In a recent op-ed in The Hill, three lead­ing phar­ma­cists wrote in sup­port of the res­o­lu­tion by the American Pharmacists Association (APhA), dis­cour­ag­ing phar­ma­cist par­tic­i­pa­tion in exe­cu­tions. Leonard Edloe, for­mer CEO of Edloe’s Professional Pharmacies, William Fassett (pic­tured), pro­fes­sor emer­i­tus of phar­ma­col­o­gy at Washington State University, and Philip Hantsen, pro­fes­sor emer­i­tus at the University of Washington School of Pharmacy, wrote, ​“The health­care com­mu­ni­ty is now unit­ed in oppo­si­tion to involve­ment in lethal injec­tion, a form of exe­cu­tion that mas­quer­ades as a med­ical pro­ce­dure yet vio­lates core val­ues of all heal­ing pro­fes­sions.” They warned that lethal injec­tions with­out the appro­pri­ate drugs, per­son­nel, and pro­ce­dures, would be ​“bru­tal and unpre­dictable cha­rades that shame this nation.” The op-ed empha­sized the over­whelm­ing sup­port of APhA mem­bers in adopt­ing the res­o­lu­tion: ​“While APhA was engaged in devel­op­ing the pol­i­cy revi­sion, prob­lems asso­ci­at­ed with using exper­i­men­tal drug pro­to­cols became glar­ing­ly vis­i­ble, par­tic­u­lar­ly after the Clayton Lockett exe­cu­tion deba­cle in Oklahoma. By the time the APhA House of Delegates met in March 2015, there was very lit­tle dis­agree­ment among APhA mem­ber phar­ma­cists that the pro­posed pol­i­cy should be adopt­ed, and no House of Delegates mem­ber spoke against its pas­sage dur­ing final delib­er­a­tions.” Read the op-ed below.

Pharmacists and executions

Last week, the American Pharmacists Association (APhA) vot­ed over­whelm­ing­ly that par­tic­i­pa­tion in exe­cu­tions is ​“fun­da­men­tal­ly con­trary to the role of phar­ma­cists as providers of health care.” The health­care com­mu­ni­ty is now unit­ed in oppo­si­tion to involve­ment in lethal injec­tion, a form of exe­cu­tion that mas­quer­ades as a med­ical pro­ce­dure yet vio­lates core val­ues of all healing professions.

The American Medical Association, the American Nurses Association, and a host of oth­er pro­fes­sion­al med­ical asso­ci­a­tions, includ­ing the Society of Correctional Physicians, declared oppo­si­tion to par­tic­i­pa­tion in exe­cu­tions many years ago. Pharmacists are key mem­bers of the nation­al health care team. What took us so long and why does our oppo­si­tion now mat­ter so much?

The answer is that phar­ma­cists had no role to play in exe­cu­tions until very recent­ly. Once mem­bers of APhA became aware of the issue they vot­ed at the ear­li­est pos­si­ble moment and almost with­out oppo­si­tion to affirm that par­tic­i­pa­tion would vio­late fun­da­men­tal val­ues clear­ly spelled out in the Pharmacist Code of Ethics. That Code was estab­lished in the con­text of ​“moral oblig­a­tions and virtues,” and has as its first oblig­a­tion the duty to ​“respect the covenan­tal rela­tion­ship between the patient and phar­ma­cist.” APhA mem­bers con­clud­ed that any pre­sump­tion that the phar­ma­cist is prepar­ing a ​“pre­scrip­tion” for the con­vict as ​“patient” is belied by this essential relationship.

APhA’s action may well prove deci­sive in end­ing lethal injec­tion because with­out access to appro­pri­ate drugs, pro­ce­dures and per­son­nel, lethal injec­tions will con­tin­ue to be bru­tal and unpre­dictable cha­rades that shame this nation.

Execution by lethal injec­tion began in the U.S. in 1977 and is now the pre­ferred method used by all 32 death-penal­ty states and the fed­er­al gov­ern­ment. Until recent­ly, prison admin­is­tra­tors obtained drugs such as propo­fol and pen­to­bar­bi­tal direct­ly from phar­ma­ceu­ti­cal com­pa­nies. That is no longer pos­si­ble because those com­pa­nies are no longer will­ing to allow gov­ern­ments to sub­vert drugs they cre­at­ed to pro­tect life to be used instead as chem­i­cals to kill people

The shelf life of chem­i­cals used in exe­cu­tions is rel­a­tive­ly short, and most death penal­ty states soon began to feel the pinch. The impact of the embar­go became clear in October 10, 2013 when Missouri Governor Jay Nixon was forced to stop an exe­cu­tion using a secret­ly acquired source of propo­fol because the European Union threat­ened to lim­it ship­ments of the drug to the U.S., poten­tial­ly affect­ing thou­sands of surg­eries performed here.

After a brief attempt to obtain chem­i­cals from shady sources over­seas, which the FDA dis­al­lowed, states turned at last to U.S. ​“com­pound­ing phar­ma­cists” who cre­ate drugs tai­lored to indi­vid­ual patients. In doing so, these states ignored the real­i­ty of their own and fed­er­al laws by which com­pound­ing phar­ma­cists must oper­ate with­in a physi­cian-patient-phar­ma­cist rela­tion­ship, and sought to seek the exe­cu­tion chem­i­cals from phar­ma­cists as if they were man­u­fac­tur­ing chemists. No pre­scrip­tion for a con­trolled sub­stance to exe­cute a per­son has ever been legal under the fed­er­al Controlled Substances Act, although the Drug Enforcement Administration has gen­er­al­ly turned a blind eye towards pris­ons that false­ly reg­is­ter under the Act as ​“hos­pi­tals” or ​“clin­ics.”

Pharmacists who have (often to their lat­er regret) sup­plied the request­ed chem­i­cals were nev­er the deci­sion-mak­ers con­cern­ing which agent was to be used, nor were they present at the exe­cu­tion to ren­der advice if some­thing went wrong. Information avail­able in some cas­es indi­cates that the phar­ma­cies were sup­plied with a pur­chase order, not a pre­scrip­tion, and promised immu­ni­ty from state pros­e­cu­tion, as well as anonymity.

Anesthesiologists are strict­ly for­bid­den — on pain of los­ing their cer­ti­fi­ca­tion from the American Board of Anesthesiology — to advise any­one on what to brew and in what dos­es. In aston­ish­ing acts of igno­rance and arro­gance, prison admin­is­tra­tors in some states decid­ed to fill the void in avail­able exper­tise by select­ing drugs them­selves using web­sites like ​“drugs​.com” and ​“Wikileaks, or what­ev­er it is.” The result was a dis­as­trous string of ​“botched exe­cu­tions” (a unique­ly American phrase used to denote legal­ly tor­tur­ing peo­ple to death).

Which brings us back to the APhA. After the first of these exe­cu­tions — of Dennis McGuire in Ohio in late January 2014 — a coali­tion of 32 human rights and reli­gious orga­ni­za­tions formed to address the issue under the lead­er­ship of SumOfUs​.org. Two months after the McGuire exe­cu­tion, they wrote to the lead­er­ship of the APhA ask­ing it to adopt a ban on participation.

In some respects, their tim­ing couldn’t have been worse. Though the let­ter was sym­pa­thet­i­cal­ly received by lead­er­ship, APhA relies exten­sive­ly on mem­ber­ship-based acad­e­mies for exper­tise and input into the pol­i­cy-devel­op­ment process. Final approval of asso­ci­a­tion pol­i­cy is vot­ed on by a 400-mem­ber House of Delegates that meets in full only once a year in the spring. Moreover, the issue caught both lead­ers and mem­bers by sur­prise, with vir­tu­al­ly none aware of the rapid­ly-grow­ing extent to which phar­ma­cists were now being asked to play a key role in executions. 

However, the APhA Board of Trustees includes the lead­ers of the APhA Academies, and the issues raised by SumOfUs were delib­er­ate­ly includ­ed into the pol­i­cy-set­ting agen­da that began in April 2014. The lead author of the pol­i­cy state­ment was a mem­ber of one of the acad­e­my lead­er­ship teams present at the April pol­i­cy development conference.

While APhA was engaged in devel­op­ing the pol­i­cy revi­sion, prob­lems asso­ci­at­ed with using exper­i­men­tal drug pro­to­cols became glar­ing­ly vis­i­ble, par­tic­u­lar­ly after the Clayton Lockett exe­cu­tion deba­cle in Oklahoma. By the time the APhA House of Delegates met in March 2015, there was very lit­tle dis­agree­ment among APhA mem­ber phar­ma­cists that the pro­posed pol­i­cy should be adopt­ed, and no House of Delegates mem­ber spoke against its pas­sage dur­ing final deliberations.

Ultimately, the APhA pol­i­cy revi­sion may be hard to rec­og­nize as any­thing but a ratio­nal response by a group of health care providers to a new­ly emerged chal­lenge, a small part of a greater social process. One of the co-authors, when queried by a reporter about the sig­nif­i­cance of his activ­i­ty, not­ed that ​“If you’re stand­ing on the shore at low tide, dis­tract­ed by the ris­ing or set­ting sun, you may sud­den­ly find your­self up to your neck in ocean. What wave marked the crit­i­cal shift from ebb to flood? Was it the first, or the last?” We are just hap­py that our pro­fes­sion has added its own small wave.

Edloe is the retired CEO and phar­ma­cist of Edloe’s Professional Pharmacies, Richmond,Va. Fassett is pro­fes­sor emer­i­tus of phar­ma­cother­a­py at Washington State University’s College of Pharmacy in Spokane; Hansten is pro­fes­sor emer­i­tus, School of Pharmacy, University of Washington.

(L. Edloe, W. Fassett, and P. Hantsen, ​“Pharmacists and exe­cu­tions,” The Hill, April 10, 2015). See New Voices and Lethal Injection.