Editing Lethal injection (section)

===Opposition===
Opponents of lethal injection have voiced concerns that abuse, misuse and even criminal conduct is possible when there is not a proper chain of command and authority for the acquisition of death-inducing drugs.

====Awareness====
Opponents of lethal injection believe that it is not painless as practiced in the United States. They argue that thiopental is an ultrashort-acting barbiturate that may wear off ([[anesthesia awareness]]) and lead to consciousness and an uncomfortable death wherein the inmates are unable to express discomfort because they have been paralyzed by the paralytic agent.<ref name=horizon>{{cite web |url=http://www.bbc.co.uk/sn/tvradio/programmes/horizon/broadband/tx/executions/ |title=How to Kill a Human Being |series=Horizon |publisher=BBC |date=January 2008 |url-status=live |archive-url=https://web.archive.org/web/20090219193825/http://www.bbc.co.uk/sn/tvradio/programmes/horizon/broadband/tx/executions/ |archive-date=February 19, 2009 |df=mdy-all }}</ref>

Opponents point to sodium thiopental's typical use as an induction agent and not in the maintenance phase of surgery because of its short-acting nature. Following the administration of thiopental, pancuronium bromide, a paralytic agent, is given. Opponents argue that pancuronium bromide not only dilutes the thiopental, but, as it paralyzes the inmate, also prevents the inmate from expressing pain. Additional concerns have been raised over whether inmates are administered an appropriate amount of thiopental owing to the rapid redistribution of the drug out of the brain to other parts of the body.<ref name = horizon/>

Additionally, opponents argue that the method of administration is also flawed. They contend that because the personnel administering the lethal injection lack expertise in anesthesia, the risk of failure to induce unconsciousness is greatly increased. In reference to this issue, [[Jay Chapman (physician)|Jay Chapman]], the creator of the American method, said, "It never occurred to me when we set this up that we'd have complete idiots administering the drugs".<ref name=":5">{{cite news |last=Weil |first=Elizabeth |url=https://www.nytimes.com/2007/02/11/magazine/11injection.t.html |title=The Needle and the Damage Done |date=February 11, 2007 |newspaper=The New York Times |url-status=live |archive-url=https://web.archive.org/web/20170203051825/http://www.nytimes.com/2007/02/11/magazine/11injection.t.html |archive-date=February 3, 2017 |df=mdy-all }}</ref> Opponents also argue that the dose of sodium thiopental must be set for each individual patient, and not restricted to a fixed protocol. Finally, they contend that remote administration may result in an increased risk that insufficient amounts of the lethal-injection drugs enter the inmate's bloodstream.<ref name = horizon/>

In summary, opponents argue that the effect of dilution or of improper administration of thiopental is that the inmate dies an agonizing death through [[suffocation]] due to the paralytic effects of pancuronium bromide and the intense burning sensation caused by potassium chloride.<ref name = horizon/>

Opponents of lethal injection, as practiced, argue that the procedure is designed to create the appearance of serenity and a painless death, rather than actually providing it. Specifically, opponents object to the use of pancuronium bromide, arguing that it serves no useful purpose in lethal injection since the inmate is physically restrained. Therefore, the default function of pancuronium bromide would be to suppress the autonomic nervous system, specifically to stop breathing.<ref name = horizon/>

====Research====
In 2005, [[University of Miami]] researchers, in cooperation with the attorney representing death-row inmates from [[List of death row inmates in the United States#Virginia|Virginia]], published a research letter in the medical journal ''[[The Lancet]]''. The article presented protocol information from Texas, Virginia, and North and South Carolina which showed that executioners had no anesthesia training, drugs were administered remotely with no monitoring for anesthesia, data were not recorded, and no peer review was done. Their analysis of toxicology reports from Arizona, Georgia, North and South Carolina showed that ''post mortem'' concentrations of thiopental in the blood were lower than that required for surgery in 43 of 49 executed inmates (88%), and that  21 (43%) inmates had concentrations consistent with awareness.<ref>{{cite journal |title=Inadequate anaesthesia in lethal injection for execution |first1=Leonidas G |last1=Koniaris |first2=Teresa A |last2=Zimmers |first3=David A |last3=Lubarsky |first4=Jonathan P |last4=Sheldon |journal=Lancet |date=April 16, 2005 |volume=365 |issue=9468 |pages=1412–1414 |url=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)66377-5/abstract |doi=10.1016/S0140-6736(05)66377-5 |pmid=15836890 |s2cid=31192408 |url-status=dead |archive-url=https://web.archive.org/web/20130729013249/http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2805%2966377-5/abstract |archive-date=July 29, 2013 |df=mdy-all |access-date=November 29, 2012 |url-access=subscription }}</ref><ref>{{cite journal |title=Inadequate anaesthesia in lethal injection for execution |first1=Leonidas G |last1=Koniaris |first2=Teresa A |last2=Zimmers |first3=David A |last3=Lubarsky |first4=Jonathan P |last4=Sheldon |journal=Lancet |date=April 16, 2005 |volume=365 |issue=9468 |pages=1412–14 |url=http://www.atypicaljoe.com/archives/LancetInadAnesth.pdf |archive-url=https://web.archive.org/web/20061030122123/http://www.atypicaljoe.com/archives/LancetInadAnesth.pdf |archive-date=October 30, 2006 |doi=10.1016/S0140-6736(05)66377-5 |pmid=15836890|url-status=usurped |s2cid=31192408 }}</ref> This led the authors to conclude that a substantial probability existed that some of the inmates were aware and suffered extreme pain and distress during execution. The authors attributed the risk of consciousness among inmates to the lack of training and monitoring in the process, but carefully made no recommendations on how to alter the protocol or how to improve the process. Indeed, the authors conclude, "because participation of doctors in protocol design or execution is ethically prohibited, adequate anesthesia cannot be certain. Therefore, to prevent unnecessary cruelty and suffering, cessation and public review of lethal injections is warranted".

Paid expert consultants on both sides of the lethal-injection debate have found opportunity to criticize the 2005 ''Lancet'' article. Subsequent to the initial publication in the ''Lancet'', three letters to the editor and a response from the authors extended the analysis. The issue of contention is whether thiopental, like many lipid-soluble drugs, may be redistributed from blood into tissues after death, effectively lowering thiopental concentrations over time, or whether thiopental may distribute from tissues into the blood, effectively increasing ''post mortem'' blood concentrations over time. Given the near absence of scientific, peer-reviewed data on the topic of thiopental ''post mortem'' [[pharmacokinetics]], the controversy continues in the lethal-injection community and, in consequence, many legal challenges to lethal injection have not used the ''Lancet'' article.

In 2007, the same group that authored the ''Lancet'' study extended its study of the lethal-injection process through a critical examination of the pharmacology of the barbiturate thiopental. This study – published in the online journal ''PLOS Medicine''<ref>{{cite journal |title=Lethal Injection for Execution: Chemical Asphyxiation? |doi=10.1371/journal.pmed.0040156 |pmid=17455994 |pmc=1876417 |volume=4 |issue=4 |journal=PLOS Medicine |page=e156 |df=mdy-all |year = 2007|last1 = Zimmers|first1 = Teresa A.|last2=Sheldon |first2=Jonathan |last3=Lubarsky |first3=David A. |last4=López-Muñoz |first4=Francisco |last5=Waterman |first5=Linda |last6=Weisman |first6=Richard |last7=Koniaris |first7=Leonidas G. |doi-access=free }}</ref> – confirmed and extended the conclusions made in the original article and goes further to disprove the assertion that the lethal-injection process is painless.

To date, these two studies by the University of Miami team serve as the only critical peer-reviewed examination of the pharmacology of the lethal-injection process.

====Cruel and unusual====
On occasion, difficulties inserting the intravenous needles have also occurred, with personnel sometimes taking over half an hour to find a suitable vein.<ref name="uk"/> Typically, the difficulty is found in convicts with diabetes or a history of intravenous drug use.<ref name=":2" /> Opponents argue that excessive time taken to insert intravenous lines is tantamount to cruel and unusual punishment. In addition, opponents point to instances where the intravenous line has failed, or when adverse reactions to drugs or unnecessary delays have happened during the process of execution.

On December 13, 2006, [[Angel Nieves Diaz]] was not executed successfully in Florida using a standard lethal-injection dose. Diaz was 55 years old and had been sentenced to death for murder. Diaz did not succumb to the lethal dose even after 35 minutes, necessitating a second dose of drugs to complete the execution. At first, a prison spokesman denied Diaz had suffered pain and claimed the second dose was needed because Diaz had some sort of liver disease.<ref>{{cite news |url=http://www.upi.com/Top_News/2006/12/14/Florida-lethal-injection-takes-34-minutes/UPI-59261166098582/ |title=Florida lethal injection takes 34 minutes |date=December 14, 2006 |location=Starke, Florida |publisher=UPI – United Press International |url-status=live |archive-url=https://web.archive.org/web/20140423172911/http://www.upi.com/Top_News/2006/12/14/Florida-lethal-injection-takes-34-minutes/UPI-59261166098582/ |archive-date=April 23, 2014 |df=mdy-all }}</ref> After performing an autopsy, the medical examiner, Dr. William Hamilton, stated that Diaz's liver appeared normal, but that the needle had pierced through Diaz's vein into his flesh. The deadly chemicals had subsequently been injected into soft tissue rather than into the vein.<ref>{{citation |url=http://www.deathpenaltyinfo.org/some-examples-post-furman-botched-executions |title=Examples of Post-Furman Botched Executions |first=Michael L. |last=Radelet |publisher=University of Colorado |date=October 1, 2010 |url-status=live |archive-url=https://web.archive.org/web/20090224024237/http://deathpenaltyinfo.org/some-examples-post-furman-botched-executions |archive-date=February 24, 2009 |df=mdy-all }}</ref> Two days after the execution, then-Governor [[Jeb Bush]] suspended all executions in the state and appointed a commission "to consider the humanity and constitutionality of lethal injections."<ref>{{cite news |url=https://select.nytimes.com/gst/abstract.html?res=F50D13F939550C758DDDAB0994DE404482&n=Top%2fReference%2fTimes%20Topics%2fSubjects%2fC%2fCapital%20Punishment |title=After Problem Execution, Governor Bush Suspends the Death Penalty in Florida |newspaper=[[The New York Times]] |date=December 16, 2006 |first1=Adam |last1=Liptak |first2=Terry |last2=Aguayo |url-status=live |archive-url=https://web.archive.org/web/20140423171723/http://select.nytimes.com/gst/abstract.html?res=F50D13F939550C758DDDAB0994DE404482&n=Top%2fReference%2fTimes%20Topics%2fSubjects%2fC%2fCapital%20Punishment |archive-date=April 23, 2014 |df=mdy-all }}</ref> The ban was lifted by Governor [[Charlie Crist]] when he signed the death warrant for [[Mark Dean Schwab]] on July 18, 2007.<ref>{{cite journal |url=http://jurist.law.pitt.edu/paperchase/2007/07/florida-governor-lifts-temporary-ban-on.php |title=Florida governor lifts temporary ban on executions |date=July 18, 2007 |first=Caitlin |last=Price |journal=JURIST |archive-url=https://web.archive.org/web/20110629100020/http://jurist.law.pitt.edu/paperchase/2007/07/florida-governor-lifts-temporary-ban-on.php |archive-date=June 29, 2011}}</ref> On November 1, 2007, the [[Florida Supreme Court]] unanimously upheld the state's lethal-injection procedures.<ref>{{cite journal |url=http://jurist.law.pitt.edu/paperchase/2007/11/florida-supreme-court-upholds-state.php |title=Florida Supreme Court upholds state lethal injection procedure |date=November 1, 2007 |first=Benjamin |last=Klein |journal=JURIST |archive-url=https://web.archive.org/web/20110629100025/http://jurist.law.pitt.edu/paperchase/2007/11/florida-supreme-court-upholds-state.php |archive-date=June 29, 2011}}</ref>

A study published in 2007 in ''[[PLOS Medicine]]'' suggested that "the conventional view of lethal injection leading to an invariably peaceful and painless death is questionable".<ref>{{cite journal|title=Lethal Injection for Execution: Chemical Asphyxiation?|date=April 2007|journal=[[PLOS Medicine]]|page=e156|doi=10.1371/journal.pmed.0040156|pmid=17455994|pmc=1876417|volume=4|issue=4|df=mdy-all|last1=Zimmers|first1=Teresa A.|last2=Sheldon|first2=Jonathan|last3=Lubarsky|first3=David A.|last4=López-Muñoz|first4=Francisco|last5=Waterman|first5=Linda|last6=Weisman|first6=Richard|last7=Koniaris|first7=Leonidas G. |doi-access=free }}</ref>

The execution of [[Romell Broom]] was abandoned in Ohio on September 15, 2009, after prison officials failed to find a vein after two hours of trying on his arms, legs, hands, and ankle. This stirred up more intense debate in the United States about lethal injection.<ref>{{cite news |first=Peter |last=Slevin |title=Execution Methods Examined |date=October 12, 2009 |newspaper=The Washington Post |url=https://www.washingtonpost.com/wp-dyn/content/article/2009/10/11/AR2009101100502.html?hpid=moreheadlines |access-date=May 2, 2010 |url-status=live |archive-url=https://web.archive.org/web/20110628202812/http://www.washingtonpost.com/wp-dyn/content/article/2009/10/11/AR2009101100502.html?hpid=moreheadlines |archive-date=June 28, 2011 |df=mdy-all }}</ref> Broom's execution was later rescheduled for March 2022, but he died in 2020 before the sentence could be carried out.

[[Execution of Dennis McGuire|Dennis McGuire]] was executed in [[Lucasville, Ohio]], on January 17, 2014. According to reporters, McGuire's execution took more than 20 minutes, and he was gasping for air for 10–13 minutes after the drugs had been administered. It was the first use of a new drug combination which was introduced in Ohio after the European Union banned sodium thiopental exports.<ref>{{cite news |publisher=CNN |url=https://edition.cnn.com/2014/01/16/justice/ohio-dennis-mcguire-execution/ |title=New drug combo used in Ohio execution |access-date=January 19, 2014 |url-status=live |archive-url=https://web.archive.org/web/20140119073837/http://edition.cnn.com/2014/01/16/justice/ohio-dennis-mcguire-execution |archive-date=January 19, 2014 |df=mdy-all }}</ref> This reignited criticism of the conventional three-drug method.<ref>{{cite news|url=http://www.ctpost.com/news/crime/article/Unclear-future-for-executions-after-Ohio-s-longest-5154773.php |title=Unclear future for executions after Ohio's longest |publisher=ctpost.com |date=January 18, 2014 |access-date=January 19, 2014 |url-status=dead |archive-url=https://web.archive.org/web/20140201225849/http://www.ctpost.com/news/crime/article/Unclear-future-for-executions-after-Ohio-s-longest-5154773.php |archive-date=February 1, 2014 }}</ref>

[[Execution of Clayton Lockett|Clayton Lockett]] died of a heart attack during a failed execution attempt on April 29, 2014, at [[Oklahoma State Penitentiary]] in [[McAlester, Oklahoma]]. Lockett was administered an untested mixture of drugs that had not previously been used for executions in the U.S. He survived for 43 minutes before being pronounced dead. Lockett convulsed and spoke during the process and attempted to rise from the execution table 14 minutes into the procedure, despite having been declared unconscious.<ref>{{cite news |url=https://www.theguardian.com/world/2014/apr/30/oklahoma-execution-botched-clayton-lockett |title=Oklahoma execution: Clayton Lockett writhes on gurney in botched procedure |work=The Guardian |first=Katie |last=Fretland |date=April 30, 2014 |url-status=live |archive-url=https://archive.today/20140430044116/http://www.theguardian.com/world/2014/apr/30/oklahoma-execution-botched-clayton-lockett |archive-date=April 30, 2014 |df=mdy-all }}</ref>

Lethal injection, by design, is outwardly ambiguous with respect to what can be seen by witnesses. The 8th amendment of the US constitution proscribes cruel punishment but only the punished can accurately gauge the experience of cruelty. In state-sanctioned executions, the inmate is unable to be a witness to their own execution, so it is up to the assembled witnesses to have the final say. Eyewitnesses to execution report very different observations, and these differences range from an opinion that the execution was painless to comments that the execution was highly problematic.<ref>{{cite web|url=https://apnews.com/article/executioners-sanitized-accounts-of-death-25d133f59039150c2e308ba1a2a5caef|title = Executioners sanitized accounts of deaths in federal cases|website = [[Associated Press]]|date = April 20, 2021}}</ref> Post mortem examinations of inmates executed by lethal injection have revealed a common finding of heavily congested lungs consistent with pulmonary edema.<ref>{{cite web|url=https://medlineplus.gov/ency/article/000140.htm|title = Pulmonary edema: MedlinePlus Medical Encyclopedia}}</ref><ref>{{Cite news|url=https://www.npr.org/2020/09/21/793177589/gasping-for-air-autopsies-reveal-troubling-effects-of-lethal-injection|title=Gasping for Air: Autopsies Reveal Troubling Effects of Lethal Injection|newspaper=NPR.org}}</ref> The occurrence of pulmonary edema found at autopsy raises the question about the actual cruelty of lethal injection. If pulmonary edema occurs as a consequence of lethal injection, the experience of death may be more akin to drowning than simply the painless death described by lethal injection proponents. Pulmonary edema can only occur if the inmate has heart function and cannot occur after death.

====European Union export ban====
Due to its use for executions in the US, the UK introduced a ban on the export of sodium thiopental in December 2010,<ref>{{cite news |url=https://www.bbc.com/news/uk-12263460 |title=Drug sold in UK to be used for execution in Georgia |work=BBC News |date=January 14, 2011 |url-status=live |archive-url=https://web.archive.org/web/20160922154903/http://www.bbc.com/news/uk-12263460 |archive-date=September 22, 2016 |df=mdy-all }}</ref> after it was established that no European supplies to the US were being used for any other purpose.<ref>{{cite news |url=https://www.bbc.com/news/uk-11865881 |title=US lethal injection drug faces UK export restrictions |work=BBC News |first=Dominic |last=Casciani |date=November 29, 2010 |url-status=live |archive-url=https://web.archive.org/web/20160922154849/http://www.bbc.com/news/uk-11865881 |archive-date=September 22, 2016 |df=mdy-all }}</ref> The restrictions were based on "the European Union Torture Regulation (including licensing of drugs used in execution by lethal injection)".<ref>{{cite web |url=https://www.gov.uk/guidance/controls-on-torture-goods |title=Controls on torture goods |publisher=Government of the United Kingdom |date=January 15, 2014 |url-status=live |archive-url=https://web.archive.org/web/20160309021241/https://www.gov.uk/guidance/controls-on-torture-goods |archive-date=March 9, 2016 |df=mdy-all }}</ref> From December 21, 2011, the European Union extended trade restrictions to prevent the export of certain medicinal products for capital punishment, stating, "The Union disapproves of capital punishment in all circumstances and works towards its universal abolition".<ref>{{cite journal |url=http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:338:0031:0034:EN:PDF |title=Commission Implementing Regulation (EU) No 1352/2011 of 20 December 2011 |journal=Official Journal of the European Union |issue=338 |pages=31–34 |date=December 21, 2011}}</ref>