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Last-Minute Complications

By Michael Cook

Botched executions provide a timely warning that assisted suicide does not necessarily lead to a peaceful death.

The gold standard for experiments on human beings is a randomly assigned double-blind placebo-controlled study. Naturally, organising one of these to assess the effectiveness of lethal drugs is unlikely. Unless you live in North Korea, the chances of getting approval from an ethical review committee is very low.

Instead, we need to rely upon experience from the United States. And this suggests that there can be glitches in choosing the date of one’s death.

In a recent issue of the Journal of Law and the Biosciences, Sean Riley, an end-of-life researcher currently studying in The Netherlands, reviewed the patchy record of the drugs used in executions and physician-assisted suicide (PAS). He summarises his findings as follows:

The pervasive belief that these, or any, noxious drugs are guaranteed to provide for a peaceful and painless death must be dispelled; modern medicine cannot yet achieve this. Certainly some, if not most, executions and suicides have been complication-free, but this notion has allowed much of the general public to write them off as humane, and turn a blind eye to any potential problems. Executions or PAS have never been as clean as they appear, even with the US’s medicalization efforts during the 1980s.

His research gives a different spin to arguments put forward by supporters of assisted suicide in Australia and elsewhere. While the horrors of botched executions in the American mid-West are reported around the world, complications with death by PAS are barely mentioned. Yet they use basically the same drugs, so it is worthwhile discussing them in tandem.

Riley addresses several practical problems about the drugs. They are most evident in capital punishment, but there is a flow-on effect to PAS.

Supplier Boycotts

Under pressure from anti-death penalty activists, pharmaceutical companies in the US and abroad have refused to supply prisons with the drug of choice for executions, pentobarbital. Efforts to circumvent this by going to shady middlemen eventually failed. Nowadays most states have ceased to import the key ingredients needed for executions.

Price Gouging for PAS Drugs

Because of the drought of lethal medications for executions, the price of pentobarbital in liquid form for PAS has skyrocketed. “Before 2012, patients would pay about US$500 for a sufficient lethal dose of the drug, but by 2016 prices had inflated to figures upwards of $25,000,” says Riley. A lethal dose of the other effective and popular drug, secobarbital, cost about US$200 8 years ago but Valeant, a Canadian pharmaceutical company, bought the drug and jacked up its price to $3,000.

Compounding Pharmacies

Faced with the huge cost of assisted death, prisons and patients began to turn to compounding pharmacies where pharmacists create the drugs from raw materials. “As the past three or so years have seen a dramatic increase in the use of compounded drugs,” writes Riley, “there has been a corresponding rise in ‘botched’ executions, though the secrecy laws have neutered most attempts to link failed executions to compounded drugs”.

Drugs made in compounding pharmacies risk being not strong enough or too strong – or contaminated. In Massachusetts a former pharmacist is on trial for supplying contaminated drugs that caused a nationwide outbreak of meningitis. Prosecutors told the court that he had used expired ingredients, falsified documents, neglected cleaning, failed to properly sterilise the drugs, shipped products before they were tested, and ignored mould and bacteria in manufacturing areas.

Last-Minute Complications

It is difficult to define what a “botched execution” is, but the dying moments of some prisoners were clearly agonising. And there are complications with PAS as well, although the data is a bit murky.

“According to data published by Oregon, 5% of patients experienced difficulties, such as regurgitation or seizures, after ingestion of the medication, since the inception of the law in 1997,” says Riley. However, the details were reported in only 51% of the cases, and “there are six reported instances where patients ingested the lethal medications, went unconscious, and awoke sometimes days later”.

As Australia debates assisted suicide, it’s important to keep in mind that the case for Yes and the case for No can both involve undue pain. Riley’s philosophical conclusion is: “The processes of death will always, to some extent, be a mystery. For now, whether a death is peaceful and painless can only be assumed.”


Michael Cook is Editor of BioEdge, an online bioethics newsletter.