The science, the ethics,
the politics and the history
of how Georgia executes
its condemned prisoners.

By Rosalind Bentley
The Atlanta Journal-Constitution

A humane end, or cruel and unusual?

The narrative around lethal injection drugs in the United States has been complicated since 1977. That’s when Dr. Jay Chapman, an Oklahoma medical examiner, developed a three-drug combination that could be used in place of electrocution to execute prisoners.

Lethal injection was considered by some officials to be “less barbarous” and was first used to kill a prisoner in Texas in 1982. The method was soon adopted by other states, including Georgia, which switched from electrocution to lethal injection in 2001.

Over the past 35 years, the specific drugs have changed, and, in some states, the number of drugs used has been modified from three to two or even one drug.

Yet, how the drugs work is an enduring point of contention. The intent of lethal injection is to end a prisoner’s life without pain. In the video below, we show you how the drugs are supposed to work in both three-drug and one-drug protocols. Later, we’ll show:

· What can go wrong during the process of lethal injection.

· A video of an actual drug that was rejected because it was “cloudy.”

· Video of AJC staff writer Rhonda Cook, who has witnessed more than a dozen executions, including one of the last electrocutions performed in Georgia.

· Excerpts from the AJC’s groundbreaking 2007 examination of how the death penalty is applied in Georgia.

Meant to heal, used to kill

By Rosalind Bentley

A person commits a heinous crime, is tried, found guilty and sentenced to death by lethal injection.

Whether you agree or disagree with the death penalty, the question of how those drugs induce death is as much a consideration of science as politics.

It's a safe bet that if people think about lethal injection drugs at all, they assume they are special drugs designed strictly for executions.

That's partially right.

Historically, the drugs used for executions were the same drugs that for decades were used by doctors in hospital operating rooms. If you've ever had surgery, it's possible you were given one of those drugs to make you unconscious or to keep your muscles still.

For executions, the dosages of those drugs were increased to toxic levels.

But in the last six years, as drug companies came under immense pressure to stop selling the drugs for executions, states began coming up with their own drug combinations and formulations for lethal injections. To make them, states turned to special apothecaries, known as compounding pharmacies.

Although compounding pharmacies are licensed by states, compounded drugs are not approved by the U.S. Food and Drug Administration.

Because of this, several states, including Georgia, enacted shield laws over the last few years to shroud the entire execution process in secrecy. In Georgia and other states, death row inmates, their defense teams and even the general public are now barred from knowing the most basic information about executions, from the names of compounding pharmacies and their inspection records to the identities and qualifications of the execution team. So it's difficult to know how compounded drugs are made, or how they work in the human body when used for lethal purposes.

But we do know how FDA-regulated drugs work in the human body when used therapeutically.

To get a sense of how they work, we talked with anesthesiologists who've either given expert testimony about these drugs on behalf of inmates facing lethal injection, or who've witnessed an execution in a nonprofessional role at the invitation of an inmate's defense team.

None of the doctors we spoke with has ever participated in an execution. Dr. Mark Dershwitz, perhaps the most prominent doctor who for years testified on behalf of states performing lethal injections and advised on drug combinations and dosages, declined comment for this story.

"It's like going to a hardware store and buying a nail gun, which is for construction, but then you turn around and use it to kill someone. This is an impersonation of the practice of medicine."

Dr. Joel Zivot, an intensive care unit doctor at Emory University Hospital

The major boards and associations representing medical professionals have warned doctors, nurses, paramedics and even pharmacies against participating in executions. The American Board of Anesthesiology even went so far as to threaten to pull the certification of any member who helps in an execution.

The rationale, they say, is simple: these drugs and the medical professionals who administer them are meant to save life, not end it.

"It's like going to a hardware store and buying a nail gun, which is for construction, but then you turn around and use it to kill someone," said Dr. Joel Zivot, an intensive care unit doctor at Emory University Hospital and a professor of anesthesiology at Emory. "This is an impersonation of the practice of medicine."

The barbiturates

When the lethal injection procedure was created almost 40 years ago by an Oklahoma medical examiner as an alternative to electrocution, it had three components: a fast-acting anesthetic to render the person unconscious, a paralytic to keep the person immobile, and a third drug to cause cardiac arrest.

The first drug in the process was a barbiturate, sodium thiopental. It's meant to induce short-term anesthesia, making a person unconscious in seconds.

Even though it has been replaced in the United States by other anesthetics, the World Health Organization still lists it among the most essential medicines any rudimentary health care system must have, right up there with ibuprofen, penicillin and morphine.

For decades anesthesiologists used sodium thiopental as one of the first drugs injected at the start of surgery. It was followed up with a more potent anesthetic to keep a person in a deeper state of unconsciousness for the duration of an operation.

Perhaps the drug's first controversial use by law enforcement was in the early 20th century as a so-called "truth serum." If given a small dose, suspects would talk without inhibition, not unlike a person who's drunk.

Yet, in later years, even as it was being replaced in hospitals by other classes of anesthetics such as Propofol, sodium thiopental was sought after by corrections departments across the country. It was cheap. It was quick. And though it wasn't a painkiller, once prisoners were strapped down in a death chamber, the drug was supposed to knock them out so quickly they wouldn't feel the effects of what was coming next.

Anti-death penalty advocates put pressure on drug companies that made sodium thiopental to stop selling it to corrections departments. Since 2011 it hasn't been available in the United States.

The fast-acting barbiturate pentobarbital soon replaced sodium thiopental as the first drug in executions, but it too is no longer available from drug makers, so states such as Georgia must have it made by compounding pharmacies.

Here's one reason why it was chosen as a replacement. In a healthy person there is a balance between neurotransmitters, which help the brain's neurons chemically talk to one another. That cellular conversation enables you to walk, talk and otherwise function normally. In a seizure, the brain's electrical impulses are in chaos. A barbiturate like pentobarbital slows them down, giving the brain time to rest and repair. That's why it was an early drug used to control severe epileptic seizures and treat massive brain trauma.

But pentobarbital isn't a painkiller on its own. That's important to remember when considering the second drug used in executions, pancuronium bromide.

The paralytics

When you're in surgery, even if you're under anesthesia, your muscles will move involuntarily. So, doctors use a paralytic to keep you still. Pancuronium bromide was used for years, though other drugs like it are used more frequently now. They block nerve signals that tell muscles to contract.

"It's like making a muscle wear earplugs," said Dr. Mark Heath, an attending anesthesiologist at New York Presbyterian Hospital/Columbia University Medical Center and an assistant professor of anesthesiology at Columbia University. "You can't generate any movement at all."

In an operating room, a doctor has the equipment and the training to make sure a person is at the right anesthetic depth before giving them a paralytic. If the patient isn't, there's the possibility of "intraoperative awareness." Essentially, you feel what's happening but you can't say a word. All your voluntary muscles from your eyelids to your toes are frozen. But one of the body's smallest glands can signal distress.

"A sign of being awake but paralyzed is tears," said Heath. "It's one of the most dreaded complications an anesthesiologist" can face.

For a person being executed, if a paralytic is injected before the prisoner is unconscious, extreme pain is assured. The high dosage turns off the lungs and diaphragm, though not the heart.

"It would be like being held underwater and you can't breathe but you need to," said Emory's Dr. Zivot. The person "would die from asphyxiation."

For that reason this step in the three drug protocol was always the most controversial. It seemed the most likely to be in violation of the Eighth Amendment prohibition against cruel and unusual punishment. Decades after he created the original three-drug procedure, Dr. Jay Chapman, the former Oklahoma medical examiner and physician, said publicly that the paralytic should probably be eliminated.

The salt

Say you're on a diuretic because you have high blood pressure and you're not supposed to have much salt. With all the urine the pill makes you excrete, you lose potassium, which is vital for good nerve, muscle and heart function. If potassium levels get too low, you can have a heart attack. To bring potassium levels back to normal, potassium chloride is prescribed.

Just as too little potassium can affect the heart, too much can stop it. That's why potassium chloride is often the third compound in a three-drug execution.

"Potassium is a finely regulated compound in the body," said Dr. Zivot. "If potassium is raised to a very high degree it can inhibit the ability of muscles to contract."

As it coursed through a person's body, a lethal dose of potassium chloride would bring on an overwhelming burning sensation. The accompanying chest pain would be excruciating.

Drug or poison?

Fewer and fewer states use a three-drug protocol, though it's still the method in Florida, Alabama and Mississippi, according to the Death Penalty Information Center. The drugs they use have been modified but are meant to achieve the same result: unconsciousness, paralysis, cardiac arrest.

Georgia began lethal injection by three drugs in 2001 and switched to one-drug, pentobarbital, in 2012. As a single compound, a toxic dose turns off all electrical impulses in the brain and causes the entire cardiovascular system to fail. Some death penalty advocates have couched the one-drug method as being more "humane" because it does not involve paralysis. While it is true pentobarbital doesn't paralyze, it is increasingly scarce. And when states do find compounding pharmacies to make it, the quality of the drugs is often challenged by defense teams.

But whether one drug or two drugs or three, as long as lethal injection is practiced, particularly with federally unregulated drugs, the debate will remain over whether drugs intended for treatment should be used as poison.

"No drug company makes any drug with a packet insert that says, 'The purpose of this drug is for execution,'" said Zivot.

Witnessing an execution

AJC reporter Rhonda Cook has witnessed more than a dozen executions. In these videos, she describes how the methods have changed and what it's like to be in attendance.

Should doctors participate in executions?

The role of medical professionals in executions has always been a minefield. Whether they observe on behalf of the state, insert the IVs for lethal injection drugs, or make the pronouncement of death, the role of doctors, nurses, emergency medical technicians and paramedics has been viewed by many as ethically problematic: How can someone who is supposed to preserve life actively work to end it?

Medical boards and associations have condemned the practice, with one threatening to revoke the certification of any doctor who assists in an execution. Though Georgia's execution procedures and identities of assisting personnel are now shielded by law, years before the statute was enacted a handful of doctors in the state assisted with lethal injections. Some helped to insert intravenous catheters that delivered the drugs. Some verified that the inmate was dead after receiving a toxic dose. They were typically paid between $850 to a few thousand dollars per execution.

Physicians who assisted in executions became the targets of lawsuits brought by other doctors who were death penalty opponents. The opponents wanted to see their colleagues medical licenses revoke. Ten years ago one such lawsuit against a Georgia doctor failed, but it highlighted the questionable role of health care practitioners in ending the lives of prisoners.

Here are statements from some of the professional organizations that have either prohibited or warned their members against involvement in executions.

"Anesthesiologists, like all physicians and all citizens, have different personal opinions about capital punishment. … Physicians should not be expected to act in ways that violate the ethics of medical practice, even if these acts are legal. Anesthesiologists are healers, not executioners."

American Board of Anesthesiology issued a statement in 2010 and updated it in 2014 that threatens to terminate the certification of any me

"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." The statement goes on to list all the ways a person could be considered a participant.

American Medical Association medical ethics code adopted in 1980

"The act of participating in capital punishment clearly inflicts harm; nurses are ethically bound to abstain from any activities in carrying out the death penalty process. Nurses must not participate in capital punishment, whether by chemical, electrical, or mechanical means."

American Nurses Association, 1983, 2010

"EMTs and paramedics should refrain from participation in capital punishment and not take part in assessment, supervision or monitoring of the procedure or the prisoner; procuring, prescribing or preparing medications or solutions; inserting the intravenous catheter; injecting the lethal solution; and/or attending or witnessing the execution as an EMT or paramedic. The fact that capital punishment is currently supported in many segments of society does not override the obligation of EMTs and paramedics to uphold the ethical mandates of the profession."

National Association of Emergency Medical Technicians, 2010 position statement

"While the pharmacy profession recognizes an individual practitioner's right to determine whether to dispense a medication based upon his or her personal, ethical and religious beliefs, IACP discourages its members from participating in the preparation, dispensing, or distribution of compounded medications for use in legally authorized executions."

International Academy of Compounding Pharmacists, 2015 position statement

Recent controversial Georgia executions

Kelly Gissendaner

In 1997 Kelly Gissendaner conspired with her boyfriend, Gregory Bruce Owen, to kill Gissendaner's husband for insurance money.

Owen beat and stabbed Doug Gissendaner and left him for dead in a wooded area of Gwinnett County in February that year.

Both Kelly Gissendaner and Owen were later charged with Doug's murder. They were offered a plea deal. Owen took it, Gissendaner opted for a trial because the deal required a life sentence with possibility of parole after 25 years.
Gissendaner was convicted and sentenced to death in 1998.

Over the next 17 years, her lawyers tried to get her sentence changed to reflect what Owen got. Their argument: Kelly Gissendaner did not actually wield the nightstick or knife that killed her husband. They also pointed to Gissendaner's apparent reformation while in prison. She'd gotten a divinity degree and counseled new prisoners. Despite those arguments, her appeals were routinely rejected, including by the United States Supreme Court in the hours before she was actually put to death on Sept. 30, 2015.

In the death chamber she expressed remorse for the crime and wished her husband's family a measure of peace. She sang a tearful rendition of "Amazing Grace," until the execution drugs killed her.

From 2004: Kelly Gissendaner's final interview
Feb. 22, 2015: Gissendaner gets death while killer gets life
Sept. 27, 2015: Questions remain on cloudy drug
Sept. 30, 2015: Gissendaner executed

Troy Davis

Troy Davis' case is among the most contentious in recent death penalty history.

Police Officer Mark MacPhail went out to stop a fight in a Burger King parking lot one night in 1989. He'd been moonlighting at an adjacent Greyhound Bus station as a security guard. MacPhail was shot in the face and chest in the lot. At the time, several witnesses said Davis fired the gun. One said Davis later told him he'd shot MacPhail. The gun wasn't recovered but investigators said the ballistics matched another shooting Davis was linked to.

Davis got a death sentence in 1991. He said he never told anyone he shot MacPhail.

Later, in multiple appeals that reached the U. S. Supreme Court, Davis's attorneys presented affidavits from witnesses in the original trial. The witnesses said they'd been mistaken, that Davis had not been the triggerman.

Sylvester "Red" Coles, who'd been in area the night of the shooting said he'd discarded a .38 caliber gun that night but he didn't know what happened to it. He implicated Davis in the murder, but was never arrested as suspect himself.
Davis' case, with its litany of recanting witnesses, turned into something of a celebrity cause and was championed by civil and human rights groups.

But in 2011, after all appeals were exhausted, Davis was killed by lethal injection.

Dec. 21, 2009: Troy Davis case raising novel legal issues
Sept. 16, 2011: Troy Davis case draws international attention
Sept. 22, 2011: Troy Davis, from gurney, proclaims innocence before execution

Warren Hill

Already serving a life sentence for shooting his 18-year-old girlfriend 11 times, Hill killed Joseph Handspike, another death row inmate in 1990. Hill beat him to death with a piece of wood that had been used to hold up a bathroom sink. Handspike was asleep at the time of the attack. A prison guard rushed to the cell after hearing the thuds and saw part of the attack.

The murder was not in question. Instead it was Hill's mental acuity. His IQ was 70. To avoid the death penalty, Georgia law requires anyone who has a mental disability to prove "beyond a reasonable doubt," that he or she is suffers from retardation. It is the most stringent standard of proof required by any state.

Life without parole was not offered as an option at sentencing. After years of appeals, including one that challenged Georgia's lethal injection shield law, Hill was executed in January 2015.

Feb. 14, 2013: State experts change opinions in condemned killer's case
Jan. 27, 2015: Parole Board denies clemency for Hill
Jan. 27, 2015: Five questions on the Warren Hill death case

Excerpt: A matter of life and death

In 2007, the AJC published a four-part series about the arbitrary nature of how death sentences are handed down in Georgia. The following is an excerpt from the first part of that series. For more, you may read Part One and Part Four in their entirety.

By Bill Rankin, Heather Vogell, Sonji Jacobs and Megan Clarke

Two men begged a ride from a Wal-Mart shopper in Milledgeville. Minutes later he was dead, shot once in the head. The killers sit on death row.

Two men begged a ride from a college student at a Tifton nightclub. Minutes later he was dead, shot four times in the stomach and chest. The killers are serving life in prison and will be eligible for parole.

Two exceedingly similar crimes, just a few months and 135 miles apart. Two starkly different outcomes.

The murders illustrate what a two-year investigation by The Atlanta Journal-Constitution has revealed: Getting the death penalty in Georgia is as predictable as a lightning strike. Thirty-five years ago, the U.S. Supreme Court threw out the death penalty nationwide after finding it was arbitrary and capricious in Georgia.

It still is. Reforms that persuaded the high court to reinstate the death penalty have fallen far short of the state's promises, the Journal-Constitution has found.

• Horrible murders are sometimes treated more leniently than lesser crimes. Reginald Acres, for instance, avoided death for viciously stabbing and killing his wife, infant daughter and a pregnant relative. But David Aaron Perkins is on death row for stabbing a drinking buddy and crushing his skull with a whiskey bottle.

• For 25 years, Georgia's Supreme Court has flubbed a critical duty, repeatedly citing cases that had been overturned to justify other death sentences.

• More prosecutors and juries are rejecting lethal injection in favor of life without parole. Since 2000, juries have decided against death in two of every three sentencing trials. The trend makes each remaining death sentence more out of step with punishment for similar crimes.

The newspaper's investigation explored the darkest depths of human behavior. Court records told tales of torture, mutilation, child murder — the kinds of cases that give cops and jurors nightmares. They were also, the newspaper found, the kinds that often didn't get the death penalty.

"It's like a roulette wheel,” said former Georgia Chief Justice Norman Fletcher.” Arbitrariness is a weakness of the death penalty."

The Journal-Constitution found 1,315 murder cases from 1995 through 2004 that could have been prosecuted for death.

But prosecutors pursued a death sentence for only one in four of those killers. Only one in 23 of them landed on death row.