US Pharm. 2013;38(10):38-40.
Most pharmacists probably think about the lethal injection
of convicted prisoners in abstract philosophical terms. Is the death
penalty a morally acceptable way of dealing with those found guilty of
heinous crimes? Should it be legal to put criminals to death, or is life
in prison without the possibility of parole a better alternative? Is
this final solution to a terrible social problem a punishment for the
offender or a deterrent to others who might consider engaging in the
aberrant behavior that could lead to the death penalty?
Perhaps the dilemma is more concrete: Is a lethal
injection a more humane way to end a person’s life than other forms of
execution like the electric chair, gas chamber, hanging, or a firing
squad? The relevance of these questions may depend on whether one lives
in a state where the death penalty is legal. Even in states where the
practice is not legal, pharmacists may be asked to ship drugs to states
that do execute the condemned.
Irrespective of how one feels about the death penalty,
pharmacists may have to face some ethical decisions if they become
involved in distributing drugs for lethal injection.1,2 Recent shortages of drugs used for lethal injections has brought some of these questions into media scrutiny.
Currently, there are 32 states where the death penalty is legal.3
Three other states (New Mexico, Connecticut, Maryland) ruled more
recently that the death penalty is unconstitutional but still have
prisoners on death row because the laws were not retroactive.4 All states that permit the death penalty allow execution to be conducted by lethal injection.5 Certain federal crimes also warrant the death penalty by lethal injection.6
Although the concept of lethal injection for the purpose of executing a
prisoner was first introduced in 1888, it was not until 1982 that Texas
became the first to use it.7 The method by which a lethal
injection is carried out has wide variability ranging from the use of a
single drug to a combination of three various and different drugs.6 The three-drug “cocktail” typically involves use of a barbiturate, a paralytic, and potassium chloride solution.
Most states once used sodium thiopental as the barbiturate. However, no domestic company has produced this drug since 2009.8
A supplier of the drug from outside the United States was not
registered with the FDA, thereby causing it to be misbranded under the
Food, Drug, and Cosmetic Act.9 Nonetheless, the FDA stated in
2011 it would not block the importation of the product under its
“enforcement discretion.” On July 23, 2013, a federal Court of Appeals
ruled that the FDA must prohibit the importation of misbranded or
unapproved new drugs, including those made by unapproved manufacturers
abroad.10 Under that ruling, the FDA cannot release any of
the products currently on hand for the purpose of conducting an
execution by lethal injection of this drug. As a result, many states
have switched to sodium pentobarbital as the “drug of choice” for the
In June 2013, the only U.S. company approved to
manufacture thiopental (Hospira) announced it will no longer produce the
drug. This decision came after a global campaign by death penalty
opponents and pressure by Italian government officials after the company
sought to shift production of the drug to an Italian plant.11 The Italian government has stated it will not allow the export of any drugs that will be used in executions.12
As the shortage of thiopental became acute in 2012, California and
Arizona obtained shipments of the drug from England. The British
government has since refused to allow exports of drugs for use in
capital punishment, a policy that is under consideration by the entire
European Union. As a result, many states have been forced to substitute
pentobarbital, which has been used alone or in concert with other drugs
in all executions in the U.S. over the past 2 years. This drug, commonly
used as a sedative, is more readily available. Pentobarbital is widely
used in veterinary medicine for animal euthanasia and is also used in
physician-assisted suicide in Oregon.11
Some states (Arizona, Georgia, Idaho, Ohio, South Dakota,
Texas, Washington) have used a single anesthetic, primarily
pentobarbital, to induce death, and three others (Arkansas, Kentucky,
Louisiana) have announced their intent to use this method of execution
in the future. However, pentobarbital has become a concern when used for
capital punishment. It was used in a U.S. execution for the first time
in December 2010, when it was administered as the first ingredient in a
three-drug cocktail for a lethal injection given to an Oklahoma inmate.
The drug also has limited FDA approval in smaller doses as a mild
anesthetic and to treat some seizures. Many physicians say they no
longer administer it to people for medical purposes. Recently, a
domestic manufacturer of pentobarbital has stated it will no longer
supply the drug for purposes of assisting executions.13
Missouri has announced plans to use propofol as its single drug.6
As might be expected, this decision was met with criticism. Propofol,
made famous by its role in Michael Jackson’s death, has never been used
in a lethal injection and could cause unnecessary pain, opponents argue.
“This is an experiment with a human subject,” said Richard Dieter, a
death penalty opponent and executive director of the Death Penalty
Information Center in Washington, DC. “This will be sort of a brute
force approach where you give them enough and they die.”14 If
administered incorrectly, propofol could lead to serious and painful
muscle contractions. The drug is generally injected by a medical
professional, but Missouri state law no longer requires a physician to
be present for an execution.15
One of the major problems in death penalty states is
finding suppliers of the drugs used for lethal injection. Texas has 317
inmates on death row, but as of August 2013 it had only one dose of
thiopental left. Its supply of pentobarbital has an expiration date of
September 2013 and, to date, no alternative source has been determined.16
This is a significant problem because Texas performs about half the
executions in the country right now. The states must scramble to obtain
these drugs, including using overseas sources, but this is complicated
by the fact that many of the manufacturers based in Europe do not want
to participate in U.S. executions.11 A recent court filing indicated that Ohio’s supply of pentobarbital will be gone by the end of September 2013.15
Many of the states purchase the drugs used for lethal
injections from pharmacies. In the states where a combination of drugs
is utilized, compounding pharmacies may become a source for the
medications. Regardless, many states are having problems obtaining
sufficient quantities of drugs to carry out lethal injection sentences.
Pharmacies and pharmaceutical suppliers are increasingly concerned with
backlashes from anti-death penalty protestors for being known as
suppliers of ingredients used to intentionally end a person’s life.
Lethal Injection Secrecy Act
Georgia recently enacted the Lethal Injection Secrecy Act,
which protects the identity of companies or individ-uals that
manufacture, supply, or prescribe drugs used in executions.17
The constitutionality of this Act has been challenged, in part, on the
basis that there is no evidence that the drug set to be used to execute a
prisoner, pentobarbital, will work as intended. The attorney for the
condemned man has stated that the drug was made by an “unregulated”
out-of-state compounding pharmacy and, as such, could be expired or
otherwise tainted, thus having the potential for causing problems during
the execution. A trial court judge has blocked the execution saying
law allows the state to withhold information
that is essential in determining the effectiveness of the drugs. The
Georgia Attorney General’s office argued that there is no evidence to
show that the drug is substandard. Further, there are valid reasons for
the state to protect the supplier of pharmaceutical preparations:
“Once that compounding pharmacy’s identity is revealed, how will the
Department of Corrections ever get another compounding pharmacy to sell
The Georgia Supreme Court will make a final determination. North Dakota has a similar secrecy law.
“States are having a tough time finding supplies; but that
doesn’t mean officials should hide information about the process,” says
Fordham University law professor Deborah Denno. “If, in fact, these
drugs are not problematic, then Department of Corrections should have no
concern about revealing what their sources are.”17
The implications of drug shortages used for lethal
injections for the pharmacy profession and individual pharmacists should
be obvious. Some commentators allege, wrongfully, that compounding
pharmacies are unregulated. Others question the very credibility of
pharmacy ethics. And others wonder if pharmacists, cloaked behind a wall
of secrecy, are supplying drugs that are tainted, out of date,
unapproved, or mislabeled. Pharmacists who do supply drugs for lethal
injections may be intimidated from doing so by vocal anti-death penalty
The American Pharmacists Association (APhA) Code of Ethics
for Pharmacists does not directly address lethal injections or the
death penalty, although several statements in the code could be
construed to have implications on the subject.1,19
Ultimately, each pharmacist must decide if supplying drugs for the
purpose of ending another person’s life by lethal injection is something
he or she might want to engage in. There is no one right or wrong
1. Vivian JC, Fink JL, Whisman TR. Use of legally marketed drugs for lethal injection. US Pharm. 2008;33(11):40-42. www.uspharmacist.com/content/d/pharmacy_law/c/11470/. Accessed September 9, 2013.
2. Romanelli F. Lethal injection as a component of a therapeutics toxicology module. Am J Pharm Educ. 2011;75:117. www.ncbi.nlm.nih.gov/pmc/articles/PMC3175686/. Accessed September 9, 2013.
3. States with and without the death penalty.
Death Penalty Information Center (DPIC). www.deathpenaltyinfo.org/states-and-without-death-penalty. Accessed September 7, 2013.
4. Authorized methods. DPIC. www.deathpenaltyinfo.org/methods-execution. Accessed September 7, 2013.
5. Authorized methods by state. DPIC. www.deathpenaltyinfo.org/methods-execution#state. Accessed September 7, 2013.
6. State by state lethal injection. DPIC. www.deathpenaltyinfo.org/state-lethal-injection. Accessed September 7, 2013.
7. Groner JL. Lethal injection: a stain on the face of
www.ncbi.nlm.nih.gov/pmc/articles/PMC1124498/. Accessed September 8,
8. Price N. Importing unapproved drugs: lethal injections and shortages. Harvard Law. July 25, 2013. http://blogs.law.harvard.edu/billofhealth/2013/07/25/importing-unapproved-drugs/. Accessed September 8, 2013.
9. 21 USC §§ 331(a), 352(c).
10. Cook v. FDA, Slip Op No. 12-5176 (1st Cir).
Accessed September 8, 2013.
11. Horne J. Lethal injection drug shortage. Capitol Ideas E-Newsletter. Sept-Oct 2013. www.csg.org/pubs/capitolideas/enews/issue65_4.aspx. Accessed September 9, 2013.
12. Eckholm E, Zezima K. States face shortage of key lethal injection drug. NY Times. January 21, 2011. www.nytimes.com/2011/01/22/us/22lethal.html?_r=0. Accessed September 9, 2013.
13. Mears B. States urge feds to help import lethal injection drugs. CNN. May 21, 2012. www.cnn.com/2012/05/21/politics/states-lethal-injection-drugs. Accessed September 9, 2013.
14. Sterbenz C. America is getting desperate for drugs to execute people. Business Insider. August 19, 2013. www.businessinsider.com/lethal-injection-drug-shortage-2013-8. Accessed September 9, 2013.
15. Lethal drug shortage has states scrambling for new execution methods. RT USA. August 15, 2013. http://rt.com/usa/lethal-drug-shortage-execution-methods-548/. Accessed September 9, 2013.
16. Graczyk M. Texas execution drug shortage: state running out of pentobarbital. Huffington Post.
August 1, 2013.
Accessed September 9, 2013.
17. Lohr K. Where do drugs for lethal injections come from? Few know. National Public Radio.
July 30, 2013.
Accessed September 7, 2013.
18. Beasley D. State of Georgia high court to hear appeal on lethal injections. Reuters.
August 26, 2013.
Accessed September 7, 2013.
19. Code of Ethics. APhA. www.pharmacist.com/code-ethics. Accessed September 9, 2013.
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