Lethal injection is the practice of injecting one or more drugs into a person (typically a barbiturate, paralytic, and potassium solution) for the express purpose of causing immediate death. The main application for this procedure is capital punishment, but the term may also be applied in a broader sense to include euthanasia and suicide. The drugs cause the person to become unconscious, stops their breathing, and causes a heart arrhythmia, in that order.

First developed in the United States, it is now also a legal method of execution in China, Thailand, Guatemala, Taiwan, the Maldives, and Vietnam, though Guatemala has not conducted an execution since 2000 and the Maldives has never carried out an execution since its independence. Although Taiwan permits lethal injection as an execution method, no executions have been carried out in this manner, probably due to drug shortages. Lethal injection was also used in the Philippines until the country re-abolished the death penalty in 2006.

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History

Lethal injection gained popularity in the late 20th century as a form of execution intended to supplant other methods, notably electrocution, gas inhalation, hanging and firing squad, that were considered to be less humane. It is now the most common form of execution in the United States.

Lethal injection was first proposed on January 17, 1888, by Julius Mount Bleyer, a New York doctor who praised it as being cheaper than hanging. Bleyer's idea was never used, due to a series of botched executions and the eventual rise of public disapproval in electrocutions. Nazi Germany developed the Action T4 euthanasia program as one of its methods of disposing of Lebensunwertes Leben ("life unworthy of life"). The British Royal Commission on Capital Punishment (1949–53) also considered lethal injection, but eventually ruled it out after pressure from the British Medical Association (BMA).

On May 11, 1977, Oklahoma's state medical examiner Jay Chapman proposed a new, less painful method of execution, known as Chapman's protocol: "An intravenous saline drip shall be started in the prisoner's arm, into which shall be introduced a lethal injection consisting of an ultrashort-acting barbiturate in combination with a chemical paralytic." After the procedure was approved by anesthesiologist Stanley Deutsch, formerly Head of the Department of Anaesthesiology of the Oklahoma University Medical School, the Reverend Bill Wiseman introduced the method into the Oklahoma legislature, where it passed and was quickly adopted (Title 22, Section 1014(A)). Since then, until 2004, 37 of the 38 states using capital punishment introduced lethal injection statutes. On August 29, 1977, Texas adopted the new method of execution, switching to lethal injection from electrocution. On December 7, 1982, Texas became the first state to use lethal injection to carry out capital punishment, for the execution of Charles Brooks, Jr.

The People's Republic of China began using this method in 1997, Guatemala in 1996, the Philippines in 1999, Thailand in 2003, and Taiwan in 2005. Vietnam first used this method in 2013. The Philippines abolished the death penalty in 2006, with their last execution being in 2000. Guatemalan law still allows for the death penalty and lethal injection is the sole method allowed, but no penalties have been carried out since 2000 when the country experienced a botched, televised execution.

The export of drugs to be used for lethal injection was banned by the European Union (EU) in 2011, together with other items under the EU Torture Regulation. Since then, pentobarbital followed thiopental in the European Union's ban.

By early 2014, a number of botched executions involving lethal injection, and a rising shortage of suitable drugs, had some U.S. states reconsidering lethal injection as a form of execution. Tennessee, which had previously offered inmates a choice between lethal injection and the electric chair, passed a law in May 2014 which gave the state the option to use the electric chair if lethal injection drugs are either unavailable or made unconstitutional. At the same time, Wyoming and Utah were considering the use of execution by firing squad in addition to other existing execution methods.

In 2016, Pfizer joined over 20 American and European pharmaceutical manufacturers that had previously blocked the sale of their drugs for use in lethal injections, effectively closing the open market for FDA-approved manufacturers for any potential lethal execution drug. In the execution of Carey Dean Moore on August 14, 2018, the State of Nebraska used a novel drug cocktail comprising diazepam, fentanyl, cisatracurium, and potassium chloride, over the strong objections of the German pharmaceutical company Fresenius Kabi.

Procedure

The condemned person is strapped onto a gurney; two intravenous cannulas ("IVs") are inserted, one in each arm. Only one is necessary to carry out the execution; the other is reserved as a backup in the event the primary line fails. A line leading from the IV line in an adjacent room is attached to the prisoner's IV and secured so that the line does not snap during the injections.

The arm of the condemned person is swabbed with alcohol before the cannula is inserted. The needles and equipment used are sterilized. Questions have been raised about why these precautions against infection are performed despite the purpose of the injection being death. The several explanations include: cannulae are sterilized and have their quality heavily controlled during manufacture, so using sterile ones is a routine medical procedure. Secondly, the prisoner could receive a stay of execution after the cannulae have been inserted, as happened in the case of James Autry in October 1983 (he was eventually executed on March 14, 1984). Third, use of unsterilized equipment would be a hazard to the prison personnel in case of an accidental needle stick.

Following connection of the lines, saline drips are started in both arms. This, too, is standard medical procedure: it must be ascertained that the IV lines are not blocked, ensuring the chemicals have not precipitated in the IV lines and blocked the needle, preventing the drugs from reaching the subject. A heart monitor is attached to the inmate.

In most states, the intravenous injection is a series of drugs given in a set sequence, designed to first induce unconsciousness followed by death through paralysis of respiratory muscles and/or by cardiac arrest through depolarization of cardiac muscle cells. The execution of the condemned in most states involves three separate injections (in sequential order):

1. Sodium thiopental or pentobarbital: ultrashort-action barbiturate, an anesthetic agent used at a high dose that renders the person unconscious in less than 30 seconds. Depression of respiratory activity is one of the characteristic actions of this drug. Consequently, the lethal-injection doses, as described in the Sodium Thiopental section below, will—even in the absence of the following two drugs—cause death due to lack of breathing, as happens with overdoses of opioids.
2. Pancuronium bromide: nondepolarizing muscle relaxant, which causes complete, fast, and sustained paralysis of the skeletal striated muscles, including the diaphragm and the rest of the respiratory muscles; this would eventually cause death by asphyxiation.
3. Potassium chloride: a potassium salt, which increases the blood and cardiac concentration of potassium to stop the heart via an abnormal heartbeat and thus cause death by cardiac arrest.

The drugs are not mixed externally because that can cause them to precipitate. Also, a sequential injection is key to achieve the desired effects in the appropriate order: administration of the pentobarbital essentially renders the person unconscious; the infusion of the pancuronium bromide induces complete paralysis, including that of the lungs and diaphragm rendering the person unable to breathe. If the person being executed were not already completely unconscious, the injection of a highly concentrated solution of potassium chloride could cause severe pain at the site of the IV line, as well as along the punctured vein, but it interrupts the electrical activity of the heart muscle and causes it to stop beating, bringing about the death of the person being executed.

The intravenous tubing leads to a room next to the execution chamber, usually separated from the condemned by a curtain or wall. Typically, a prison employee trained in venipuncture inserts the needle, while a second prison employee orders, prepares, and loads the drugs into the lethal injection syringes. Two other staff members take each of the three syringes and secure them into the IVs. After the curtain is opened to allow the witnesses to see inside the chamber, the condemned person is then permitted to make a final statement. Following this, the warden signals that the execution may commence, and the executioner(s) (either prison staff or private citizens depending on the jurisdiction) then manually inject the three drugs in sequence. During the execution, the condemned's cardiac rhythm is monitored. Death is pronounced after cardiac activity stops. Death usually occurs within seven minutes, although, due to complications in finding a suitable vein, the whole procedure can take up to two hours, as was the case with the execution of Christopher Newton on May 24, 2007. According to state law, if a physician's participation in the execution is prohibited for reasons of medical ethics, then the death ruling can be made by the state medical examiner's office. After confirmation that death has occurred, a coroner signs the condemned's death certificate.

Delaware and Missouri use a lethal injection machine designed by Massachusetts-based Fred A. Leuchter consisting of two components: the delivery module and the control module. Two staff members each have a station in which the key on the machine and depress two stations' buttons to be ready in case of mechanical failure. Each person presses one station button on the console which travels to a computer which starts all three injections electronically. The computer then deletes who actually started the syringes, so the participants are not aware if their syringe contained saline or one of the drugs necessary for execution (to assuage guilt in a manner similar to the blank cartridge in execution by firing squad). The delivery module has eight syringes. The end syringes (i.e., syringes 7 and 8) containing saline, syringes 2, 4 and 6 containing the lethal drugs for the main line and syringes 1, 3 and 5 containing the injections for the backup line. The system was used in New Jersey before the abolition of the death penalty in 2007. Illinois previously used the computer, and Missouri and Delaware use the manual injection switch on the delivery panel.

Eleven states have switched, or have stated their intention to switch, to a one-drug lethal injection protocol. A one-drug method is using the single drug sodium thiopental to execute someone. The first state to switch to this method was Ohio, on December 8, 2009.

In 2011, after pressure by activist organizations, the manufacturers of sodium thiopental and pentobarbital halted the supply of the drugs to U.S. prisons performing lethal injections and required all resellers to do the same