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Evidence uncovered during Michael Morales’ constitutional challenge to California's lethal injection procedure reveals an astonishing history of negligence, incompetence, and irresponsibility. California copied itsbizarre and dangerous three-drug protocol from the national leader in executions, Texas, which itself had simply taken the idea from an Oklahoma medical examiner with no pharmacology experience who concocted the protocol in 1977.

Lethal injections look peaceful and painless—which is why California and all but one of the other death penalty states adopted them to replace the more gruesome spectacles of execution by hanging, firing squad, lethal gas, or electrocution. The condemned prisoner is strapped to a gurney and injected with a massive dose of the anesthetic sodium pentothal, which should render him unconscious and stop his breathing. Next he is injected with pancuronium bromide, a drug that paralyzes voluntary muscles, including the lungs and diaphragm. Finally, he is injected with potassium chloride, which should bring swift cardiac arrest.

California copied this bizarre and dangerous drug protocol from the national leader in executions, Texas, which itself had simply taken the idea from an Oklahoma medical examiner with no pharmacology experience who concocted the protocol in 1977. When the Morales court earlier this year ordered California to review the protocol because of evidence that it may put prisoners at risk of unnecessary pain, California officials chose not to undertake a careful inquiry.

Instead, they held a short meeting during which the state’s lawyers rejected the suggestion by one doctor in the group of an alternative single drug protocol that would carry much less risk of suffering by the prisoner. When the drugs in the three-drug lethal injection protocol are administered properly, the prisoner should be motionless— as well as unable to feel pain—within a minute or two. But a California doctor has testified that during four executions he observed prisoners’ chests moving up and down long after the drugs were administered. Execution logs from six recent executions also reveal body movements inconsistent with the proper administration of the lethal injection drugs, particularly the anesthetic. If the prisoners were not sufficiently anesthetized, they may have felt themselves suffocating from the pancuronium bromide, or they may have felt their veins burning up as the potassium chloride coursed its way to their heart.

Indeed, potassium chloride is so painful that U.S. veterinarian guidelines prohibit its use on domestic animals unless a veterinarian first ensures that they are deeply unconscious. But California does not require anyone to stay at the prisoner’s side to make sure he is in fact deeply anesthetized and unconscious before the second and third drugs are administered.

Has California taken care to ensure the drugs are properly administered? Hardly. Members of execution teams have revealed they never practiced mixing the sodium pentothal before executions. The testimony of four members of one team reveals each had a different understanding of the quantity of the anesthetic that should be used and the number of syringes needed to administer it. Worse, guidelines for how to mix the drug for intravenous administration are not even included in the written protocol—they are posted on the wall of the room where the executioners work—a darkened room lit only by one dim red bulb.

During the hearings we learned that a nurse in charge of preparing the anesthetic for lethal injections decided that she had no need to study how to do it since she would not be doing it every day. Execution teams conduct rehearsals of the lethal injection procedure, but they do not rehearse responses to problems that might arise. The team member responsible for training said that since it was not possible to anticipate all the potential problems, they didn’t practice what to do for any. When a member of Stanley Williams’ execution team noticed that the intravenous tube was not connected properly and the drug was not being administered as it should, he never bothered to tell the execution team leader or the warden about this problem. Indeed, although the warden is responsible for stopping an execution if he notices anything going wrong, the observation room has been so crowded during some executions that the warden could not even see clearly into the execution chamber.

As more court documents in the Morales case are made public, this sorry litany of negligence, botches and bungling will no doubt grow longer. Executions are inherently cruel and inconsistent with fundamental human rights. But if California is going to have the death penalty, it must ensure that executions are conducted in as pain free a manner as possible. The Morales hearings reveal that those put in charge of executing California’s prisoners have either never understood what they were supposed to do or never tried.

Sarah Tofte is a researcher at Human Rights Watch and is co-author of the 2006 Human Rights Watch report, “So Long as They Die: Lethal Injections in the United States”

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