Contemplating Fentanyl’s Double Duty

Bioethics in the News logoThis 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

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Image description: a medical syringe is shown on a flat white surface, with the needle in focus with a drop of liquid hanging from the tip of the needle. The background is not in focus. Image source: Dr. Partha Sarathi Sahana/Flickr Creative Commons

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.

ford-cropSabrina 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.

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