This post is a part of our Bioethics in the News series
By Sabrina Ford, PhD
In August 2018, Nebraska used fentanyl as part of a lethal cocktail to execute Carey Dean Moore, a prisoner sentenced to the death penalty for committing murder. This action by the state presents an ethical paradox. Tens of thousands of lives are lost to opioid overdose each year and fentanyl now was being used as part of a powerful execution cocktail. How do we comprehend this curious juxtaposition of the use of synthetic opioid drugs, complicated by our understanding of the human condition? To further muddy this absurdity, President Donald Trump suggested that illegal dealers of synthetic opioids, like fentanyl, should be sentenced to death if convicted.
To be clear, this neither is a commentary on the death penalty nor is it intended to be read as a political stance, but instead is an exploration of the phenomenon of dousing physical pain and avenging emotional pain. That is, how do we understand powerful pain-killing prescription medications as a solution to relieve suffering… physical, emotional, societal?
To give further context to this conundrum, the news media seemed equally confused. On August 14, 2018, The Washington Post reported on the fentanyl execution in Nebraska, with minimal mention about the epidemic of deaths by synthetic opioid. In fact, the word “overdose” did not appear in the news article. On August 18, 2018 the Post ran a separate opinion piece on synthetic opioid overdose deaths in the United States, but failed to mention the execution that took place just four days earlier. On August 23, 2018, Bloomberg reported on Trump’s comment about enacting the death penalty for those convicted of illegally dealing fentanyl. Does it stand to reason that a fentanyl dealer would be executed by a fentanyl cocktail? This gives new meaning to “all who draw the sword will die by the sword”.5
Connecting the Dots
BBC News did attempt to connect the dots between overdose and execution, but only as factual statements placed side by side. The BBC News and other news outlets outlined the combination of drugs used to execute Moore including diazepam, fentanyl, cisatracurium besylate, and potassium chloride. One reason why Nebraska State Penitentiary chose fentanyl was because that drug is obtainable – available in the prison for the medical treatment of pain for inmates. Interestingly, controversy about the use of this drug combination was not because it included fentanyl, with a reputation for ending life, but instead was because it was an untested chemical combination administered by lethal injection to enforce the death penalty.
Pleasure and Pain
Human suffering typically is experienced existentially – mentally and physically. In our daily lives, we often think of suffering as psychological and emotional, and in sickness and death, suffering is associated with a physical state. The philosophical understanding of suffering is grounded in Hedonism. Hedonism is an ethical framework that posits pleasure is good and pain is bad. There is not enough space to explore ethical and epistemological digressions, but let us take a short cut for now.* Pleasure and pain present a long-standing dilemma to the human experience. As hedonistic creatures, we are wired to seek pleasure and longevity, but sometimes our search for pleasure ends in pain, suffering, and even death—the very state we seek to avoid. Akin to searching for the fountain of youth, some opioid users are searching for good in the form of pleasure, an ethereal altered state of consciousness. Too much of a good thing can lead to bad, in the form of death by opioid overdose. How to untangle the conundrum of addiction is something physicians, psychologists, and philosophers have attempted to solve for thousands of years.
Double Duty
Alas, we know that opioid addiction has as one of its greatest risks, titration of just enough of the drug to achieve the ultimate high—just close enough to death to touch heaven. Fentanyl as a prolific painkiller has become America’s death knell. On August 14, 2018, fentanyl also became an elixir to carry out justice and avenge murder. Interestingly, as mentioned above, the pharmaceutical combination was administered by a series of four drugs delivered by intravenous drip: diazepam, to induce sleep; fentanyl, a potent pain medication; cisatracurium besylate, to paralyze and stop breathing; and potassium chloride, to stop the heart; not too different from the process of dying by opioid overdose.
How do we as Americans make sense of this strange state of affairs? We want our suffering to stop, whether it be physical, mental, or even societal. It would seem that fentanyl has become a drug of choice.
*Suggested reading: Epicurus. Epicurus – Stanford Encyclopedia of Philosophy. Metaphysics Research Lab, Stanford University. 2018.
Many thanks to Jamie Alan, RPh, PharmD, PhD and Cara Poland, MD, Med, FACP, DFASAM for technical assistance.
Sabrina Ford, PhD, is an Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Biology and the Institute for Health Policy in the Michigan State University College of Human Medicine. Dr. Ford is also adjunct faculty with the Center for Ethics and Humanities in the Life Sciences.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, December 13, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.
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References
- Berman, M. Nebraska becomes the first state to use fentanyl in an execution. The Washington Post. August 14, 2018: https://www.washingtonpost.com/news/post-nation/wp/2018/08/14/nebraska-prepares-for-first-u-s-execution-using-fentanyl/?noredirect=on&utm_term=.e9e22d644130.
- Ahmad FB, Rossen LM, Spencer MR, Warner M, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2018. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
- Jacobs J, Dennis ST. Trump tells Sessions he favors the death penalty for fentanyl dealers. Bloomberg. August 23, 2018. https://www.bloomberg.com/news/articles/2018-08-23/trump-is-said-to-propose-death-penalty-for-fentanyl-dealers.
- Editorial Board. Fentanyl overdoses are killing Americans: The country must not accept business as usual. The Washington Post. August 18, 2018. https://www.washingtonpost.com/opinions/fentanyl-overdoses-are-killing-americans-the-country-must-not-accept-business-as-usual/2018/08/18/b5532ea0-a255-11e8-83d2-70203b8d7b44_story.html?utm_term=.cac8e448df17.
- Matthew 26:52. The Holy Bible. King James Version.
- Nebraska first in US to use opioid fentanyl in execution. BBC News. August 14, 2018. https://www.bbc.com/news/world-us-canada-45185687.
- Duggan J. How Carey Dean Moore’s execution, Nebraska’s first lethal injection, will be carried out. Omaha World-Herald. August 12, 2018. https://www.omaha.com/news/nebraska/how-carey-dean-moore-s-execution-nebraska-s-first-lethal/article_a5bffee0-5d80-55b2-b1ba-77c94b411ef7.html.
- Gander K. Nebraska’s first lethal injection execution will use new cocktail of drugs, including fentanyl. Newsweek. August 8, 2018. https://www.newsweek.com/nebraskas-first-lethal-injection-execution-will-feature-cocktail-drugs-never-1060228.
MSU Bioethics 
Thanks to Dr. Ford for a thought provoking article.
The dual use of fentanyl is not so much a conundrum as an irony.
The dual use of the drug, fentanyl, should come as no surprise. The very word for drug in ancient Greek, pharmakon, means both drug and poison. Sola dosis facit venenum, “the dose makes the poison ” is a basic toxicological principle attributed to Paracelsus. Off label use of drugs and dual use research of concern (DURC) both show that the same thing can be used for different purposes, some good, some evil. In fact, any object can be dual used for good or evil, an observation that led Kant to maintain that no external object is good without qualification; the only good thing without qualification is a good will,
Many of the drugs that have been used for lethal injection in the past are no longer available; some no longer are being produced; others because public pressures has forced manufacturers not to sell them for the purpose of lethal injection. It is therefore ironic we are forced to use a drug for lethal injection whose ready but illegal availability kills so many opioid users. But the real conundrum is why some pretended for so long that the new opioids were safe and why society has been so slow to find a comprehensive way to regulate them that acknowledges their potential for both good and evil.
Thank you, Dr. Ortmann for your thoughtful response. I am appreciative of your insightful and informative response to the blog. Yes, we might think of the dual use of fentanyl as ironic. My commentary could be considered more dichotomous than multifaceted. With that being said, the irony of principles including pleasure versus pain, good versus evil, and maybe even life versus death may be more fitting. Yet, a proper dose of drugs like fentanyl is useful and can work miracles for healing. As suggested by Barbara Hodgson’s book, ‘In the Arms of Morpheus,’ can relieve pain, poverty and boredom and, I suggest, even address the discomfort of crime and punishment.
Now, the off label use of medication for execution warrants its own ethical and philosophical discussion. Yet, the off label use of medication affords us much relief from various disease states and complications of the human condition. When not tested fully, off label use of medications can lead to harm. When reflecting on good and evil, finding a “humane” way to carry out an execution does create a conundrum.
Our society’s hazy laudanum-like delusion that opioids are/were safe is troublesome. Your observation that the real problem is that policy makers are lagging in finding a solution to regulate opioids is well founded. My question is: do we really want to curb the appeal of such a delicious drug used for pain or pleasure–good or evil?
Thank you, again, Dr. Ortmann. Your comments elucidated my thesis and there is much more to be said.
Thank you for your interesting article!
For me, this is something that does not come as a surprise. I don’t know whether that is due to my age and the things I have heard or my obliviousness to the death penalty and the ways in which it can be conducted. I hear on the news all the time of people overdosing and dying, and come to find out, the drug was laced with fentanyl. As far as i’m aware, death penalty was the use of an electric chair, but has since been pushed to more humane alternatives, such as lethal injection. It is quite sad that people are dying from a drug that is now used in the death penalty, but I do not find it surprising. We must educate more on the risks associated with taking such a drug for a high, because too much of a good thing can be deadly.
So true, Sierra. It is not surprising nevertheless unsettling especially in context of suggesting the death penalty for those who sell fentanyl illegally. What are we trying to say as a society? Is life that cheap that we can snuff a life either by accident or intentionally? You bring up an interesting point–that the public wants a more humane way to implement the death penalty. This brings up another ethical question for me…should an execution for a heinous crime be humane? So many questions.
Dr. Ford thank you for this interesting yet educational article.
In today’s society and drug use, nothing comes as a surprise anymore. People are capable of anything these days. However, the double duty of fentanyl is just sad and unfortunate with the epidemic of opioid addiction and the high number of deaths. There should have been more media coverage in regards to the lethal injection and the execution of the prisoner listed. I also believe education on fentanyl and its combination with other drugs should be widely covered and discussed as it should not be used for double duty and should be banned.
This is such a thought-provoking article. I was unaware of fentanyl’s role in the death penalty, and find this to be ironic and a counterintuitive use contrary to its pain medication uses. I am also surprised at the current lack of media coverage in regards to this use. Do you feel that this usage will change if this information became more widely available? What do you see happening in the future with this trend?
This is such an interesting and provoking article. I was aware of fentanyls use as a drug, however, I was extremely unaware that it was also being used as a medication to help with the death penalty. With there being such a high usage of opioids in the United States it surprises me that this is being used as well for the death penalty and is unfortunate because of the high usage of drug users. Do you think that this will continued to be used or increase in use in the future?
Alexis, Jessica, and Caitlin, thank you for your response. Similarly, I wondered why the execution by fentanyl cocktail was reviewed quietly in the media. I believe more thoughtful media coverage would have opened a discussion for Americans about fentanyl’s role in our society. I asked a few colleagues from a medical society I belong to write an op-ed similar to this blog and they declined. It seems that this topic is too political because it encompasses the death penalty that is a hot button for many Americans.
Thank you for discussing this! I had not heard before of this curious juxtaposition. It leads me to wonder about the ambiguous definition of “drug dealer”, and whether or not the dealer or the user is to blame for an overdose. Addiction has many participants, but it seems like a blatant double standard to say that the government is allowed to offer lethal doses of a drug as a direct consequence for anyone else doing the same, especially when the receiver of the drug is unwilling in the former and very willing in the latter.
The drug dealer question could lead to another provocative commentary. The drug dealer can be the pharmaceutical industry, pain clinics, pill mills or street dealers. Thus, the earlier comment by Dr. Ortmann about regulation is important one. In addition, as mentioned in several of the responses to this blog, as a society, we are sorely in need of education about pain and suffering and how to relieve it. I am hopeful that a new generation will contemplate alternative solutions to promote well-being, before reaching for the pill bottle.
Wow! Even after having family live in Nebraska for years, I never knew that the death penalty was still enacted over there, let alone that they were using fentanyl! This article was very informative and I’m intrigued as to where this will go in the future. It’s interesting that President Trump suggests that drug dealers die of the same lethal injection, but how is this different than the lethal injection that prisoners have been receiving for decades? Is it more affordable? This leads me to wonder, what if someone was selling drugs with fentanyl in it, but they were unaware? Would they still be subjected to the same fate?
Renee, thank you so much for your response. Yes, as previous posts have mentioned, somehow this story slipped under the news radar. Although, I think that it was probably a pretty big deal in Lincoln (location of the Nebraska State Penitentiary) and the Omaha World-Herald. Interestingly enough a news article was published December 6, 2018 about the status of the death penalty law. The death of Carey Dean Moore, the first execution in Nebraska in 21 years opened death penalty conversation again. As you noted, however, the discussion here is not about the death penalty, but the variable use of fentanyl. December 12 2018, the CDC released a report on Drugs Most Frequently Involved in Drug Overdose Deaths*. In 2016, Fentanyl, by far, was the most common cause of overdose deaths above heroin and cocaine. You asked: how is a lethal injection cocktail for execution different from those that have been used in the past. One, the combination and order of drugs administered is considered more humane that previous drug combinations used for execution. Two, some pharmaceutical companies have refused or limited the use of its drugs for executions. It seems fentanyl is available for double-duty: a suitable execution cocktail utilized to carry out the death penalty and death through overdose. You questioned that if the death penalty was enacted as a sentence for unsuspecting fentanyl drug dealers would they still be executed, I do not know who could answer that question given our complicated justice system. I wonder if fentanyl dealers’ arrests would have a cultural bias similar to arrests during the crack cocaine epidemic. The more we discuss, the more questions are generated.
* Hedegaard H, Bastian BA, Trinidad JP, Spencer M, Warner M. Drugs most frequently involved in drug overdose deaths: United States, 2011–2016. National Vital Statistics Reports; vol 67 no 9. Hyattsville, MD: National Center for Health Statistics. 2018.
Thanks for the intriguing article. I truly appreciated your acknowledgement of the concept of pain in our society. In my opinion, our society believes in zero pain. I had never thought of this concept in relation to painkillers and overdoses. I also find it interesting how the producers of Fentanyl, and presumably other pharmaceutical companies, do not want their drugs used in execution. I wonder how they feel about the overdoses and the drug addictions that their drugs are used in.