Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca8-06-03651/USCOURTS-ca8-06-03651-0/pdf.json

Parties Involved:
Larry Crawford
Appellant
James D. Purkett
Appellant
Michael Anthony Taylor
Appellee

Document Text:

United States Court of Appeals

FOR THE EIGHTH CIRCUIT

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No. 06-3651

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Michael Anthony Taylor,

Appellee,

v.

Larry Crawford, Director, Missouri

Department of Corrections; James

D. Purkett, Superintendent, Eastern

Reception Diagnostic &

Correctional Center,

Appellants.

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Appeal from the United States

District Court for the

Western District of Missouri.

 [PUBLISHED]

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Submitted: January 10, 2007

Filed: June 4, 2007

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Before RILEY, BEAM, and HANSEN, Circuit Judges. 

________________

HANSEN, Circuit Judge.

The State of Missouri, through its officers Larry Crawford and James D. Purkett

(collectively "the State"), appeals the district court's judgment, which concludes that

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We will not here recount the facts of his crime as they are not relevant to this

appeal. 

-2-

Missouri's lethal injection protocol is unconstitutional. Finding no wanton infliction

of cruel and unusual punishment in violation of the Eighth Amendment, we reverse.

I.

Michael Anthony Taylor pleaded guilty and was sentenced to death in Missouri

state court for the abduction, abuse, and brutal murder of 15-year-old Ann Harrison.1

His convictions and sentence have withstood judicial scrutiny on direct appeal, see

State v. Taylor, 929 S.W.2d 209 (Mo. 1996) (en banc), cert. denied, 519 U.S. 1152

(1997), and in federal habeas corpus proceedings, see Taylor v. Bowersox, 329 F.3d

963 (8th Cir. 2003), cert. denied, 541 U.S. 947 (2004). Mr. Taylor filed this 42 U.S.C.

§ 1983 action in the federal district court, the timeliness of which was not contested,

challenging the State's three-chemical procedure used in carrying out a sentence of

death by lethal injection. See Mo. Rev. Stat. § 546.720 (describing the manner of

execution as either the administration of lethal gas or lethal injection, and authorizing

the department director to make sufficient provisions for carrying out either method).

At the time Mr. Taylor brought suit, the State intended to use its unwritten

procedure of administering a lethal combination of three chemicals through an

intravenous line (IV) placed in the femoral vein. In prior executions, a physician

placed the IV and prepared the chemicals, and nonmedical prison personnel

administered the injections in a three-step process. First, a 5-gram dose of sodium

pentothal (also known as thiopental) was injected to render the inmate unconscious.

Second, a 60-milligram dose of pancuronium bromide was administered to paralyze

the inmate's muscles, and third, a 240-milliequivalent injection of potassium chloride

was injected to stop the heart. A saline flush followed each injection. Mr. Taylor now

asserts that Missouri's procedure creates a significant risk that he might suffer the

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The procedural particularities of this case are recounted fully in our prior

decisions, Taylor v. Crawford, 445 F.3d 1095, 1096-98 (8th Cir. 2006) (retaining

jurisdiction but remanding for additional discovery and a continued evidentiary

hearing), and Taylor v. Crawford, 457 F.3d 902, 904 (8th Cir. 2006) ( remanding for

the district court to consider the State's proposed written protocol in the first instance).

We will not repeat that procedural history here, except as necessary for a clear

understanding of the current appeal.

-3-

wanton infliction of pain because if the first chemical, thiopental, does not sufficiently

anesthetize him, he will feel the pain of the third chemical, potassium chloride, which

indisputably will cause an excruciating burning sensation as it travels through his

veins to induce a heart attack, and yet he would be unable to indicate that he is

experiencing pain due to the paralyzing effects of the second chemical, pancuronium

bromide. 

The district court failed to set a hearing on the merits of Taylor's complaint in

a timely fashion, and this court ultimately ordered the chief district judge to reassign

the case to a different judge who would hold an immediate hearing and make a ruling.2

In an order dated January 31, 2006, the district court initially concluded that the threechemical sequence was not unconstitutional, and Mr. Taylor appealed. Concluding

that justice was not served by the expedited nature of that hearing, though the district

court had fully complied with our prior order requiring it, we remanded for additional

discovery and a continuation of the evidentiary hearing to provide Mr. Taylor an

adequate opportunity to fully present the merits of his claim. 

On remand, the district court permitted the parties to engage in a period of

additional discovery and reconvened the evidentiary hearing on June 12-13, 2006.

The additional discovery permitted access to the Department of Correction's

documents and logs pertaining to the last six executions and a limited anonymous

deposition of John Doe I ("Dr. Doe I"), the physician in charge of mixing the

chemicals and inserting the IVs for the past six executions. The execution logs reveal

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that Missouri does no toxicology reporting following an execution to ascertain the

amount of chemicals actually in the body at the time of death. Dr. Doe I indicated that

the chemical amounts listed in the execution logs are not always accurate as they

represent only "an approximation" of the chemicals used and disposed of; he does not

record the amount of the dose actually administered to the inmate as the logs are used

only for prison inventory and DEA reporting requirements. (See Appellants' App. at

647-49.) In each of the past six executions, however, death occurred in five minutes

or less from the time the first chemical was administered, and there was not a scintilla

of evidence that any prisoner ever suffered any pain other than what was necessary to

acquire access to the prisoner's circulatory system through the insertion of the needed

intravenous lines. 

Dr. Doe I revealed that he has dyslexia, which causes him to transpose letters

and numbers, but he asserted that his condition is not significant to his work. "I can

make these mistakes, but it's not medically crucial in the type of work I do as a

surgeon." (Id. at 660.) As he understood Missouri's unwritten procedure, he had the

independent authority to alter the chemical doses at will based on his medical

judgment, and that in fact, there were occasions when he chose to give a dose of only

2.5 grams of thiopental without notifying the director, but in his opinion, this dose was

sufficient. Under the unwritten procedure, Dr. Doe I would monitor the anesthetic

depth of the inmate to ensure he was fully unconscious solely by observing the

inmate's facial expression through an observation window.

The district court allowed the plaintiff to conduct a Rule 34 inspection and

videotaped tour of Missouri's execution chamber. The inspection revealed that the

operations room in which the chemicals are mixed and administered is lit when the

chemicals are mixed but dark during the execution, though the execution chamber

remains lit during the execution. The observation window from which Dr. Doe I

observes the procedure is partially obstructed by blinds, and the inmate faces away

from the window. During the procedure, the inmate's face is left uncovered, but the

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rest of his body, including the femoral vein injection site, is completely covered by a

sheet. 

At the continued evidentiary hearing, Mr. Taylor presented the testimony of Dr.

Mark Heath, an anesthesiologist, and Dr. Thomas Henthorn, an expert in

pharmacokinetics. These experts agreed that the third injection (the potassium

chloride) would be exceedingly painful if administered without having first achieved

adequate anesthetization of the condemned inmate.

Dr. Heath criticized the State's lack of a written protocol, asserting that a clearly

written protocol is important so the procedure can be rehearsed and to ensure a

humane execution. He noted that significant variations from the articulated procedure

had occurred, citing Dr. Doe I's testimony that he had in fact prepared a dose of only

2.5 grams for the previously carried out execution, as well as for Taylor's previously

scheduled execution despite the State's representation that it used a 5-gram dose. Dr.

Heath noted that Dr. Doe I admitted he did not keep accurate chemical logs, contrary

to standard practice. In Dr. Heath's opinion, Dr. Doe I, a board-certified surgeon, is

not competent to oversee the induction of general anesthesia and would not be hired

at any hospital in the United States as an anesthesiologist. 

Dr. Heath opined that a humane execution under this three-chemical protocol

requires a state of anesthesia deep enough for surgery. He admitted that a dose of

either 2.5 or 5 grams of thiopental would be sufficient to reach this depth and that, in

fact, rapid induction of anesthesia for surgery is generally achieved in the average

adult with a 0.28-gram dose. He expressed concern, however, that setting a high

dosage level alone does not guarantee the successful delivery of that dose into

circulation and urged the use of additional independent monitoring to ensure

successful delivery of the chemical into the bloodstream.

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Dr. Henthorn testified that an anesthetic depth known as "burst suppression,"

which is deeper than that required for surgery, must be reached for a humane lethal

injection protocol because absent this depth, it is possible to be unconscious and still

feel pain. He testified that burst suppression will be achieved in one minute and 45

seconds using a 5-gram dose of thiopental and in just under three minutes using a dose

of 2.5 grams. He was of the opinion that the State's past practice did not include a

long enough wait time to ensure adequate anesthetization before administering the

second and third chemicals. He also stated that once burst suppression is achieved

with a 5-gram dose of thiopental, it will be maintained for at least 45 minutes with no

additional monitoring necessary. He identified several potential problems that can

adversely affect the proper delivery of the anesthetic, such as an improperly prepared

dose, a leaking tube that could not be detected if the IV site is covered by a sheet, or

an IV insertion error that could cause the anesthetic to be administered into tissue

rather than the bloodstream. 

Mr. Taylor also presented the testimony of Dr. Stephen Johnson, a radiologist

and expert in femoral line placement. Dr. Johnson testified that femoral vein access,

which had been used routinely under the unwritten protocol, is unnecessary and

produces an unreasonable risk of unnecessary pain. He opined that the risk of pain

from the IV procedure can be significantly reduced by using peripheral access–the

standard IV placement on the top of the hand. 

Testifying for the State, Dr. Mark Dershwitz, an anesthesiologist, stated that

rapid sequence inducement of unconsciousness is achieved in approximately 45

seconds with a dose of as little as 0.3 to 0.4 grams of thiopental in a clinical setting,

and no pain beyond that point will be perceptible to the inmate. In his opinion, while

the high dose of thiopental administered in the lethal injection process will achieve

burst suppression, that level of anesthesia is far in excess of the anesthetic depth

targeted for surgery, and in his opinion, a depth of unconsciousness sufficient to

eliminate pain occurs much earlier than burst suppression. Dr. Dershwitz testified that

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he had recently examined the results of a bispectral index monitor ("BIS monitor")

that had been used in a North Carolina execution to monitor the level of the inmate's

consciousness. Dr. Dershwitz stated that a BIS value of between 60 and 40 is targeted

for surgery, with 40 being the deepest level of unconsciousness used in a clinical

setting. He stated that a BIS level of 40 is the point at which burst suppression begins,

and any level lower than 40 is considered to be unnecessarily deep for surgery. He

testified that the North Carolina execution logs indicated that a three-gram dose of

thiopental was administered and the protocol required a BIS level of 60 before

permitting the administration of the remaining two chemicals. Dr. Dershwitz said that

the logs indicated that there had been no pause in the injection of the chemicals in that

case because once the thiopental and saline flush had been completely administered,

a process that lasted approximately 1-1/2 minutes, the BIS value was already at zero

with a flat line electroencephalogram (EEG). 

Dr. Dershwitz agreed with Dr. Henthorn that either a 2.5-gram or a 5-gram dose

of thiopental, successfully delivered, will produce burst suppression requiring no

further need to monitor anesthetic depth. He stated that mixing the thiopental is not

a difficult task and that "certainly, most people who are intelligent can be taught to

mix up a drug like thiopental properly." (June 13, 2006, Hearing Tr. at 331.) Dr.

Dershwitz expressed the opinion that putting a patient to sleep is easy; the skill of the

anesthesiologist lies in keeping the surgery patient stable and alive and successfully

waking the patient at the end of the procedure. The last two purposes, of course, are

not the objects of a lethal injection execution procedure. 

Larry Crawford, the Director of the Department of Corrections (the

Department) since early 2005, acknowledged that he has the overall responsibility for

the execution process, that the process had been put in place before his arrival in the

office with heavy reliance on the expertise of Dr. Doe I, but that he had independently

considered the procedure when he first arrived. He admitted he had not been notified

when Dr. Doe I made the decision to lower the dose of thiopental to 2.5 grams.

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In a post-oral argument submission, the State informed our court that it was no

longer its intention to utilize the services of Dr. Doe I. Although the State's frequent

and solemn prior representations to us and to the district court that it had always used

a 5-gram dose of thiopental proved to be erroneous, in this instance we will take the

State at its word. 

-8-

Director Crawford indicated that he was planning to issue a new directive with a

defined protocol setting forth the procedure and articulating the areas of discretion.

Director Crawford indicated that he was confident in Dr. Doe I’s competence and

expected that he would continue working with the execution process.3

 Director

Crawford testified that he did not intend to carry out Mr. Taylor's execution before

issuing a new directive, stating, "I want to assure that the process is better." (Id. at

377.) 

Following the hearing, the district court entered an order on June 26, 2006,

concluding that Missouri's existing three-chemical procedure presents an unnecessary

risk that an inmate will suffer unconstitutional pain during the lethal injection process.

See Taylor v. Crawford, No. 05-4173-CV-C-FJG, 2006 WL 1779035 (W.D. Mo. June

26, 2006) (unpublished). The district court identified several concerns with Missouri's

execution protocol, namely, the lack of a written protocol specifying the chemicals

and doses, the lack of consistency in its administration, the total discretion placed in

the hands of Dr. Doe I, and the lack of any oversight of his conduct during the

process. Additional concerns included Dr. Doe I's dyslexia, his lack of concern over

how that might affect his ability to mix the lethal chemicals, and his limited ability to

monitor the anesthetic depth of the inmate reliably when his view is partially

obstructed by blinds, and the inmate's position in the execution room. 

The district court then invoked its equitable powers to fashion a detailed

remedy. Specifically, the court ordered the Department of Corrections to prepare a

written protocol requiring the participation of a board-certified anesthesiologist, not

less than a 5-gram dose of thiopental, certification that the inmate has achieved

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sufficient anesthetic depth before injecting the last two chemicals, and giving

discretion to the anesthesiologist to choose the best method and location for the

injection site. The order also required the Department to include a procedure for

monitoring anesthetic depth, which may require the purchase of additional equipment

and the repositioning of the inmate in the execution room; a contingency plan to deal

with problems that may arise during the procedure; and an auditing process to ensure

that the individuals involved are complying with the protocol. The district court

further ordered that once approved, the protocol may not be changed absent prior

court approval. Finally, the district court stayed all executions pending approval of

a new protocol. In compliance with our prior instructions, see Taylor, 445 F.3d at

1099, the district court certified its order to this court.

On July 14, 2006, the State submitted a written lethal injection protocol to the

district court. Taylor objected on grounds that this new protocol was too vague and

did not follow the district court's requirement to secure the participation of a boardcertified anesthesiologist. The district court correctly noted that it lacked jurisdiction

to consider the new protocol because the case was on appeal to this court. On August

9, 2006, we therefore remanded the entire dispute to provide the district court the first

opportunity to consider the constitutionality of the newly propounded protocol.

Taylor, 457 F.3d at 904. 

On September 12, 2006, the district court entered an order concluding that the

State's written protocol, while "an improvement over the previous procedures," was

still inadequate to provide sufficient constitutional protections. (Appellants' Add. at

27.) The district court ordered that to continue using the three-chemical protocol, the

State must modify the proposal to provide that Dr. Doe I shall not participate, to

require a physician with training in anesthesia to mix the chemicals, to provide for the

possibility of purchasing additional equipment to monitor anesthetic depth, and to

alter the record-keeping requirements. Instead of complying with that order, the State

sought reconsideration, which the district court denied. 

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The State appeals, asserting that the district court erred in concluding that its

lethal injection protocol violates the Eighth Amendment. We review de novo

questions of law arising under the Constitution, Hayes v. Faulkner County, Ark., 388

F.3d 669, 673 (8th Cir. 2004), and the district court's findings of fact for clear error,

Royal v. Kautzky, 375 F.3d 720, 722 (8th Cir. 2004), cert. denied, 544 U.S. 1061

(2005). 

II.

We think it prudent at the outset to set forth clearly what this case is not about.

To do so, we borrow the apt words penned recently by Judge Fogel, United States

District Judge for the Northern District of California, dealing with the same issue: 

[C]ourts . . . exist not to resolve broad questions of social policy but to

decide specific legal and factual disputes . . . . This case is not about

whether the death penalty makes sense morally or as a matter of policy:

the former inquiry is a matter not of law but of conscience; the latter is

a question not for the judiciary but for the legislature and the voters. Nor

is it about whether [Missouri's] primary method of execution–lethal

injection–is constitutional in the abstract: the arguments and evidence

presented by the parties address the specific manner in which [Missouri]

has implemented that method and proposes to do so in the future.

Morales v. Tilton, 465 F. Supp. 2d 972, 973 (N.D. Cal. 2006) (internal citations

omitted) (finding serious but correctable deficiencies in the implementation of

California's lethal injection protocol and urging California's executive branch to

address the implementation problems).

The Eighth Amendment's prohibition of cruel and unusual punishments, which

applies to the states through the Fourteenth Amendment, Wilson v. Seiter, 501 U.S.

294, 296-97 (1991), requires, in part, an inquiry into whether a punishment is

excessive, and that inquiry has two aspects. See Gregg v. Georgia, 428 U.S. 153, 173

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(1976) (plurality). "First, the punishment must not involve the unnecessary and

wanton infliction of pain. Second, the punishment must not be grossly out of

proportion to the severity of the crime." Id. (internal citations omitted). Mr. Taylor

presents no argument that the penalty of death by lethal injection is grossly out of

proportion to the severity of his crime. Instead, the question in this case is limited to

whether the process of carrying out the lethal injection sentence involves "the

unnecessary and wanton infliction of pain." Id.

The State begins by challenging the standard used by the district court. The

State first argues that the district court erred in finding a constitutional violation on

the basis of its determination that the Missouri lethal injection protocol involves an

unnecessary risk of causing the wanton infliction of pain. The State asserts that the

Supreme Court's articulation of the standard forbids only punishment that actually

involves "the unnecessary and wanton infliction of pain," id. at 173 (emphasis added),

not a mere risk of pain. We respectfully disagree. "An inmate's challenge to the

circumstances of his confinement . . . may be brought under § 1983." Hill v.

McDonough, 126 S. Ct. 2096, 2101 (2006). In Hill, the Court included within this

rule an action challenging a state's lethal injection protocol. The Court quoted the

petitioner's statement of his claim, noting, "[t]he specific objection is that the

anticipated protocol allegedly causes 'a foreseeable risk of . . . gratuitous and

unnecessary' pain." Id. at 2102. While we do not imply that the Court thereby

adopted a new constitutional standard, we do observe that the Court expressed no

dissatisfaction with that statement of the issue, and further, we find it to be consistent

with settled Eighth Amendment jurisprudence. 

In general conditions-of-confinement claims involving either a prison condition

allowed to exist or the specific conduct of prison officials, neither of which is

sanctioned as part of the prisoner's sentence, the Court has recognized that "conditions

posing a substantial risk of serious harm" may rise to the level of an Eighth

Amendment violation. Farmer v. Brennan, 511 U.S. 825, 834 (1994). "That the

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Eighth Amendment protects against future harm to inmates is not a novel

proposition." Helling v. McKinney, 509 U.S. 25, 33 (1993); see also id. at 34-35

(rejecting the proposition "that only deliberate indifference to current serious health

problems of inmates are actionable under the Eighth Amendment," and permitting the

case to proceed). "Court of Appeals cases to the effect that the Eighth Amendment

protects against sufficiently imminent dangers as well as current unnecessary and

wanton infliction of pain and suffering are legion." Id. at 34; see also Aswegan v.

Henry, 49 F.3d 461, 464 (8th Cir. 1995) (noting that deliberate indifference to

"conditions posing a substantial risk of serious future harm" violates the Eighth

Amendment). 

Although Mr. Taylor's situation does not fit neatly within the general

conditions-of-confinement context because the conduct of which he complains is

necessary to carry out his punishment, as opposed to a mere condition of his

imprisonment, we nevertheless see no logical reason to disregard a substantial risk that

may exist in the procedure necessary to carry out a sentence of death. It is our grave

responsibility to apply constitutional principles that will guard against the unnecessary

and wanton infliction of pain in the procedure through which the State proposes to

carry out a sentence of death, and to successfully do so in the death penalty context,

we must consider whether the procedure to be used presents a substantial risk of

inflicting unnecessary pain. We see no error in the district court's consideration of

whether there is an unnecessary risk that the State's proposed lethal injection protocol

will cause the unnecessary and wanton infliction of pain. See Hudson v. McMillian,

503 U.S. 1, 8 (1992) ("What is necessary to show sufficient harm for purposes of the

Cruel and Unusual Punishments Clause depends on the claim at issue, for two

reasons:" (1) we must apply the wanton infliction of pain standard by giving "due

regard for differences in the kind of conduct against which the Eighth Amendment

objection is lodged," and (2) the "prohibition of cruel and unusual punishments

draw[s] its meaning from the evolving standards of decency that mark the progress of

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a maturing society, and so admits of few absolute limitations." (internal quotations and

citations omitted) (alteration in original)).

We emphasize, as did the district court, that we are not concerned with a risk

of accident. The focus of our inquiry is whether the written protocol inherently

imposes a constitutionally significant risk of pain. "The cruelty against which the

Constitution protects a convicted man is cruelty inherent in the method of punishment,

not the necessary suffering involved in any method employed to extinguish life

humanely." Louisiana ex rel. Francis v. Resweber, 329 U.S. 459, 464 (1947)

(plurality). A "risk of accident cannot and need not be eliminated from the execution

process in order to survive constitutional review." Campbell v. Wood, 18 F.3d 662,

687 (9th Cir.), cert. denied, 511 U.S. 1119 (1994). If Missouri's protocol as written

involves no inherent substantial risk of the wanton infliction of pain, any risk that the

procedure will not work as designated in the protocol is merely a risk of accident,

which is insignificant in our constitutional analysis. Resweber, 329 U.S. at 464

(noting that a risk of an "unforeseeable accident" interfering with the designated

procedure is not constitutionally significant). 

Second, the State asserts that the district court applied the wrong standard by

not requiring Mr. Taylor to demonstrate deliberate indifference on the part of the

prison officials in order to prevail on his § 1983 claim. As noted above, this claim is

not the typical conditions-of-confinement claim challenging prison conditions in

general nor does it involve the action of a particular officer that is not part of the

designated punishment for the crime. See Nelson v. Campbell, 541 U.S. 637, 644

(2004) (articulating the difficulty of categorizing this particular type of claim). The

Supreme Court requires an inquiry into the state of mind of particular state officials

only where the official conduct does not purport to be part of the official penalty for

the crime. See Wilson, 501 U.S. at 302. 

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The source of the intent requirement is . . . the Eighth Amendment itself,

which bans only cruel and unusual punishment. If the pain inflicted is

not formally meted out as punishment by the statute or the sentencing

judge, some mental element must be attributed to the inflicting officer

before it can qualify.

Id. at 300. The potential pain alleged in this case would be inflicted as the statesanctioned punishment because the proposed protocol is intended to be used to carry

out the lawfully imposed sentence. See Nelson, 541 U.S. at 644 (noting that the

"imposition of the death penalty presupposes a means of carrying it out"). The

infliction of capital punishment is itself a deliberate act, deliberately administered for

a penal purpose. See Wilson, 501 U.S. at 300. The protocol at issue is created by the

Department's director, in whose discretion state law places the matter, and it is created

for the purpose of carrying out the sentence in a humane manner. See Mo. Rev. Stat.

§ 546.720 (placing the responsibility for carrying out a lawful sentence of death by

lethal injection solely within the hands of the Director of the Department of

Corrections). The propriety of this proposed protocol in the first instance (that is,

whether it achieves the goal of carrying out the punishment in a humane manner or

in fact uses torturous methods), therefore, depends upon whether the protocol as

written would inflict unnecessary pain, aside from any consideration of specific intent

on the part of a particular state official.

The State relies on language in Resweber for its insistence that the plaintiff

must demonstrate a purpose to inflict harm, but Resweber presented a different

situation. The Court there concluded that a second attempt at electrocution (after the

first attempt had failed due to technical problems) was not unconstitutional, finding

there was "no purpose to inflict unnecessary pain." Resweber, 329 U.S. at 464

(emphasis added). A state of mind inquiry was necessary in that case because the

conduct at issue – a second application of electrocution – was not authorized by

statute nor was it the regular procedure adopted by state officials for carrying out a

sentence of death. The Court found that the state official's decision to apply

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electrocution a second time was constitutional because it was the result of an accident

and was not done for the purpose of inflicting pain. See id. (emphasizing that the

unforeseeable equipment failure during the first electrocution made a second attempt

necessary, and "an unforeseeable accident . . . cannot . . . add an element of cruelty");

see also id. at 471 (Frankfurter, J., concurring) (indicating that a different outcome

may have resulted had there been a showing of willful multiple applications of

electrocution). The conduct challenged in the present case is neither alleged to be

accidental nor a deviation from the official procedure, which would require a showing

of an intent to harmor deliberate indifference. Instead, the official conduct challenged

is the State's designated procedure for deliberately carrying out the prescribed penalty

intended to punish the inmate.

We turn then to the task of assessing whether Missouri's lethal injection

protocol amounts to cruel and unusual punishment, involving a substantial foreseeable

risk of the wanton infliction of pain. The Eighth Amendment prohibits the

unnecessary and wanton infliction of pain through torture, barbarous methods, or

methods resulting in a lingering death. See Gregg, 428 U.S. at 170. The Eighth

Amendment is interpreted in a flexible manner, "'acquir[ing] meaning as public

opinion becomes enlightened by a humane justice.'" Id. at 171 (quoting Weems v.

United States, 217 U.S. 349, 378 (1910)). "'The Amendment must draw its meaning

from the evolving standards of decency that mark the progress of a maturing society'"

and "accord with 'the dignity of man.'" Id. at 173 (quoting Trop v. Dulles, 356 U.S.

86, 100-01 (1958) (plurality)).

 

The evidence reveals that the only inherent risk in Missouri's written procedure

arises from the specific chemicals chosen by the State to carry out the sentence of

death by lethal injection. Lethal injection itself "is commonly thought to be the most

humane form of execution." Abdur'Rahman v. Bredesen, 181 S.W.3d 292, 306 (Tenn.

2005), cert. denied, 126 S. Ct. 2288 (2006); see also Beardslee v. Woodford, 395 F.3d

1064, 1074 (9th Cir.) (specifically noting that humane concerns were a motivation for

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Specifically, the procedure requires 15 syringes – the first 4 syringes contain

a total quantity of 5 grams of thiopental, the next syringe contains only saline solution,

then 60 milligrams of pancuronium bromide, then saline solution, then two syringes

containing a total of 240 milliequivalents of potassium chloride, and the tenth syringe

contains saline solution. Four additional syringes, each containing an extra 1.25 gram

dose of thiopental, are prepared in case additional anesthetic is required, and one

additional syringe of extra saline solution is prepared. 

-16-

adopting lethal injection as the presumptive method of execution in California), cert.

denied, 543 U.S. 1096 (2005). There is no dispute, however, that the third and last

chemical chosen for use in this protocol will cause excruciating pain if the inmate is

not adequately anesthetized and that use of the second chemical in the sequence will

simultaneously mask any visible sign of that pain. Because of those inherent

properties of two of the chemicals chosen to carry out the sentence of death, we must

carefully evaluate the designated procedure to determine whether it sufficiently

safeguards against the infliction of this excruciating pain such that any lingering risk

is not of constitutional magnitude.

The written protocol is a four-page document divided into six sections–(A)

describing the execution team; (B) describing the preparation of the chemicals; (C)

describing the process for inserting the intravenous lines; (D) setting rules for

monitoring the prisoner; (E) setting rules for administering the chemicals; and (F)

documenting the chemicals. The protocol requires a more than adequate 5-gram dose

of thiopental, and the quantities of chemicals prescribed in the sequence may not be

changed without prior approval of the department director.4

 The execution team

consists of contracted medical personnel and department employees. As noted earlier,

the State has indicated that Dr. Doe I will not be participating in the procedure. A

physician, nurse, or pharmacist prepares the chemicals, which are injected by

nonmedical department employees. A physician, nurse, or emergency medical

technician holding either an "EMT-intermediate or EMT-paramedic" certification

inserts the intravenous lines, establishing both a primary and a secondary IV (which

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must be a peripheral line) unless the prisoner's physical condition prevents the use of

two lines. (Appellants' Add. at 32.) The protocol provides the medical personnel with

discretion to determine the best place to insert the IV lines, and it requires that the

medical personnel be qualified with the appropriate training, education, and

experience to perform the IV placement procedure determined to be most appropriate.

The protocol requires medical personnel to confirm that the IV lines are

working properly both before and during the procedure and to attach and monitor an

electrocardiograph during the execution procedure. Medical personnel must supervise

the injection of the contents of the syringes by department employees. Before the

second and third chemicals are injected, medical personnel must examine the prisoner

physically to confirm that he is unconscious using standard clinical techniques and

must inspect the catheter site again. The second and third chemicals are injected only

after confirmation that the prisoner is unconscious and after a period of at least three

minutes has elapsed from the first injection of thiopental. The protocol also requires

accurate documentation of the chemicals given, the order in which they were given,

and the quantities of chemicals used and discarded. Any deviations from the written

protocol must be promptly reported to the department director. 

The district court concluded that the State's written protocol, while an

improvement over the unwritten procedure, was still constitutionally deficient. The

court ordered the State to modify its proposal as follows: (1) the written protocol

must require the participation of a physician with training in the administration of

anesthesia and must prohibit Dr. Doe I from participating in the lethal injection

process, (2) the written protocol must provide for the purchase of additional

equipment to adequately monitor anesthetic depth, (3) the written protocol's recordkeeping procedures must comply with specific requirements set forth by the court, (4)

the protocol must provide for court review of any deviation from it, and (5) the written

protocol may not be implemented by medical personnel such as paramedics or EMTs

unless they are employed by the supervising physician.

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Our independent review of the State's written protocol and the record in this

case leads us to the conclusion that the written protocol does not violate the Eighth

Amendment, and thus, the district court had no basis on which to impose an equitable

remedy requiring further modification of the protocol. The concerns that the district

court noted and required to be modified do not rise to the level of creating a

constitutionally significant risk of pain. 

The experts agree that if a 5-gram dose of thiopental is successfully delivered,

there is virtually no risk that an inmate will suffer pain through Missouri's threechemical sequence. The experts also agree that a properly functioning IV, even

peripherally placed, will adequately deliver the dose and that the inmate will then be

sufficiently unconscious in less than two minutes, without the need of any further

monitoring. The written protocol requires a 5-gram dose of thiopental and a threeminute wait before injecting the final two chemicals. The written protocol sufficiently

provides for proper delivery of that dose by requiring the IV insertions to be

accomplished by medical personnel (a physician, nurse, or EMT) who is qualified to

perform the task, who must confirm before the procedure begins that the IV is

functioning properly and not obstructed, and who must inspect the site again before

the final two chemicals are injected. The physician, nurse, or EMT is given discretion

only with regard to determining the proper placement of the IV and the appropriate

procedure for insertion of the IV. The physician, nurse, or EMT is required to

examine the prisoner physically using standard clinical techniques to determine that

he is unconscious before the second and third chemicals are administered.

Because of the pain that undoubtedly would be inflicted by the third chemical

if administered without adequate anesthetization, it is imperative for the State to

employ personnel who are properly trained to competently carry out each medical step

of the procedure. The protocol adequately requires trained medical personnel to carry

out these steps and to verify that the IV is working properly. The protocol provides

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no opportunity for personal judgment regarding the proper dose, because the protocol

mandates a dose large enough to render anyone deeply unconscious, as long as it is

delivered properly. The protocol is designed to ensure a quick, indeed a painless,

death, and thus there is no need for the continuing careful, watchful eye of an

anesthesiologist or one trained in anesthesiology, whose responsibility in a hospital's

surgery suite (as opposed to an execution chamber) is to ensure that the patient will

wake up at the end of the procedure. "For exceedingly practical reasons, no State can

carry out an execution in the same manner that a hospital monitors an operation."

Workman v. Bredesen, No. 07-5562, 2007 WL 1311330, at *12 (6th Cir. May 7,

2007), cert. denied, 127 S. Ct. 2160 (May 8, 2007). Absent some specific

disqualifying characteristic of the chosen medical personnel, we would be hard

pressed to say that a physician, a trained nurse, or a licensed pharmacist is not

qualified to mix the chemicals. We know of no decision holding that the Constitution

requires a physician to become the executioner. See generally id. at *12 (stating that

the Constitution does not require the State to hire an anesthesiologist for each

execution); McKenzie v. Day, 57 F.3d 1461, 1469 (9th Cir.), cert. denied, 514 U.S.

1104 (1995) (stating, "we are aware of no authority for the proposition that the

prisoner is entitled, for example, to have a lethal injection administered by a

physician"). 

Neither does the record justify requiring the continuous monitoring of the

anesthetic depth of the inmate by one trained in anesthesia or by additional equipment.

The written protocol requires a 5-gram dose of thiopental to be delivered through a

properly placed and working IV, combined with a three-minute wait and a physical

confirmation of unconsciousness before the last two chemicals are administered. The

experts agree that this dose, successfully delivered, will cause burst suppression in less

than three minutes and last at least 45 minutes, which eliminates any need for further

monitoring. Given the dose of thiopental provided in the protocol, the precautions

taken to ensure it is successfully delivered, the three-minute wait built into the

protocol before administration of the second and third chemicals, the ready

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availability of syringes containing an additional five grams of thiopental, and the

physical examination of the prisoner and the IV site prior to administering the second

and third chemicals, there simply is no realistic need for further monitoring of

anesthetic depth by a physician or sophisticated equipment to prevent a

constitutionally significant risk of pain.

The Constitution does not require the use of execution procedures that may be

medically optimal in clinical contexts. See Hamilton v. Jones, 472 F.3d 814, 816

(10th Cir.), cert. denied, 127 S. Ct. 1054 (2007). "The state has broad discretion to

determine the procedures for conducting an execution . . . ." McKenzie, 57 F.3d at

1469. "[W]e recognize that what could be done to update or even improve the

protocol is not the appropriate legal inquiry to be undertaken by this or any other

reviewing court." Abdur'rahman, 181 S.W.3d at 309. Where the "procedures are

reasonably calculated to ensure a swift, painless death," they are "immune from

constitutional attack," McKenzie, 57 F.3d at 1469, as the Constitution protects only

against the wanton and unnecessary infliction of pain. What the Sixth Circuit said

about the Tennessee protocol is equally true about Missouri's: "The whole point of

the [Missouri] lethal-injection protocol is to avoid the needless infliction of pain, not

to cause it." Workman, 2007 WL 1311330, at *9. The State's written protocol does

not present any substantial foreseeable risk that the inmate will suffer the unnecessary

or wanton infliction of pain. The abundant dose of thiopental, lethal in itself and over

17 times that given for surgeries, combined with built-in checks to ensure that the IV

is properly placed by medical personnel trained for the procedure and that the IV is

working and not obstructed, renders any risk of pain far too remote to be

constitutionally significant. See id. at *12 (noting that the risks of pain in a similar

protocol "remain remote []and do not occur when the procedure is properly

implemented"); Hamilton, 472 F.3d at 816-17 (noting that the risk involved must be

of constitutional magnitude; and denying an injunction upon concluding that the

district court correctly determined, in light of the precautions built into Oklahoma's

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protocol, that the risk of failure to monitor resulting in the alleged pain is far too

remote to rise to a constitutional level).

We emphasize that Mr. Taylor has not adduced evidence at any stage of this

litigation that carries his burden of proving a constitutional violation. We have very

carefully examined the entire record, and we find no evidence to indicate that any of

the last six inmates executed suffered any unnecessary pain that would rise to an

Eighth Amendment violation or that any state actor was deliberately indifferent to the

Constitution's requirement that no unnecessary pain be wantonly inflicted during the

execution process. 

III. 

We conclude that Missouri's written lethal injection protocol does not violate

the Eighth Amendment. The judgment of the district court is reversed, and the

injunction the district court issued is vacated. 

______________________________

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