The case for legalising assisted suicide and euthanasia simplistically assumes that once legalised such deaths will be both rapid and peaceful. However, this is not the case. As a 2019 article in the journal Anaesthesia found:
Complications related to assisted dying methods were found to include difficulty in swallowing the prescribed dose (≤9%), a relatively high incidence of vomiting (≤10%), prolongation of death (by as much as seven days in ≤4%), and failure to induce coma, where patients re-awoke and even sat up (≤1.3%).This raises a concern that some deaths may be inhumane.
Technical problems, complications and problems with completion in the administration of lethal drugs for euthanasia have been reported from the Netherlands.
Technical problems occurred in 5% of cases. The most common technical problems were difficulty finding a vein in which to inject the drug and difficulty administering an oral medication.
Complications occurred in 3% of cases of euthanasia, including spasm or myoclonus (muscular twitching), cyanosis (blue colouring of the skin), nausea or vomiting, tachycardia (rapid heartbeat), excessive production of mucus, hiccups, perspiration, and extreme gasping. In one case the patient’s eyes remained open, and in another case, the patient sat up.
In 10% of cases the person took longer than expected to die (median 3 hours) with one person taking up to 7 days.
From 2016 to July 2018 the Board of Procurators General reported on 11 cases of euthanasia with serious breach of protocols by the doctor, including a failed assisted suicide because the doctor ordered the wrong drug;
seven cases of the muscle relaxant being administered when the person was not in a full coma and therefore potentially causing pain;
and three cases where a first attempt at euthanasia failed and the doctor had to leave the person to get a second batch of lethal drugs.
In Oregon in 2020 nearly all (99.6%) deaths by ingesting a lethal dose involved an experimental cocktail in which morphine sulphate was the main lethal substance. These experimental lethal cocktails do not always result in a swift and peaceful death.
In fact, there are reported complications each year, with an overall failure rate of 0.42% (8 people recovered consciousness out of 1905) and an overall complication rate of 6.3% (52 out of 827 people for whom this data is available).
In 2020 there were five cases of complications out of 72 – 6.94% of those for whom information about the circumstances of their deaths is available. This included one case of seizures and 3 cases of difficulty ingesting or regurgitating the poison. In 2019 nearly one in ten (9.84%) experienced complications. In 2018 nearly one in eight (12.12%) had complications and additionally, one person failed to die and regained consciousness. Two people had seizures in 2017.
The interval from ingestion of lethal drugs to unconsciousness has been as long as four hours (in 2017). In 2019, at least one person took 90 minutes after ingestion to lose consciousness.
The time from ingestion to death has been as long as 104 hours (4 days and 8 hours) in a person who ingested pentobarbital (the lethal poison being used for suicides under Victoria’s law).
One person in 2019 took nearly two days (47 hours) to die after using DDMP2 and another person took 19 hours to die after using DDMA In 2020 one person took 8 hours to die after using DDMA, and another two people took more than 6 hours to die.
8 people have regained consciousness after taking the supposedly lethal dose, including one person in 2018.
In 2005, one person became unconscious 25 minutes after ingestion, then regained consciousness 65 hours later.
This was lumberjack David Prueitt who, after ingesting the prescribed barbiturates spent three days in a deep coma, then suddenly woke up, asking his wife “Honey, what the hell happened? Why am I not dead?” David survived for another 14 days before dying naturally from his cancer. [“Oregon man wakes up after assisted-suicide attempt”, Seattle Times, 4 March 2005]
Since 2005 seven other people have regained consciousness after ingesting the lethal medication.
In 2017 one person took 6 hours to lose consciousness after ingesting the lethal dose and one person took 35 hours to die after ingesting the lethal dose. In 2016 one person took 11 hours to lose consciousness after ingesting the lethal dose. In 2015 one person took 72 hours (3 days) to die after ingesting the dose. In 2013 one person took 3 hours to lose consciousness after ingesting the lethal dose and one person took 41 hours (1 day and 17 hours) to die after ingesting the dose. In 2009 two people awakened after initially losing consciousness. In 2014 one person suffered seizures after ingesting the lethal medication.
At least 18 patients have regurgitated the lethal medication. Seven of these cases occurred in 2016 alone.
This may be related to the use of new experimental cocktails of lethal drugs being used since the price of the previously used drugs, secobarbital and pentobarbital (Nembutal), escalated.
The first of the new cocktails is a mix of phenobarbital, chloral hydrate and morphine sulfate. It was prescribed in 88 cases in 2015 and 106 cases in 2016 but no longer prescribed in 2017 no doubt due to the fact that it was found to be very caustic and to cause a profound burning in the throat.
The second experimental cocktail includes morphine sulfate, propranolol, diazepam, digoxin and a buffer suspension. It was used in 4 cases in 2015, 53 cases in 2016 and 130 cases (66%) in 2017.
Although the legal reasons for intentionally ending a human life under the death penalty or by euthanasia or assistance to suicide are different, in all these cases the same physiological process – causing death rapidly and painlessly – is the stated aim.
It is not surprising then that some of the same lethal substances are used.
Sodium pentobarbital has been used for assistance to suicide in the Netherlands, Oregon and Washington (until 2015), and Victoria as well as by several States in the United States in the execution of prisoners.
David Waisel, MD, an anaesthesiologist, has testified about the use of this drug in executions:
… as the lethal injection commenced Mr. Blankenship jerked his head toward his left arm and made a startled face while blinking rapidly. He had a “tight” grimacing expression on his face and leaned backward. Shortly thereafter, Mr. Blankenship grimaced, gasped and lurched twice toward his right arm. During the next minute, Mr. Blankenship lifted his head, shuddered and mouthed words. Three (3) minutes after the injection, Mr. Blankenship had his eyes open and made swallowing motions. Four (4) minutes after injection, Mr. Blankenship became motionless. About thirteen (13) minutes after the injection, Mr. Blankenship was declared dead. Again, his eyes were open throughout.
Based on his lurching toward his arms and the lifting of his head and the mouthing of words, I can say with certainty that Mr. Blankenship was inadequately anesthetized and was conscious for approximately the first three minutes of the execution and that he suffered greatly. Mr. Blankenship should not have been conscious or exhibiting these movements, nor should his eyes have been open, after the injection of pentobarbital.
Given prior executions of Brandon Rhode and Emanuel Hammond in September 2010 and January 2011, respectively, during which these inmates reportedly exhibited similar movements and opened their eyes (Rhode’s eyes were open throughout the execution process), Mr. Blankenship’s execution further evidences that during judicial lethal injections in Georgia there is a substantial risk of serious harm such that condemned inmates are significantly likely to face extreme, torturous and needless pain and suffering. (State of Massachussetts, County of Suffolk., Affidavit of David B. Waisel, MD, p. 2-3)
Another anaesthesiologist, Joel Zivot, MD writes:
In 2014, I watched the lethal injection of Marcus Wellons in a Georgia prison.
I noticed that Wellons’s fingers were taped to the stretcher, which made little sense, given his body had already been restrained by heavy straps. I kept asking myself why. I read into the subject and came across a report of the lethal injection execution of another death row inmate, Dennis McGuire, five months earlier. During that 24-minute process at the Ohio jail, McGuire clenched his fists. Perhaps it was a final, futile show of defiance. Perhaps it was an outward display of pain. With his fingers secured, Wellons could not have made any such gesture.
In 2017, I obtained a series of autopsies of inmates executed by lethal injection, which confirmed my worst fears. Wellons’s autopsy revealed that his lungs were profoundly congested with fluid, meaning they were around twice the normal weight of healthy lungs. He had suffered what is known as pulmonary oedema, which could only have occurred as he lay dying. Wellons had drowned in his secretions. Yet even my medical eye detected no sign of distress at his execution.
Wellons was executed with a chemical called pentobarbital, which caused his pulmonary oedema. If a post-mortem examination were to be performed on a body after assisted suicide, it’s very likely that similar pulmonary oedema would be found.
A 2020 review, published by NPR, of 216 autopsies conducted after execution in US States by lethal injection found signs of pulmonary oedema in 84% of the cases. The findings were similar across the states and, notably, across the different drug protocols used.
Not all states conduct autopsies after lethal injections. Texas, which has performed by far the most lethal injections of any state, has a policy of not conducting autopsies. When asked by NPR about this, a spokesperson for the Texas Department of Criminal Justice said, "We know how they died."
Euthanasia and assistance to suicide laws often include provisions designed to preclude autopsies such as excluding such deaths from being “reportable” to the Coroner and falsifying the death certificate by stating the cause of death as the medical condition for which euthanasia or assistance to suicide had been requested.
The protocol for self-administration of a lethal poison to cause death under Victoria’s law, for example, includes an anti-emetic and an anti-anxiety drug to be taken before drinking a mixture containing 15 g of pentobarbital. However, the person will still be conscious when the pentobarbital is ingested.
Dr Zivot comments that “without a general anaesthetic, many will be in great discomfort, even if outwardly they don’t appear to be suffering.”
In her 2015 dissent in Glossip v Gros, US Supreme Court Justice Sotomayor, characterised death by lethal injection as “the chemical equivalent of being burned at the stake”.
While drug regimes used to execute offenders in the United States are subject to scrutiny in the courts where evidence can be presented that they may cause a painful death, there is no such scrutiny of the drug regimes used for euthanasia and assistance to suicide, which are just as likely to result in such painful and inhuman deaths.