Lethal injections for executions: Medics, ethics and the futile search for the least painful method

The Supreme Court of India (‘SC’) recently put the spotlight on the mode of execution of the death penalty. While hearing a public interest litigation (PIL) case pending since 2017, a three-judge bench called upon the state to present data on the specifics of ‘death by hanging’ to assess whether it meets constitutional muster. In the 1983 case of Deena v UOI,[1] the SC upheld the constitutional validity of hanging and deemed it as the only way of administering the death penalty in India. Twenty years later, the 187th Law Commission of India Report (‘LCR’) of 2003 revisited this stance and proposed a shift towards the American model of executing prisoners through lethal injections. The LCR, and the petitioners in the PIL case, contended that lethal injection is the most humane way of carrying out executions.

These developments have re-opened the debate on the mode of execution in India (see here and here). Scholars have relied on the American experience to highlight the inadequacies of the lethal injection. We further these broad discussions by specifically analyzing the role of medical practitioners in such executions. We argue that replacing hanging with lethal injections will raise serious concerns about medical ethics. We suggest that the reluctance of medical practitioners to oversee executions would impede the possibility of the quick, painless death promised by lethal injections.

The above argument, however, does not imply that hanging should be retained. There is enough authoritative evidence, including from the LCR, to attest to the barbaric and inhumane nature of hanging. The larger purpose of the above argument is to show that the search for the least painful method is a futile one. We will begin by examining international and Indian opinions on the participation of practitioners in executions. We will then explain the implications of the lack of medical expertise on executions through evidence from the USA. We end with a brief discussion of the futility of the search for the ‘least painful’ method.

To grasp the significance of the role of medical practitioners in the process of administering injection-based executions, it is essential to understand the complexities of the procedure. Lethal injection, as a method of execution, usually entails the sequential injection of three distinct drugs: an anaesthetic, a muscle relaxant, and potassium chloride. This combination aims to induce cardiac arrest and effectively carry out the execution. Clearly, therefore, the procedure necessitates medical expertise.[2]

In light of multiple botched executions, US states have been eager to enlist medical professionals’ assistance.[3] Practitioners, organizations, and medical ethics commentators have underscored the unethicality of physician involvement in executions. The American Medical Association’s (AMA) ethics guidelines hold that a member of the professions dedicated to preserving life should not be a participant in state-sanctioned executions. Even doctors who are in favour of the punishment in an individual capacity are reluctant to compromise on medical ethics.[4] Similar concerns echo throughout the world with the British Medical Association, Danish Medical Group against the Death Penalty, Nordic Medical Council, and World Medical Association agreeing that physicians must not participate in executions because such participation is incompatible with their role as ‘healers’.

The World Medical Association even amended the Hippocratic oath to include that the participation of doctors in executions is against medical ethics. The Indian Medical Association (‘IMA’), followed suit and included the statement within India’s medical ethics code. They even wrote a letter to the Medical Council of India urging the government to excuse doctors from participating in executions. Currently, the role of doctors in executions in India is limited to verifying suitability for hanging and pronouncing death. It is unlikely that the IMA would change its stance if lethal injections were given validity in India, as that would require greater active participation from doctors in the execution process.

The 187th LCR recognized the above limitations, however, their solution – training prison officials to administer lethal injection – was not well thought out. The LCR had relied on the US model where prison officials were trained to carry out evictions to make their suggestions. However, evidence from the USA shows that the absence of expertise during administration prolongs and increases the suffering of the condemned prisoner.[5] A 2022 Death Penalty Information Center (DPIC) report revealed that 35% of all executions in the US in the past year were botched due to executor incompetence, failure to follow proper protocol or defects within the pre-execution protocols such as preparation of veins etc. Multiple executions were called off due to the prison staff’s inability to set up something as basic as intravenous (IV) lines.

The inability to perform the procedure sometimes compels the state to turn to barbaric forms of execution. Recently, the State of Alabama requested that the State Supreme Court grant permission to execute a prisoner by forcing him to inhale pure nitrogen after a botched execution as he did not have a usable vein. This method has never been used before in American history and Alabama would be the first state to adopt this method. Nitrogen hypoxia is a largely untested method and the state having to turn to such inhumane methods for executions raises serious questions about the feasibility of administering the death penalty.

Executor incompetence can lead to prolonged suffering for those facing executions. The DPIC cites one example of an execution lasting over 3 hours due to mistakes in setting up IV lines. There have been claims that the anaesthetic involved in lethal injection, if administered in inadequate amounts, wears off before the prisoner dies, leaving them fully aware of their surroundings but unable to move or react. A lot of factors such as – height, weight, history of drug abuse, age, and time of last meal – have to be accounted for while administering anaesthesia.

Therefore, the smallest of inaccuracies can prolong the suffering of the prisoner undergoing execution. For example, a study that analyzed autopsies from more than 200 injection executions found that 84% showed signs of pulmonary edema, a condition that induces an extremely uncomfortable sensation of suffocating and drowning. Most of these executions were administered by prison officials due to physicians’ reluctance to participate. There is, however, no clear evidence showing that such instances would be mitigated if medical practitioners oversaw executions instead of prison officials. The evidence shows that in the absence of medical expertise, executions by lethal injection can be long, excruciating, and extremely painful for the person undergoing execution.

Having explained the complexities of lethal injection procedures and their potential for causing prolonged suffering, the idea that lethal injections are a painless or the ‘least painful’ method of execution comes under strict scrutiny. The evidence shows that the pitfalls of the procedure can make the process excruciating for the condemned person. Thus, the criterion of a quick, painless, and humane death remains unmet in executions by lethal injections. The situation is such that the only popularly touted alternative to hanging might effectively be as inhumane as the method being replaced. On this basis, we believe that the need is to recognize that the search for a painless, or ‘least painful’ method of causing a prisoner’s death is futile. Or, as Professor Anup Surendranath puts it: “The search for the ‘least painful method’ is ultimately an endeavour in how much cruelty we are willing to tolerate.” The question of the execution of the death penalty is not a question of legal procedure or retribution alone. It transcends mere legal procedure and carries within it a reflection of our values, humanity, and social aspirations.

Kanishk Gaurav Pandey is a second year undergraduate student at the National Law School of India University (NLSIU). He is particularly interested in questions of criminal justice and constitutional law. 

Harshal Chhabra is a second year undergraduate student at the Gujarat National Law University (GNLU). He loves researching and learning more about constitutional law and how it shapes society.

[1] (1983) 4 SCC 645 [88] (Supreme Court of India).

[2] Rebecca Walker, ‘Dr. Death? Professionalism, virtue, and U.S. physician participation in the death penalty’ 36 Criminal Justice Ethics 78.

[3] ibid.

[4] Atul Gawande, ‘When law and ethics collide – Why physicians participate in executions’ 354 New England Journal of Medicine 1221.

[5] Austin Sarat, Gruesome Spectacles: Botched Executions and America’s Death Penalty (Stanford University Press 2014).

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