrogenicus because it highlights physician folly, and in the wake of the botched execution of Christa Pike, it is imperative that I highlight the great harm that a physician named Joel Zivot is causing condemned men, however good his intentions may be. 

A frequent commentator in the New York Times about lethal injection, he authored his own piece in today's paper. In it, he admits something I find arrantly horrifying, teetering between abject stupidity and raw evil:

I was a medical expert in three separate execution cases in Tennessee over the past 10 years. In each instance, the prisoner elected to die by the electric chair instead of by lethal injection.

Jesus fucking Christ! If you don't understand my stupefaction and exasperation, read this afticle of an eyewitness account of what the author said should be the last execution by electric chair in Tennessee. I have nightmares of this macbre scene, years after reading about Holton there and in the NYT. Or, refer to Gawande's piece in the NEJM a generation ago. Or, read Sarat's book "When The State Kills" and gaze at the photos of Davis if you have the stomach for it.

I start from the position of asking what method I would choose if the state were to kill me. Lethal injection, hands down, through a central catheter (venous or arterial), or a peripheral IV if they must. Next I would choose nitrogen gas hypoxia, and the reasons for that I will not elaborate here as it will take me too far afield. The electric chair I would avoid at all costs, in part because of the sheer terror it strikes in the heart of any reasonable man who ponders the prospect. Indeed "the chair" has been used as an instrument of terror. That article quotes Florida Attorney General Bob Butterworth after Pedro Medina caught on fire in the chair (that case or the earlier Jose Tafero was probably the "inspiration" behind the movie The Green Mile):

''People who wish to commit murder, they better not do it in the state of Florida because we may have a problem with our electric chair."

I do not wish to engage here in disputation about what some consider the immorality of capital punishment. For now, I wish just to discuss the practical reality that it is legal in the USA, and states are going to carry it out one way or another. Despite every NYT article discussing it mentioning that support for the death penalty has been in (slow) decline for decades, the majroity of Americans still support it. Nonetheless, the "abolitionists" as I shall call them search for every angle to attack not only the institution, but the methods. And sadly I must report that every time the SCOTUS has explored whether the electric chair violates the 8th amendment, going back over 100 years, they have held that the chair is not cruel and unusual! But lethal injection, now the most common method, has been the subject of many SCOTUS cases because of problems with IV access and the burning that potassium can cause in a peripheral IV. Abolitionists have also made it harder for states to secure the drugs needed to carry out death sentences by lethal injection. First sodium thiopental, now pentobarbital and indeed all execution drugs. So we have cases like Clayton Lockett in Oklahoma, where a misguided and ill-fated attempt to kill him with midazolam led to the expected result: prolonged death from hypoxia and hypoventilation.

Undeterred, the abolitionists keep trying to make it harder for the states to kill effectively, some may say humanely. In the process, the forseeable but unwanted side effect is that hamstrung wardens, whose solemn duty it is to carry out the sentences, must resort to less and less effective drugs, and skip potassium chloride altogether because of the exaggerated claim that the burning sensation is tantamount to torture. No, the electric chair is torture; read the protocols, the cycles, the amps, the voltage, the duration. All starting from a point of complete consciousness. 

In essence, the abolitionists are using individual condemned men (and occasionally women) as pawns in their grand abolition scheme. Collateral damage. They are convincing condemned inmates that a struggle to get an IV or some burning - things experienced daily by countless hospitalized patients - are worse than riding the lightning of 2500 volts in multiple cycles. 

But what got my goat today is Zivot again quoting his autopsy reviews (he must be proud of this review) citing heavy lungs and pulmonary edema in patients who died of lethal injection, surmising that:

"prisoners could have felt as if they were drowning, even if some looked peaceful as they were dying."

I've got some news, my friends: if you look peaceful while you're drowning, it's because you're unconscious and unable to experience any sensation from your lungs filling with fluid as you're dying of shock and heart failure. We know this from accidental overdoses of opioids and other drugs in patients treated in the ICU: the patients who recover from their overdose and lung injury never never never, hardly ever awaken and describe the agony of unconscious drowning. 

But here's the crux: what do you think the lungs of a person executed in the electric chair look like on autopsy? You guessed it; heavy, hemorrhaged, and full of pulmonary edema. On Dr. Zivot's counsel and by his own admission three condemned men in Tennessee are going to suffer pulmonary edema from electrocution to avoid pulmonary edema caused by pentobarbital, which, for it to cause pulmonary edema, will render you comatose by shutting down the brain and precipitating cardiogenic and vasodilatory shock. Will the inmates be rendered instantly unconscious by the first jolt of electricity? I don't know, but they do have respiratory efforts between cycles and sometimes after all cycles are completed, requiring additional cycles. Ethel Rosenberg was one of many such people.

I cannot know Dr. Zivot's motives. I have to think and hope that he's well-meaning. But his counsel leading men to choose the chair over the needle is unconscionable to me. I'm reminded of Hanlon's razor:

"Never attribute to malice that which can be explained by stupidity."

No matter what your position on capital punishment, you can ask yourself a simple question: if it were I who was condemned to death, what method would I choose? The answer is self-evident. Abolitionalists can pursue their agenda, but they should be cognizant and wary of unintended but forseeable harms to the condemned as they chip away at the most "humane" method - the only one that begins the causal sequence to death with unconsciousness. The entire sequence not only begins with, but depends upon unconsciousness; that's the mechanism, shutting down the brain and the autonomic nervous system.

Motivated reasoning is dangerous. But here, as is often the case, the danger is amplified by the reckless abandon of the non-combatant. Dr. Zivot, what method would you choose for yourself?