The details surrounding the botched, horrifying execution of Clayton Lockett in the state of Oklahoma can be read in full here (June Atlantic issue). Clayton Lockett had confessed to the grisly murder of a 19 year old woman in 1999. He spent 15 years on death row. By the time all appeals had been exhausted and an execution date set, the process for how capital punishment is carried out in Oklahoma, and in many states where lethal injection is employed, had changed considerably.
As the public appetite for electric chairs and hangings and the firing squad waned, lethal injection became the predominant killing method for states where the death penalty is still legal. It was seen as clean, anti-septic, humane, clinical. No more hooded figures thrashing about strapped down in a chair, rapidly cooking from the inside. No more Wild West public hangings. No more Gulag-style firing squads with criminals lined up against a graffiti-littered wall. It was a neater, cleaner, more "civilized" way for the government to go about ending a human's life. A clean quiet white room. Medical personnel in white masks. The beeping of a monitor indicating heart rate and oxygen levels. An IV inserted adroitly in the forearm. Then, a series of three drugs, infused in quick succession. One to anesthetize, one to paralyze, and then the killer--- high dose potassium chloride to stop the heart. Bing, bang, boom. The convict lies sedately on a flat white bed. His eyes close. He seems to be sleeping. And then the rhythm monitor goes flat. He is pronounced dead. The state has completed its act of retributive justice. We can all go home feeling satisfied.
But not all is always as it seems. Sometimes things don't go as expected. In the United States, it has become very difficult for states to acquire the preferred sedative, sodium thiopental, due to international pressures on pharmaceutical companies who produce it. You see, the countries where capital punishment occurs with the highest frequency are: China, Iran, Iraq, Saudi Arabia, Somalia, and..... the United States. This is not a collection of nations one would ordinarily like to find oneself grouped. The United States, paragon of freedom and liberty and western civilization, executes more people than all but a few repressive, authoritarian regimes. The drug giant Hospira, the only FDA approved distributor of sodium thiopental, no longer sells its products to states for use in executions. The European Union outlawed export of drugs to be used in lethal injections in 2011, thereby forcing states to adopt more creative methods. Our nation has staked out a position on an island, morally and ethically. We kill our criminals. The rest of the advanced world has deemed the practice barbaric and backward.
My original intent was not to make this an anti-death penalty rant (although perhaps that is the way it is trending). My intention is to focus on a specific aspect of how the death penalty is carried out in general, and the Clayton Lockett execution in particular. To wit, what is the role of a physician in all this? The American Medical Association (AMA) statement on capital punishment and the practicing physician is as follows:
As the public appetite for electric chairs and hangings and the firing squad waned, lethal injection became the predominant killing method for states where the death penalty is still legal. It was seen as clean, anti-septic, humane, clinical. No more hooded figures thrashing about strapped down in a chair, rapidly cooking from the inside. No more Wild West public hangings. No more Gulag-style firing squads with criminals lined up against a graffiti-littered wall. It was a neater, cleaner, more "civilized" way for the government to go about ending a human's life. A clean quiet white room. Medical personnel in white masks. The beeping of a monitor indicating heart rate and oxygen levels. An IV inserted adroitly in the forearm. Then, a series of three drugs, infused in quick succession. One to anesthetize, one to paralyze, and then the killer--- high dose potassium chloride to stop the heart. Bing, bang, boom. The convict lies sedately on a flat white bed. His eyes close. He seems to be sleeping. And then the rhythm monitor goes flat. He is pronounced dead. The state has completed its act of retributive justice. We can all go home feeling satisfied.
But not all is always as it seems. Sometimes things don't go as expected. In the United States, it has become very difficult for states to acquire the preferred sedative, sodium thiopental, due to international pressures on pharmaceutical companies who produce it. You see, the countries where capital punishment occurs with the highest frequency are: China, Iran, Iraq, Saudi Arabia, Somalia, and..... the United States. This is not a collection of nations one would ordinarily like to find oneself grouped. The United States, paragon of freedom and liberty and western civilization, executes more people than all but a few repressive, authoritarian regimes. The drug giant Hospira, the only FDA approved distributor of sodium thiopental, no longer sells its products to states for use in executions. The European Union outlawed export of drugs to be used in lethal injections in 2011, thereby forcing states to adopt more creative methods. Our nation has staked out a position on an island, morally and ethically. We kill our criminals. The rest of the advanced world has deemed the practice barbaric and backward.
My original intent was not to make this an anti-death penalty rant (although perhaps that is the way it is trending). My intention is to focus on a specific aspect of how the death penalty is carried out in general, and the Clayton Lockett execution in particular. To wit, what is the role of a physician in all this? The American Medical Association (AMA) statement on capital punishment and the practicing physician is as follows:
An individual’s opinion on capital punishment is the personal moral decision of the individual. A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution. Physician participation in execution is defined generally as actions which would fall into one or more of the following categories: (1) an action which would directly cause the death of the condemned; (2) an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned; (3) an action which could automatically cause an execution to be carried out on a condemned prisoner.
The AMA, of course, has no legal authority to punish or discipline any doctor who chooses to violate this dictum. It cannot suspend medical privileges or revoke state licenses. It is simply a clarification of expected physician conduct, an elucidation of a code of ethics to guide physician behavior. Violations are violations of spirit, not of law. The American Board of Anesthesiology, actually stepped up in 2014 and incorporated the AMA code of conduct into its own professional standing policy. This actually has some teeth. Anesthesiologists who actively participate in executions run the risk of having board certification status revoked. Many hospital systems will only credential and issue privileges to board certified physicians. No privileges = no income. For all other specialties, however, the AMA directive on capital punishment is essentially an elective guideline. State medical boards have historically not taken action against physicians who involve themselves in state executions. No physician in America has ever had her state license suspended or revoked due to actions related to an execution.
The case of Johnny Zellmer, MD bears scrutiny. Dr Zellmer is listed as a family practice physician in Oklahoma City, Oklahoma. He has been in practice 15 years and the Lockett fiasco was the second execution where he had been present. In general a physician is retained on the day of an execution in order to legally pronounce death. As per AMA guidelines, physicians are not expected to participate in the actual killing mechanism. But that's not the role Dr Zellmer chose to fill that day. After numerous failed attempts to gain IV access, the paramedic in the death chamber called for assistance. Inexplicably, Dr. Zellmer responded to her call. He tried to get an IV in Lockett's jugular vein. He tried several times to get a triple lumen catheter in his subclavian vein. He asked for the availability of an intraosseus needle. Then he moved to the groin. They had been trying to get an IV into Lockett for an hour. For some reason he used a standard short length (1.5 inch) angiocatheter to obtain access to Lockett's femoral vein (generally we like to insert 5-8 inches of catheter length into the access site) . Lockett was covered in drapes and the execution commenced. Unsurprisingly, the catheter retracted out of the vein and most of the infused drugs went into Lockett's subcutaneous fatty tissue instead of his vascular system. No one noticed this right away. After infusion of the death cocktail, Lockett was still able to speak and move. Dr. Zellmer then entered the chamber, pulled back the drapes and noticed a giant swelling in the groin where the IV had been placed; unmistakable evidence of subcutaneous infusion. So Zellmer then decided to place another line in the opposite groin. He hit the artery instead of the vein and called for more drugs to be administered. The paramedic demurred, insisting that he must access a vein. He pulled the catheter from the artery. He held pressure. Blood was all over the drapes. Chaos reigned. No one knew what to do. Zellmer and the paramedic briefly considered the idea of resuscitating the still alive Clayton Lockett with CPR. An emergency phone call was placed to the governor's office. Permission was granted to halt the execution. But by that time, enough of the lethal cocktail had been absorbed through his subcutaneous tissues that his breathing and heart rates slowed and eventually stopped. He was declared dead an hour and a half after the initial attempt to gain IV access. It was a long, slow, agonizing death.
Dr Johnny Zellmer participated in the execution of an inmate last year in Oklahoma. This is undeniable. Without Zellmer's intervention, no matter how incompetent or maladroit it may have been, Clayton Lockett would not have died that day. The estate of Clayton Lockett has filed a lawsuit naming Dr Zellmer as defendant for 8th amendment violations. It is highly unlikely that this will amount to much. But I think this is a case where our profession needs to keep its own house in order. We need to make sure an episode like this never happens again. I think the AMA ought to publicly censure Dr Zellmer by name. Area hospitals where Zellmer may practice ought to consider this event when evaluating him during the credentialing process. The state medical board of Oklahoma has the authority to determine his eligibility for license renewal. At minimum, a suspension of his license seems appropriate. From my perspective, Johnny Zellmer, due to his actions on April 29 of last year, has forfeited his privilege to call himself "doctor" for the rest of his days.
The case of Johnny Zellmer, MD bears scrutiny. Dr Zellmer is listed as a family practice physician in Oklahoma City, Oklahoma. He has been in practice 15 years and the Lockett fiasco was the second execution where he had been present. In general a physician is retained on the day of an execution in order to legally pronounce death. As per AMA guidelines, physicians are not expected to participate in the actual killing mechanism. But that's not the role Dr Zellmer chose to fill that day. After numerous failed attempts to gain IV access, the paramedic in the death chamber called for assistance. Inexplicably, Dr. Zellmer responded to her call. He tried to get an IV in Lockett's jugular vein. He tried several times to get a triple lumen catheter in his subclavian vein. He asked for the availability of an intraosseus needle. Then he moved to the groin. They had been trying to get an IV into Lockett for an hour. For some reason he used a standard short length (1.5 inch) angiocatheter to obtain access to Lockett's femoral vein (generally we like to insert 5-8 inches of catheter length into the access site) . Lockett was covered in drapes and the execution commenced. Unsurprisingly, the catheter retracted out of the vein and most of the infused drugs went into Lockett's subcutaneous fatty tissue instead of his vascular system. No one noticed this right away. After infusion of the death cocktail, Lockett was still able to speak and move. Dr. Zellmer then entered the chamber, pulled back the drapes and noticed a giant swelling in the groin where the IV had been placed; unmistakable evidence of subcutaneous infusion. So Zellmer then decided to place another line in the opposite groin. He hit the artery instead of the vein and called for more drugs to be administered. The paramedic demurred, insisting that he must access a vein. He pulled the catheter from the artery. He held pressure. Blood was all over the drapes. Chaos reigned. No one knew what to do. Zellmer and the paramedic briefly considered the idea of resuscitating the still alive Clayton Lockett with CPR. An emergency phone call was placed to the governor's office. Permission was granted to halt the execution. But by that time, enough of the lethal cocktail had been absorbed through his subcutaneous tissues that his breathing and heart rates slowed and eventually stopped. He was declared dead an hour and a half after the initial attempt to gain IV access. It was a long, slow, agonizing death.
Dr Johnny Zellmer participated in the execution of an inmate last year in Oklahoma. This is undeniable. Without Zellmer's intervention, no matter how incompetent or maladroit it may have been, Clayton Lockett would not have died that day. The estate of Clayton Lockett has filed a lawsuit naming Dr Zellmer as defendant for 8th amendment violations. It is highly unlikely that this will amount to much. But I think this is a case where our profession needs to keep its own house in order. We need to make sure an episode like this never happens again. I think the AMA ought to publicly censure Dr Zellmer by name. Area hospitals where Zellmer may practice ought to consider this event when evaluating him during the credentialing process. The state medical board of Oklahoma has the authority to determine his eligibility for license renewal. At minimum, a suspension of his license seems appropriate. From my perspective, Johnny Zellmer, due to his actions on April 29 of last year, has forfeited his privilege to call himself "doctor" for the rest of his days.
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