On August 24th, the State of Florida carried out the lethal injection of convicted murderer Mark Asay using etomidate as the sedation medication for the first time. Etomidate, originally manufactured in 1963 by Johnson & Johnson, which opposes its use in lethal injection, is widely used by physicians for short-acting sedation during brief procedures or as a bridge to general anesthesia. Yet never for execution, until now. Recent drug shortages and objections by pharmaceutical suppliers have left correctional facilities looking to non-traditional medications to complete their lethal injection cocktails.
As a physician who has administered etomidate to hundreds of patients for anything from placement on a breathing machine to shocking a heart or setting a broken bone, I'm very skeptical of Florida's choice of etomidate. It should be a last-choice sedation medication to use for a procedure like lethal injection.
Etomidate is a short-acting medication with a quick onset of about 30 seconds, and quick offset of about ten minutes. It's used predominantly for these scenarios: If a complication was encountered, such as a failure to place the breathing tube in the correct area, or if there is a mechanical malfunction with equipment. In these situations, the patient only needs to be supported with oxygen and a breathing bag for the remaining ten minutes until they wake up.
Here's why it's a bad idea for an execution: If anything were to go wrong with the prisoner's IV access, as for instance was the case in 2014 with Oklahoma's execution of Clayton Locket (who took 43 minutes to be pronounced dead, and during whose execution he "raised his head up" said "man," and "started moaning"), the mere ten minutes of sedation provided by etomidate would be woefully unacceptable. A person risks coming out of sedation while the other drugs take effect. This would violate the Constitution's 8th amendment against cruel and unusual punishment.
Secondly, in my experience, roughly 20 percent of patients given etomidate will have involuntary myoclonus, or general muscle spasms, that could be interpreted as seizures or awareness. Asay likely experienced a brief and mild episode of myoclonus; according to the Associated Press, "About a minute after the first drug was administered, Asay's feet jerked slightly and his mouth opened." Fortunately "a minute or two later he was motionless and subsequently was pronounced dead by a doctor," well before etomidate's sedating effects would have worn out.
Lethal injection is traditionally achieved via three drugs given in the following order: a sedation medication to cause unconsciousness, a paralytic medication to prevent movement and halt breathing, and concentrated potassium to interfere with the normal electrical signals of the heart and induce cardiac arrest. Up until 2010, most American correctional facilities used the American-manufactured and FDA-approved sedation drug thiopental. In March of 2010, then-manufacturer Hospira requested prison officials in multiple states to discontinue thiopental's use in executions, writing "Hospira provides these products because they improve or save lives and markets them solely for use as indicated on the product labeling…we do not support the use of any of our products in capital punishment procedures."
Officials quietly attempted to purchase non-FDA approved thiopental from a wholesaler in Britain, but once its intended use was discovered they were eventually met with strict export control by the capital-punishment–opposed European Union. Since 2010, correctional facilities in the 34 states with legal lethal injection have been shifting their drug cocktails according to drug availability. But in the 15 states that have death penalty secrecy laws (which includes Florida), the reasons for drug selection, method of drug procurement, and qualifications of the executioner do not have to be publicly disclosed. These laws protect pharmaceutical suppliers from investor and public scrutiny.
According to the Associated Press, "[Florida] state corrections officials have defended the choice of etomidate, saying it has been reviewed." But because of the death-penalty secrecy laws, the Florida corrections department can refuse to answer questions about how it chose etomidate, instead citing earlier this month that four expert witnesses demonstrated that Asay "is at small risk of mild to moderate pain." Tonic contacted the Florida corrections department for comment by phone and email; they have yet to reply.
The reality is that capital punishment in America exists, and the alternative methods to lethal injection—electrocution, hanging, gas chamber, and firing squad are much less utilitarian. It is against my own values and those of the American Medical Association to suggest alternative medications, but there's widespread agreement that if lethal injection were to be done most humanely it would use a more careful selection of medications, while avoiding improper ones like etomidate.
Darragh O'Carroll, MD, is an emergency physician in Hawaii.
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