In re Ohio Execution Protocol Litigation (868 F. Supp. 2d 625, 2012)

OPINION AND ORDER

GREGORY L. FROST, District Judge.

Can Ohio now be trusted?

The context surrounding this question necessarily starts with the axiomatic proposition that the United States Constitution does not require a perfect execution. Its protections do not require perfect adherence to every single provision of Ohio’s execution protocol without deviation, much less perfect adherence to every protocol provision in training sessions. But the Constitution does require that Ohio apply its protocol in a manner that does not offend constitutional protections.

Ohio has routinely offended these protections.

These offenses have not been simple errors of no importance. Mistakes happen. The random misadventure that can result when Ohio errs by not following its protocol may be regrettable but constitutional, depending upon the circumstances involved. What is not constitutional is a policy of sporadic adherence to the execution protocol that allows if not endorses institutional incompetence and presents aberrational state conduct endangering rights the Constitution confers on everyone, no matter how heinous a crime an inmate has committed. Thus, although Ohio does not need to follow each step in its protocol in an identical manner in every execution the state conducts, Ohio does need to apply the protocol under the same set of permissible overarching rules for each capital inmate.

Ohio argues that regardless of what happened in the past, the state can now be trusted to do the right thing.

Against this backdrop, the captioned case is before the Court for consideration of Plaintiff Mark Wiles’ motion for a temporary restraining order and a preliminary injunction (ECF No. 84) and Defendants’ memorandum in opposition (ECF No. 95). Plaintiff seeks a stay of his scheduled April 18, 2012 execution, while Defendants seek to persuade this Court once again that they are able to implement Ohio’s execution protocol in a constitutional manner.

Ohio has time and again failed to follow through on its own execution protocol. The protocol is constitutional as written and executions are lawful, but the problem has been Ohio’s repeated inability to do what it says it will do. As a result, this Court has dealt with inmate challenges to the constitutionality of Ohio’s execution protocol for close to eight years. During that time, the litigation has morphed from focusing primarily on allegations of cruel and unusual punishment to allegations of equal protection violations. And as this Court has previously stated, “Ohio has been in a dubious cycle of defending often indefensible conduct, subsequently reforming its protocol when called on that conduct, and then failing to follow through on its own reforms.” In re Ohio Execution Protocol Litig. (Lorraine), 840 F.Supp.2d 1044, 1046 (S.D.Ohio 2012). Ohio has now come forward with yet another set of reforms to its practices that it assures this Court will remedy the state’s unconstitutional conduct.

The Court is admittedly skeptical about Ohio’s ability to following through on its latest reforms. At the heart of these reforms is Ohio’s promise that newly implemented chain-of-'command and documenting procedures and a renewed if not newfound commitment to conducting constitutional executions finally mean that the state can carry out executions in a constitutional manner.

Thus, the question before the Court is whether it should believe Ohio’s latest round of promises. If this Court cannot, then the end result is a stay of the Wiles execution based on analysis that will likely lead to a court-ordered moratorium on executions in Ohio. If this Court does believe Ohio, then the state can proceed to execute Wiles and this Court will soon learn whether it erred in believing Ohio once again and perhaps one time too many.

The answer to the foregoing question turns on the burden involved. Wiles has the burden of convincing this Court that Ohio cannot be trusted, even in light of the new facts presented to the Court. Because he has failed to meet that burden, with the evidence nearly if not completely equally balanced on whether this Court can trust Ohio, Ohio can proceed to fulfill its lawful duty to execute Wiles.

I. Background

This litigation is a 42 U.S.C. § 1983 civil rights action brought by multiple inmates who challenge various facets of the execution protocol used by the State of Ohio. Most recently, various plaintiffs have sought to obtain stays of their execution dates based on claims that Ohio’s execution protocol and practices violate the Equal Protection Clause of the United States Constitution.

The Court issued one such stay in a July 8, 2011 decision in which it set forth at length numerous deviations by state actors from the state execution protocol then in effect, including core deviations that subverted the key constitutional principles that control the execution process. Cooey (Smith) v. Kasich, 801 F.Supp.2d 623 (S.D.Ohio 2011). This Court enjoined Ohio and any person acting on its behalf from implementing an order for the execution of Plaintiff Kenneth Smith until further Order from the Court.

In response, Defendants revised Ohio’s execution protocol and practices. This resulted in the current iteration of the state’s execution protocol, 01-COM-ll, which became effective on September 18, 2011. Ohio then proceeded to pursue the resumption of executions.

The next inmate seeking a stay via injunctive relief to come before this Court was Reginald Brooks. Brooks’ stay motion came on for a hearing from October 31, 2011 through November 2, 2011. The Court took the motion under advisement and, after examining the new protocol and the proffered evidence of Defendants’ practices in implementing that protocol, issued a November 4, 2011 Opinion and Order that explained that “[t]he dispositive questions ... have been whether [Brooks] is correct that Defendants routinely deviate from mandated or core provisions set forth in the written protocol and whether [Brooks] has sufficiently proved that the protocol fails to address sufficiently varied constitutional concerns. The answer to both questions is no.” Cooey (Brooks) v. Kasich, Nos. 2:04-cv-1156, 2:09-cv-242, 2:09-cv-823, 2:10-cv-27, 2011 WL 5326141, at *12 (S.D.Ohio Nov. 4, 2011).

Notably, the crux of the rationale behind the Brooks decision is that he failed to present evidence that he was likely to prove that Defendants are not doing what they say they are doing in conducting executions under the current protocol. Of significance is that, unlike in the Smith proceedings, Defendants were now saying that they got the message that their actions must match their words. Trust us, Defendants said, we will not deviate from the core components of the protocol. This Court accepted that contention. Trust us, Defendants continued, we will let only the Director decide whether to allow any potentially permissible deviation from the non-core components of the protocol. This Court also accepted that statement. Unfortunately, Defendants once again fooled the Court.

On January 11, 2012, this Court issued an Opinion and Order granting Plaintiff Charles Lorraine’s motion for a temporary restraining order staying his execution scheduled for January 18, 2012. In re Ohio Execution Protocol Litigation (Lorraine), 840 F.Supp.2d 1044 (S.D.Ohio 2012). The Court identified three provisions of Ohio’s execution policy from which the state had deviated during the November 15, 2011 execution of Brooks and emphasized that those deviations were constitutionally impermissible because they “were not approved in the only manner in which they could have been approved.” Id. at 1053. This Court explained that “the Director and only the Director can approve non-core protocol deviations,” which constitutes the fifth core component of the protocol. Id. at 1053. The Court proceeded to criticize the state because it did not appear from evidence presented during the Lorraine injunctive relief hearing that any of the three Brooks deviations had been presented to Director Mohr or that the state at any point thereafter had recognized or corrected course. Such deviation from the fifth core component of the protocol problematically suggested that the remaining four core components were open to similar disregard. Id. (“It is thus not the individual non-core deviations themselves or in the aggregate that lead to this Court’s rejection of substantial compliance. Rather, what is significant is the overarching core concern implicated that makes the non-core deviations errors as opposed to approved departures.”). Although the Court issued what can be fairly characterized as a stinging rebuke of Ohio’s continued failure to follow its own protocol, the Court made clear once again that it had no interest in micro-managing Ohio’s executions. Id. at 1058-59.

The latest plaintiff to seek a stay is Mark Wiles, an inmate on Ohio’s death row who is set to be executed on April 18, 2012. On February 15, 2012, Wiles filed a motion for a temporary restraining order and preliminary injunction to stay his execution. (ECF No. 84.) Pursuant to S.D. Ohio Civ. R. 65.1(a), the Court held an informal preliminary conference with the parties on February 16, 2012, at which time the Court set a briefing schedule and a hearing date. (ECF No. 87.)

The Court held the hearing on Wiles’ motion for injunctive relief from March 20, 2012, through March 28, 2012. The following witnesses testified: Team Member # 23, Team Member # 17, Ohio Department of Rehabilitation and Correction (“ODRC”) Planning Section Chief Ron Erdos, Southern Ohio Correctional Facility (“SOCF”) Health Care Administrator Roseanna Clagg, Chillieothe Correctional Institution (“CCI”) Health Care Administrator Beth Ann Higginbotham, CCI attending physician Dr. Gary Krisher, SOCF Deputy Warden of Operations Michel Oppy, Pharmacological expert Dr. Mark Dershwitz, SOCF Deputy Warden of Special Services Anthony Cadogan, CCI Warden Norman Robinson, ODRC Deputy Planning Section Chief James Goodman, ODRC Director Gary Mohr, Team Member # 10, and SOCF Warden Donald Morgan. Wiles and Defendants each presented approximately one-hundred document-exhibits. This Court then held an additional telephone conference with the parties on March 29, 2012, at which various evidentiary issues were resolved.

The hearing testimony presented post-Lorraine factual developments. Director Mohr testified during the Wiles hearing that he was “upset” upon reading the Court’s decision regarding Lorraine. He explained that “[t]his is my 38th year, July 1st is my 38th year, and I have never read anything that was quite as negative about an operation that I have been responsible for ....” (Wiles Hr’g Tr„ Vol. VI, at 40.) Several days later, according to Director Mohr, ODRC East Regional Director Edwin Voorhies and ODRC in-house counsel Greg Trout pitched to him the idea of implementing Incident Command System (“ICS”) into Ohio’s execution process. As set forth in an ICS training document that Wiles submitted during the hearing and about which Planning Section Chief Ron Erdos testified:

The ICS is a management system designed to enable effective and efficient domestic incident management by integrating a combination of facilities, equipment, personnel, procedures, and communications operating within a common organization structure, designed to enable effective and efficient domestic incident management. A basic premise of ICS is that it is widely applicable. It is used to organize both near-term and long-term field-level operations for a broad spectrum of emergencies, from small to complex incidents, both natural and manmade. ICS is used by all levels of government-Federal, State, local, and tribal-as well as by many private-sector and nongovernmental organizations. ICS is also applicable across disciplines. It is normally structured to facilitate activities in five major function areas: command, operations, planning, logistics, and finance and administration.

(Pl.’s Ex. 72.)

Director Mohr testified that he thought Regional Director Voorhies’ suggestion of implementing ICS was a “great idea” because “fflt is a uniform command system, which is exactly what this Judge is telling us that this Director better be doing to micromanage this process.” (Wiles Hr’g Tr. Vol. VI, at 42.) Director Mohr testified that Regional Director Voorhies spent the weekend putting together a proposal (Defs.’ Ex. 45) that Director Mohr reviewed on Monday, January 16, 2012. (Wiles Hr’g Tr. Vol. VI, at 42-43.) Director Mohr testified that after discussing the proposal in-house with ODRC Assistant Director Stephen Huffman, SOCF Warden Donald Morgan, ODRC in-house counsel Greg Trout, and ODRC Planning Section Chief Ron Erdos, as well as with the Governor’s legal counsel and staff, “[m]y decision was to implement ICS as a supporting part of the execution protocol.” (Wiles Hr’g Tr. Vol. VI, at 45.)

For purposes of implementing ICS into Ohio’s execution process, it was decided early in the planning process for the Webb execution that the time period leading up to each execution would be divided into two operational periods. The first operational period would start at 8:00 a.m. approximately thirty (30) days out from a scheduled execution date and conclude at 7:00 a.m. on the day preceding that scheduled execution date. The second operational period would begin at 7:00 a.m. on the day preceding the scheduled execution date and conclude at 1:00 p.m. the next day. Thus, by way of illustration, the Webb execution, deemed an incident in ICS terminology, was scheduled for February 22, 2012, at 10:00 a.m. The first operational period began at 8:00 a.m. on January 23, 2012, and concluded at 7:00 a.m. on February 21, 2012. (Defs.’ Ex. 4.) The second operational period began at 7:00 a.m. on February 21, 2012, and concluded at 1:00 p.m. on February 22, 2012. (Defs.’ Ex. 18.)

According to the testimony and evidence, each operational period has its own distinct organizational structure. For each operational period of every execution, Director Mohr serves as the Incident Commander (“IC”). According to Director Mohr’s testimony, that meant that he would be “ultimately responsible for approving the objectives, approving the incident action plan and insuring that the resources are appropriate to carry out that incident action plan.” (Wiles Hr’g Tr. Vol. VI, at 46.) Turning again to the incident Webb execution, the organizational structure was as follows: Director Mohr served as the IC. His command staff consisted of Assistant Director Stephen Huffman serving as the Deputy IC; Melissa Adkins serving as the Recorder; JoEllen Smith serving as the Public Information Officer; and ODRC Chief Counsel Greg Trout serving as Safety Officer. Beneath the IC and his command staff, there existed four sections: Operations, Planning, Finance, and Administration. The latter two contained no personnel. The Planning Section was headed by ODRC Special Operations Commander Ron Erdos serving as Planning Section Chief.

The Operations Section for the first operational period was headed by Regional Director Edwin Voorhies serving as Operations Section Chief. Serving under Operations Section Chief Voorhies was SOCF Warden Donald Morgan, filling the role of the supervisor of all operations at SOCF for the first operational period. Beneath Warden Morgan was Team Member # 10, the Execution Team Leader, serving as the execution team task force leader. During the first operational period, the primary activities assigned to SOCF personnel are the carrying out of weekly execution rehearsals, as required by Section VI(B)(4) of Ohio’s execution protocol with Team Member # 10 documenting among other matters attendance and absences, and reporting the same to SOCF Warden Morgan. Warden Morgan would in turn recount those matters in detail during weekly meetings involving the IC, the IC’s command staff, SOCF personnel, and CCI personnel.

Also serving under Operations Section Chief Voorhies was CCI Warden Norm Robinson, filling the role of the supervisor of all operations at CCI for the first operational period. Beneath Warden Robinson were Dr. Gary Krisher, serving as the Medical Team Task Force Leader, and Rebecca Casto, serving as the Mental Health Task Force Leader. (Eventually, a third task force was created called the Observation/Watch Task Force, with J. Netter serving as the Task Force Leader. (Defs.’ Ex. 53, at 8.) According to documents, the Observation/Watch team will be tasked with moving the inmate to a new housing assignment approximately 72 hours prior to the scheduled execution, maintaining constant watch over the inmate, and completing a constant watch log.) Dr. Krisher’s task force consisted of Nurse Beth Ann Higginbotham, the CCI Health Care Administrator (“HCA”). Ms. Casto’s task force included Dr. Jerome Gotthardt, CCI staff psychologist. During the first operational period, Ohio’s execution policy requires CCI personnel to perform a number of tasks, including but not limited to: providing notification of the confirmed execution date; performing specified hands-on vein and physical assessments, medical chart review, and mental health assessments, with each documented in the inmate’s medical chart and any problems being reported immediate to the CCI Warden and SOCF Warden; and ensuring completion of the Execution Information Release form.

The first operational period was concluded by demobilization of the sections and units to which tasks had been assigned upon completion of those tasks. Planning Section Chief Ron Erdos was responsible for Demobilization, which involved conducting debriefing sessions, followed by the collection, review, and maintaining of documentation generated by the sections and units in completing their assigned tasks, followed finally by the “release” of the personnel. (Defs.’ Ex. 17.)

For the second operational period of the incident Webb execution, the organization structure was as follows: Director Mohr served as the IC. His command staff consisted of Assistant Director Stephen Huffman serving as the Deputy IC; Captain William Cool serving as the Recorder; JoEllen Smith serving as the Public Information Officer; Regional Director Edwin Voorhies serving as Safety Officer; and Robert Clagg serving handling Prison Management. (Defs.’ Ex. 20, at 176.) Beneath the IC and his command staff, there existed four sections: Planning, Logistics, Operations, and Finance. The Finance Section contained no personnel. The Planning Section was headed by ODRC Special Operations Commander Ron Erdos serving as Planning Section Chief. James Goodman served as Deputy Planning Section Chief, while Charlie Miller and Brenda Purtee were assigned to the Situation Unit.

The Logistics Section was headed by SOCF Deputy Warden Anthony Cadogan serving as Logistics Section Chief. Under the service unit within the Logistics Section, Chuck Bobst headed the communications unit and Sean Taylor headed the employee/inmate support services unit.

The Operations Section for the second operational period was headed by SOCF Warden Donald Morgan serving as Operations Section Chief. SOCF Deputy Warden Michel Oppy served as the Deputy Operations Section Chief. The Operations Section contained several divisions that were staffed with personnel. Team Member # 10, the Execution Team Leader, served as the Task Force leader for the Execution Strike Force/Task Force. His division included Team Member # 11. Jay Debold served as the Task Force leader for Transport. SOCF’s Health Care Administrator, Rosie Clagg, served as the Medical Task Force Leader. Team Member # 23 served as the Task Force Leader for the medical team members of the execution team. Finally, Mike Williams served as the Mental Health Task Force Leader.

The initial step that Director Mohr took to implement ICS into the execution process consisted of a planning meeting that took place on January 19, 2012. (Defs.’ Ex. 3, at 234.) According to Director Mohr, “we didn’t have a lot of time.” (Wiles Hr’g Tr. Vol. VI, at 45.) As Director Mohr explained, with the execution of Michael Webb scheduled for February 22, 2012, “we scheduled a planning meeting to launch this [ICS] process with the Webb execution.” (Id. at 46.) The January 19, 2012 planning meeting included via telephonic conference the IC’s Command Staff, CCI personnel, and SOCF personnel. From this point on, meetings were conducted no less than once per week. At every meeting, according to testimony, whether it is a planning meeting or a status briefing, Director Mohr has emphasized his expectation of strict compliance with Ohio’s execution policy, his expectation that no one, including himself, could deviate or authorize a deviation from the four core components listed on page 3 of the protocol, and his expectation that no one could deviate or authorize a protocol deviation from any non-core component without Director Mohr’s approval. Only the Director can approve a non-core deviation.

Implementing ICS into Ohio’s execution process involved (and will continue to involve) the following procedures. Turning again to the Webb execution by way of illustration, Planning Section Chief Ron Erdos began the process by developing a Formal Written Incident Action Plan and obtaining the IC’s approval of that plan. (Defs.’ Exhs. 4 and 5.) The documents he prepared included a form called the ICS 202 identifying objectives for the incident. Those objectives were to prepare for the humane execution of Inmate Michael Webb and to conduct appropriate medical and mental health evaluations and reviews no later than 21 days before the scheduled deadline for those tasks, January 31, 2012. (Defs.’ Ex. 5.) Erdos also prepared a form called the ICS 203 listing the organization summary for the first operational period, a form called the ICS 205 setting forth the communication plan, and a form called the ICS 206 setting forth the medical plan. Task Force members received their assignments on forms called ICS 204’s. (Defs.’ Ex. 7.) Each section’s activities were documented on forms called ICS 214 Unit Logs. (Defs.’ Exhs. 10, 11, 12, 13, 14.) Section and Division chiefs communicated with each other, as well as to the IC and command staff, using forms called ICS 213’s, documenting their progress on assigned tasks. (Defs.’ Exhs. 15 and 16.)

Returning to the initial planning meeting that took place on January 19, 2012, Director Mohr explained that the immediate focus turned to certain tasks that the protocol required to be carried out thirty (30) days prior to the scheduled execution date — namely, CCI Warden Robinson providing notification to the IC, as well as numerous other parties identified in Section VL(B)(1) of the protocol, of a “firm date” for the scheduled execution of an inmate and the CCI staff moving the inmate to 30-day watch status for purposes of ensuring the inmate’s safety. Attention focused also on the tasks that the protocol required to be carried out no later than twenty-one (21) days in advance of a scheduled execution. According to Director Mohr:

[T]he physical hands-on vein assessment, the medical chart review and assessment, and the mental health assessment are to be done within 21 days. So, we talked about completion of those three to four days in advance of that 21-day period, which would mark our next status briefing at that point to insure that we had an update to confirm that those were done and documentation to support the fact that they were done.

(Wiles Hr’g Tr. Vol. VI, at 61.) The planning and preparation process for the incident Webb execution also included the conducting and documenting of the execution team’s weekly rehearsals at SOCF — specifically, one per week for four weeks preceding the scheduled execution date. (Wiles Hr’g Tr. Vol. VI, at 62-63; Defs.’ Ex. 1, at 6.)

Next in the process was a status briefing on January 23, 2012, at which time Director Mohr approved the written incident action plan for the first operational period of the incident Webb execution. (Wiles Hr’g Tr. Vol. VI, at 64.) On that same date, CCI Warden Robinson provided the 30-day notification required by 01-COM-11 and advised the IC of the same via an ICS 213 form. (Defs.’ Ex. 1, at 5; Wiles Hr’g Tr. Vol. VI, at 66-67; Defs.’ Ex. 16, at 294.) The following day, January 24, 2012, CCI Warden Robinson sent another ICS 213 form notifying the IC that appropriate CCI personnel had completed all of the assessments and documentation required by the policy — several days in advance of the 21-day deadline, as the IC and Warden Robinson had discussed at the initial planning meeting. However, because CCI had completed those tasks before they had actually received their ICS 204’s specifying their assigned tasks, Director Mohr directed them to re-do all of those tasks after they received their 204’s. (Wiles Hr’g Tr. Vol. VI, at 69.)

Before CCI could re-do those tasks, this Court on January 26, 2012, issued an order staying the execution of Michael Webb. Instead of aborting the process and planning for the next scheduled execution, Director Mohr decided to continue the process for Webb as if the execution were still scheduled to be carried out on February 22, 2012. Of that decision, Director Mohr explained:

Everyone involved in this process, including this Director, needed to be trained and needed additional exposure and training as we were, one, insuring that we were compliant with the policy, and two, continuing to get used to some of the supporting documents like the checklist, and three, with incident command being made available as a supporting protocol, we all needed practice.

(Wiles Hr’g Tr. Vol. VI, at 55.)

Proceeding with the incident Webb execution as a training exercise, CCI re-did the assessments and documentation required by the protocol to be completed no later than 21 days in advance of the scheduled execution. (Defs.’ Ex. 16, at 300.) Because the incident had become a training exercise, the CCI personnel simulated those tasks rather than performing them again on an inmate who no longer had an imminent execution date. (Wiles Hr’g Tr. Vol. IV, at 184, 189; Wiles Hr’g Tr. Vol. VI, at 70.) Similarly, all of the resulting documentation included notations clearly reflecting that they were a part of “training.” (Defs.’ Ex. 16, at 302-04.) One of the last tasks that the protocol requires CCI, or the “parent institution,” to carry out consists of the warden of the parent institution ensuring that the condemned inmate completes an “Execution Information Release”- — a form ODRC 1808. (Defs.’ Ex. 1, at 7.) CCI Warden Robinson sent an ICS 213 message on February 14, 2012, indicating that CCI had completed that task. (Defs.’ Ex. 14, at 279.)

Weekly meetings continued, with status briefings held on January 27, 2012, February 1, 2012, and February 7, 2012. Whenever possible, status briefings were conducted immediately preceding the execution rehearsals. As Director Mohr explained, “it exposes more people, number one, and two, any direction that may come out can be conveyed to the entire team, any of that information, just enhanced communication.” (Wiles Hr’g Tr. Vol. VI, at 75.) Thus, Director Mohr participated in many of the status briefings from SOCF in Lucasville, Ohio, rather than the central office in Columbus, Ohio. Another status briefing and rehearsal were conducted on February 15, 2012. That status briefing, according to Director Mohr, included the closing of “the Chillicothe loop” because CCI had completed all tasks that Ohio’s execution policy required them to complete. (Wiles Hr’g Tr. Vol. VI, at 76.)

The next step that occurred in the incident Webb execution training exercise was a planning meeting on February 17, 2012, to launch the second operational period that would commence on February 21, 2012, at approximately 7:00 a.m. (Wiles Hr’g Tr. Vol. VI, at 77-78; Defs.’ Exhs. 18-23.) During that meeting, Planning Section Chief Ron Erdos presented a written incident action plan that he had developed and that Director Mohr had approved. Director Mohr emphasized as he did at every meeting his expectations of strict compliance with the protocol. Everyone proceeded to discuss in detail the events that would take place at SOCF for the two days comprising the second operational period — February 21 and February 22, 2012. (Wiles Hr’g Tr. Vol. VI, at 81.) Further, Director Mohr approved several changes, the first of which consisted of moving Deputy Warden Oppy, who was serving as Warden Morgan’s back-up or “shadow,” from the Command Center to the Death House for execution rehearsals and actual executions. The second change involved restricting Team Member #21 from participating in the February 22, 2012 rehearsal, due to the fact that contractual issues had prohibited Team Member #21-a medical team member-from participating in the weekly rehearsals leading up to the February 22, 2012 execution training exercise. Finally, Director Mohr approved a “procedural change” in the manner in which the execution drugs would be transported from the SOCF infirmary in one building to the Death House, which was a separate building. Director Mohr explained an intention to have the pharmacist deliver the execution drugs from the SOCF safe to Health Care Administrator Clagg in the SOCF infirmary. Clagg would then turn those drugs over to the drug administrator assigned with the task of actually administering the drugs for the execution, witnessed by a second drug administrator, while still in the SOCF infirmary. Those two drug administrators and Nurse Clagg would then walk the execution drugs from the SOCF infirmary to the Death House. Previously, Clagg alone had transported the execution drugs from the infirmary to the Death House.

Testimony and evidence established that the execution rehearsal scheduled for February 22, 2012, would be not just a training session or rehearsal, but a “full-scale scenario.” Full-scale scenarios are intended to be as close to the real incident as possible. Thus, whereas execution rehearsals typically commence with the SOCF Warden reading the Death Warrant to the condemned inmate-actor at the cell front in the Death House, the full-scale scenario for the Webb execution training exercise included such simulated tasks as the transport of Webb from CCI to SOCF on the morning of February 21, 2012, the assessments of Webb following his arrival at SOCF, and the transport of the drugs from the SOCF infirmary to the Death House. The full-scale scenario for the Webb execution training exercise also included such actual tasks as conducting a confirmed information briefing and transporting the execution drugs from the infirmary to the Death House, albeit without using any actual drugs. Testimony and evidence established that two execution run-throughs occurred on February 22, 2012, with the first being the full-scale scenario involving the “Plan A” intravenous administration of drugs (Defs.’ Ex. 1, at 13-14) that concluded with the simulation of a funeral director taking possession of the inmate’s body, and a second more informal run-through during which the team practiced the “Plan B” intramuscular administration of drugs (Defs.’ Ex. 1, at 10,14-15).

The February 22, 2012 Webb execution training exercise concluded with a debriefing and after action review. (Defs.’ Ex. 44, at 197.) SOCF Warden Morgan subsequently sent to Director Mohr an After-Action Review report dated February 28, 2012. (Defs.’ Ex. 48.) In an email from Director Mohr to SOCF Warden Morgan dated March 1, 2012, Director Mohr stated that he accepted Warden Morgan’s February 28, 2012 report with the exception of two points. As Director Mohr set forth:

1. Please include in your After Action Report the Confirmed Information Briefing held prior to the commencement of the execution procedure at which time I confirmed that the elements contained in the policy had been completed, reviewed and approved. This planned meeting that is to take place prior to the commencement of each execution and become a regular step in our protocol and confirmed in our after action report.

2. A security challenge was introduced prior to the rehearsal for Webb directing the Drug Administration Task Force Team Leader #23 not to call into the command center to report the drug preparation. In fact, at the completion of the drugs being prepared, Drug Administrator # 17 noticed that the Task Force Leader #23 did not report as he should and advised the Team Leader that the task had occurred and that it should be reported to the Command Center. The Team Leader called the preparation of the drugs to the Command Center. Please revise the After Action Report to reflect that I approved the variation in reporting the drug administrator’s preparation of the drugs as a result of the security challenge, that the Team Leader called it in at the direction of Drug Administrator # 17 and that the team leader communication is approved by the Director.

(Defs.’ Ex. 49, at 1.) SOCF Warden Morgan accordingly submitted a revised After-Action Review report dated March 6, 2012. (Defs.’ Ex. 50.)

Testimony and evidence established that all involved personnel, from the IC and his command staff, to the CCI personnel, to the SOCF personnel, currently are within the first operational period preceding the Mark Wiles execution scheduled for 10:00 a.m. on April 18, 2012. The IC and Planning Section Chief conducted a planning meeting on Friday, March 16, 2012, involving all personnel from the command staff, CCI, and SOCF. The IC and Planning Section Chief introduced a written incident action plan which the IC subsequently approved on March 16, 2012, at 12:30 p.m. (Defs.’ Ex. 53, at 1.) The planning meeting covered the incident objectives, the organizational summary list, the ICS 204 task force assignment lists, the communications plan, and the medical plan. (Defs.’ Ex. 53, at 1-15.) All involved personnel then participated in a status briefing the following Monday — March 19, 2012 — at which time they gauged their progress on completion of tasks required by the protocol and assigned to task force members in the ICS 204 forms.

The first operational period for the Wiles execution thus began on March 19, 2012, at 8:00 a.m. and will conclude on April 17, 2012, at 7:00 a.m. Testimony and evidence established that certain tasks required by Ohio’s execution policy leading up to the April 18, 2012 execution date have been completed. At SOCF, the execution team has been conducting the weekly rehearsals required in Section VI.B.4. of the execution policy. (Defs.’ Ex. 1, at 6.)

CCI Warden Norm Robinson, approximately 30 days prior to the scheduled execution, notified Director Mohr that a firm date — April 18, 2012 — is scheduled for inmate Mark Wiles’ execution. (Defs.’ Ex. 1, at 5.) CCI Warden Robinson sent a copy of that notification to Planning Section Chief Ron Erdos, who subsequently sent notification to the Regional Director, DRC Chief Counsel, Assistant Director, APA, Ohio State Highway Patrol (Portsmouth and Jackson), and the Office of Victim Services. Following an “impromptu telephone conference” on Friday March 23, 2012, involving the IC, Erdos, Robinson and others, CCI Warden Robinson subsequently sent the notification again to the Regional Director, DRC Chief Counsel, Assistant Director, APA, Ohio State Highway Patrol (Portsmouth and Jackson), and the Office of Victim Services. Further, the hands-on vein assessment, medical chart review and physical assessment, and the mental health assessment have been conducted at CCI, with documentation of the same indicated in Wiles medical chart and no problems detected that might pose a problem carrying out the execution or require contingency plans. (Defs.’ Ex. 1, at 5.)

II. Injunctive Relief Analysis

A. Standard Involved

In considering whether injunctive relief staying Wiles’ execution is warranted, this Court must consider (1) whether Wiles has demonstrated a strong likelihood of success on the merits; (2) whether Wiles will suffer irreparable injury in the absence of equitable relief; (3) whether a stay would cause substantial harm to others; and (4) whether the public interest is best served by granting a stay. Cooey v. Strickland, 589 F.3d 210, 218 (6th Cir. 2009) (citing Workman v. Bredesen, 486 F.3d 896, 905 (6th Cir.2007); Ne. Ohio Coal, for Homeless & Serv. Employees Int’l Union, Local 1199 v. Blackwell, 467 F.3d 999, 1009 (6th Cir.2006)). The Sixth Circuit has explained that “ ‘[tjhese factors are not prerequisites that must be met, but are interrelated considerations that must be balanced together.’ ” Id. (quoting Mich. Coal, of Radioactive Material Users, Inc. v. Griepentrog, 945 F.2d 150, 153 (6th Cir.1991)).

B. Likelihood of Success

Wiles’ motion asserts arguments falling under his fourth claim, which is an Equal Protection claim under 42 U.S.C. § 1983. Section 1983 provides:

Every person who, under color of any statute, ordinance, regulation, custom, or usage, of any State ... subjects, or causes to be subjected, any citizen of the United States or other person within the jurisdiction thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law, suit in equity, or other proper proceeding for redress ....

42 U.S.C. § 1983. Thus, in order to prevail on his § 1983 claim, Wiles must show that, while acting under color of state law, Defendants deprived or will deprive him of a right secured by the Federal Constitution or laws of the United States. See Alkire v. Irving, 330 F.3d 802, 813 (6th Cir.2003).

Wiles pleads that “Defendants’ overarching execution policy, including their wholly discretionary approach to their written execution protocol and their informal policies, violates [his] rights to equal protection under the law as guaranteed by the Fourteenth Amendment.” (ECF No. 4 ¶ 1077.) He contends that the protocol is facially invalid because it codifies disparate treatment of similarly situated individuals without sufficient justification so as to be arbitrary, irrational, and capricious.

The Sixth Circuit has explained the inquiry this argument necessitates:

“The Equal Protection Clause of the Fourteenth Amendment commands that no state shall ‘deny to any person within its jurisdiction the equal protection of the laws.’ U.S. Const, amend. XIV, § 1. The Supreme Court has stated that this language ‘embodies the general rule that States must treat like cases alike but may treat unlike cases accordingly.’” Radvansky v. City of Olmsted Falls, 395 F.3d 291, 312 (6th Cir.2005) (quoting Vacco [v. Quill], 521 U.S. [793] at 799, 117 S.Ct. 2293[, 138 L.Ed.2d 834 (1997) ]). To establish a claim for relief under the Equal Protection Clause, a plaintiff must demonstrate that the government treated the plaintiff disparately as compared to similarly situated persons and that such disparate treatment either burdens a fundamental right, targets a suspect class, or has no rational basis. Id.; see also TriHealth, Inc. [v. Board of Com’rs, Hamilton County, Ohio], 430 F.3d [783] at 788 [ (6th Cir. 2005) ].

Club Italia Soccer & Sports Org., Inc. v. Charter Twp. of Shelby, Mich., 470 F.3d 286, 298 (6th Cir.2006). When the disparate treatment burdens a fundamental right, strict scrutiny applies. Miller v. City of Cincinnati, 622 F.3d 524, 538 (6th Cir.2010). What this means is that the state action is permissible only if it is narrowly tailored to a compelling governmental interest. Cf. Does v. Munoz, 507 F.3d 961, 964 (6th Cir.2007).

One fundamental right involved in inmate claims such as that asserted by Wiles is the right to be free from cruel and unusual punishment. As they have in the past, Defendants continue to attempt to transform this Fourteenth Amendment claim into a pure Eighth Amendment claim. But as this Court has previously explained in its Smith Opinion and Order,

the former claim sufficiently targets that sweeping core deviations would at least burden Plaintiffs fundamental right by negating some of the precise procedural safeguards that this Court and the Sixth Circuit heralded in prior discussions of Eighth Amendment claims in this same litigation. For present purposes, it does not matter whether there is a qualifying risk of severe pain-a conclusion rejected by the only medical expert who testified-but only the creation of unequal treatment impacting the fundamental protection involved.

Cooey (Smith), 801 F.Supp.2d at 653. This Court is again reluctant to hold that there can only be an equal protection violation when there is an Eighth Amendment violation.

There is relatively little authority in regard to the burden on a fundamental right that would warrant strict scrutiny here. Recently, the Ninth Circuit addressed a § 1983 equal protection claim that implicated similar analysis in Towery v. Brewer, 672 F.3d 650 (9th Cir.2012). After rejecting the argument that the state execution protocol at issue violated the Eighth Amendment prohibition on cruel and unusual punishment — a protocol that affords significantly more discretion than Ohio’s protocol does — that court of appeals explained:

As we have already determined, the protocol as it will be implemented for [plaintiffs’] executions does not violate their right under the Eighth Amendment to be free from cruel and unusual punishment. Where there is no Eighth Amendment violation, the district court ruled, that necessarily means that there has been no interference with fundamental rights sufficient to trigger strict scrutiny under the Equal Protection Clause. See Mass. Bd. of Ret. v. Murgia, 427 U.S. 307, 312, 96 S.Ct. 2562, 49 L.Ed.2d 520 (1976). We do not need to adopt this broad proposition to conclude that given the ways the Director has chosen to exercise his discretion in the upcoming executions, there has been no showing here of any burden on the right to be free of cruel and unusual punishment.

Id. at 659. Thus, the Ninth Circuit expressly declined to adopt the proposition that “burdens a fundamental right” means nothing less than a full violation of the fundamental right. The Ninth Circuit explained:

[Plaintiffs] argue otherwise, relying on Bush v. Gore, 531 U.S. 98, 105, 121 S.Ct. 525, 148 L.Ed.2d 388 (2000). Urging that there is a distinction between state action that violates a fundamental right and state action that merely burdens a fundamental right, they proffer that the latter was sufficient to trigger strict scrutiny in Bush and should also be here.

The right to vote, however, “ ‘can be denied by a debasement or dilution of the weight of a citizen’s vote just as effectively as by wholly prohibiting the free exercise of the franchise.’ ” Id. (quoting Reynolds v. Sims, 377 U.S. 533, 555, 84 S.Ct. 1362, 12 L.Ed.2d 506 (1964)). A prisoner’s right to be free of cruel and unusual punishment, in contrast, is not affected simply because that prisoner is treated less favorably than another, where one means of execution is no more likely to create a risk of cruel and unusual punishment than the other, and both are constitutionally available. Treating one similarly situated prisoner differently from another with regard to punishment does not inherently impact the right to be free of cruel and unusual punishment (although it might for other reasons violate the Equal Protection Clause).

That is not to say that there could not be exercises of discretion that do burden the right to be free of cruel and unusual punishment. The contrast with the litigation surrounding Ohio’s lethal injection protocol, invoked by [plaintiffs] in support of their fundamental rights Equal Protection argument, is instructive. In those cases, plaintiffs were able to show an actual pattern of treating prisoners differently in ways that did affect the risk of pain to which they would be subjected, and therefore the risk of being subjected to cruel and unusual punishment. See In re Ohio Execution Protocol Litig., 840 F.Supp.2d 1044, 1053-54 (S.D.Ohio 2012), motion to vacate stay denied, 671 F.3d 601 (6th Cir.2012). Here, no such showing has been made, either generally or with respect to the planned application of the protocol to [plaintiffs’] executions. The fundamental rights prong of Equal Protection analysis therefore cannot apply.

Id. This analysis is instructive. The prior deviations upon which various plaintiffs in this litigation previously focused often were “more likely to create a risk of cruel and unusual punishment” than an execution without the deviations and “did affect the risk of pain to which they would be subjected, and therefore the risk of being subjected to cruel and unusual punishment.” Id. Many of the non-core deviations eliminated the procedural safeguards upon which the Sixth Circuit and this Court have expressly relied in the past in concluding that Ohio’s execution procedures survived Eighth Amendment scrutiny. And the practice of core deviations that arose once again in Lorraine undercuts the purported inability of Ohio to deviate from core deviations, pointing to at least a burden on the fundamental right involved if not outright disregard of that right.

To require an Eighth Amendment violation would suggest a narrow perspective that transforms the Equal Protection Clause into nothing more than a redundant backdoor route to the Eighth Amendment. Cf. Special Programs, Inc. v. Courier, 928 F.Supp. 851, 855-56 (E.D.Va.1996) (explaining that “it is mere impingement upon, not impermissible interference with, the exercise of a fundamental right that triggers strict scrutiny”). Moreover, the Sixth Circuit’s express reliance in Kasich v. Lorraine, — U.S.—, 132 S.Ct. 1306, 181 L.Ed.2d 1034 (2012), on this Court’s prior equal protection analysis points to partial if not full agreement with this Court’s rationale. Even if this Court is incorrect and no fundamental right is burdened here, there is still the possibility of rational basis review, discussed in the following text.

Wiles also asserts that he is a class of one subject to treatment that burdens his fundamental rights in a manner that is not rationally related in any way to a legitimate state interest. It is well settled that “the Supreme Court has recognized that a ‘class-of-one’ may bring an equal protection claim where the plaintiff alleges that: (1) he or ‘she has been intentionally treated differently from others similarly situated’; and (2) ‘there is no rational basis for the difference in treatment.’ ” United States v. Green, 654 F.3d 637, 651 (6th Cir.2011) (quoting Vill. of Willowbrook v. Olech, 528 U.S. 562, 564, 120 S.Ct. 1073, 145 L.Ed.2d 1060 (2000)). Defendants’ argument in opposition to Wiles’ class-of-one claim is that because Ohio allegedly fails to apply its protocol consistently from execution to execution, as opposed to deviating intentionally in regard to any particular inmate, there is no equal protection violation. (ECF No. 95, at 7-8.)

Fairly characterized, Defendants’ reasoning amounts to “because we consistently act inconsistently in regards to the protocol, we cannot be regarded as intentionally treating any specific capital inmate differently from others similarly situated.” In other words, Defendants argue that overarching ineptness in applying the protocol provides a shield against the challenge that Ohio fails to apply its own protocol. This is the epitome of close enough for government work. The extant question is whether such a disappointing approach is good enough for the Constitution.

This Court has grown increasingly suspect about the vitality of a class-of-one claim in this context; there are issues surrounding the first prong of the test that present this Court with issues. The Ninth Circuit’s discussion of such a claim in Towery perhaps provides some guidance, with the court of appeals explaining that

[ajbsent any pattern of generally exercising the discretion in a particular manner while treating one individual differently and detrimentally, there is no basis for Equal Protection scrutiny under the class-of-one theory. In other words, the existence of discretion, standing alone, cannot be an Equal Protection violation. At the very least, there must be some respect in which the discretion is being exercised so that the complaining individual is being treated less favorably than others generally are.

Towery, 672 F.3d at 661. Discretion alone is therefore not a problem, but the exercise of that discretion in a detrimental manner would suggest a possible class-of-one claim.

Sometimes deviations occur and no one can explain why or how they happened, as this Court has discussed numerous times in prior orders. Sometimes deviations are intentional, as in the failed execution of Rommell Broom when Defendants introduced a doctor into the execution proceedings who was not a member of the execution team (a direct violation of the protocol) and who promptly attempted to start an IV site only to hit the inmate’s ankle bone in the process before the doctor fled from the room (and from a protocol violation that resulted in the infliction of pain by someone who was not supposed to even be in the building, much less an ad hoc member of the execution team).

Broom was certainly treated intentionally differently than other inmates. Bringing in an unhelpful doctor to assist was in violation of the protocol, and the result was the imposition of pain caused by someone who should not have even been in the Death House. The pattern of such deviations that past executions have revealed does not render Wiles’ class-of-one claim ridiculous under this first prong.

The Sixth Circuit has explained the remaining prong of the class-of-one inquiry as follows:

Under the rational basis test, courts will not overturn government action “unless the varying treatment of different groups or persons is so unrelated to the achievement of any combination of legitimate purposes that [the court] can only conclude that the [government’s] actions were irrational.” Kimel v. Fla. Bd. of Regents, 528 U.S. 62, 84, 120 S.Ct. 631, 145 L.Ed.2d 522 (2000) (internal quotation marks and citation omitted). There are two ways that a “class-of-one” plaintiff may demonstrate that a government action lacks a rational basis: (1) showing pure arbitrariness by negativing every conceivable basis that might support the government’s decision; or (2) showing an illegitimate motive such as animus or ill will. Warren v. City of Athens, Ohio, 411 F.3d 697, 711 (6th Cir.2005).

Green, 654 F.3d at 651-52. Here, evidence has revealed a consistent pattern of arbitrary deviations from the protocol. The only real explanation for this pattern is that Ohio was trying to end an inmate’s life under any procedure that might accomplish the task. Such a reason cannot suffice because it exists in every execution, as well as in every scenario in which a rational basis test would apply: there is always an ultimate goal. Some of the deviations with which this Court has dealt have failed to present a rational relationship to a legitimate state interest.

Notably, the Ninth Circuit did not outright reject a class-of-one claim in Towery. Rather, the court of appeals explained that under the specific circumstances presented, the claim was not viable:

Even if we were to subject the protocol’s grant of discretion to the Director to rational basis review, it would survive our consideration. It is rational for ADC to conclude that the Director is best situated to select the execution team from those available who meet the criteria listed in the protocol (assuming those criteria do not themselves create a risk of harm greater than that tolerable under the Eighth Amendment), or to decide that the Director should be the one to select which of the four possible drug sequences to use, or to assign to the Director and the IV Team Leader the task of selecting which IV site to use. It is entirely rational for these determinations to be made on a ease-by-case basis, as they may well depend on individualized and changing factors such as the availability of particular people to participate in the execution, the supply of drugs available to the State at a given time, and the condition of the prisoner’s veins. The Equal Protection claim, as framed here, cannot succeed on the merits.

Towery, 672 F.3d at 661 (emphasis added).

Against these claims, Wiles points to Ohio’s pattern of unintentional and intentional deviations and argues that the state actors involved in carrying out Ohio’s protocol neither understand the protocol requirements nor are able or willing to fulfill their roles under the execution procedures. He argues that the demonstrated pattern of deviations that this litigation has so often addressed evinces a continuing unwillingness or inability of Defendants to adhere to equal application of the protocol.

The underlying rationale behind such arguments is essentially twofold. Wiles asserts that the evidence indicates that too few, if any, of the state actors truly understand the protocol, so that even if the protocol on its face is constitutional, this Court cannot take Defendants at their word that they are capable of following the protocol. Beyond arguing simply this “junk in, junk out” rationale, Wiles also asserts that the plans for his execution present improper deviations that offend equal protection and that ICS cannot catch, much less prevent.

This Court disagrees that the evidence indicates that Defendants do not understand the protocol. The Court also disagrees that the evidence indicates either that Defendants intend to violate the protocol or that ICS is likely ineffectual.

The evidence does suggest some inconsistency among select state actors as to what the protocol requires or what various components of ICS mean. For example, Team Member # 23 had some notable difficulty remaining consistent in his usage of ICS terms, confusing the specific titles assigned to supervisors and groups within the ICS command structure. This does not present sufficient evidence of an inability to adhere to the fundamental ICS principles that Defendants assert will remedy past issues with implementing the execution protocol. Continued training under the relatively newly implemented ICS system will enable execution participants to learn the system better.

Additionally, evidence indicated that key actors in the ICS command structure were considering utilizing a Powerpoint presentation to ensure that those individuals labeled “the doers” — those who are assigned the jobs of carrying out the actual tasks constituting action under the protocol— fully recognize who holds what positions and what those positions mean. Mixing up terms such as “strike force” with “task force” or other similar misstatements does not necessarily mean that an individual does not know and understand his or her specific role in the ICS structure and the protocol duties that accompany that role. Every state actor who testified, regardless of the depth of his or her understanding of ICS, appeared to understand the two-part mantra that Mohr and the execution team management have been emphasizing: there can be no deviation from any core component of the protocol, and any potential non-core deviation must flow up to the Incident Commander, who everyone recognized to be Mohr.

Wiles argues that even if everyone understands that these are the twin controlling precepts of the protocol scheme and its ICS-enhanced surrounding procedures, such understanding is worthless if the state actors do not actually understand what is a core deviation versus a non-core deviation. In other words, simply saying the right words does not matter if the speakers do not understand what those words actually mean. You cannot report that which you do not perceive.

Wiles argues that Defendants are attempting to circumvent recognition of deviations by talking around what the protocol requires. At the hearing, much evidence focused on what Defendants deemed “procedural changes” versus protocol deviations. Defendants characterized procedural changes as meaning changes in the procedures as to how a protocol task gets accomplished. This Court does not care what label a change receives. What the Court does care about is the effect of that change. In other words, semantics do not matter for purposes of today’s inquiry. What matters is that the procedural change cannot effectuate a substantive change in the protocol that creates a deviation from the requisite what must be done, but it can sometimes present a change in how that something is accomplished depending upon the specificity of whichever protocol provision is implicated in the change.

Depending upon the particular circumstances involved, there can be more than one permissible way of accomplishing a protocol task. So long as there is no substantive departure from the protocol task, the label assigned to an alteration in the means employed to fulfill that task does not matter. Wiles’ attempt to conflate procedural change with altering the policy without altering the policy is therefore unfounded. Far from presenting a system in which Defendants can do virtually anything they want so long as they deem it a procedural change and not a deviation, the evidence instead presents that there is an inherent restriction on the scope of what can be done as a procedural change.

Of greater concern to this Court is whether the state actors involved understand what constitutes a core deviation and a non-core deviation. Some subordinate actors displayed confusion over this issue, and some displayed a dubious understanding of whether past executions presented deviations. But everyone understands that every change flows to Mohr in his role as Incident Commander. This finding necessitates making two points.

The first point is that the evidence does not rise to the level required for the Court to accept the contention that confusion invariably presents unconstitutionality. Wiles argues that if the state actors involved do not understand what the protocol requires, then logic dictates that they cannot recognize when there is a deviation (regardless of its core versus non-core nature). He posits that unrecognized deviations are unlikely to flow up the chain of command as the protocol requires and as ICS is meant to ensure. The logical leap in this reasoning is that it presumes solitary actors who are not subject to constant and consistent corrective review.

An execution participant such as a doer may not recognize when he or she engages in a deviation of any nature, but an effectively implemented ICS system subjects that individual and the process to accountability by continual review. Reporting of task-oriented actions flows upward, and the regular reviews that often include a plethora of checklists and other documentation presents a system of checks and balances in which a potential misstep is likely to be recognized even when the actor whose actions will constitute or have constituted a deviation is unaware of the deviation. To obtain a stay on his lack-of-understanding argument, Wiles has the burden of establishing sufficiently that evidence of select confusion by various actors presents a substantial likelihood of a constitutional violation. The evidence does not rise to this level.

The second requisite point is that Mohr has a fundamental understanding of his protocol sufficient to overcome any inadvertent or misguided mischaracterization he may possess. This conclusion speaks to Mohr’s construction of the third of five core components of the protocol. Section V of the protocol provides in part that “[f]unctions required to be performed by medically-qualified persons, as described in this policy, shall be performed by Medical Team Members.” Mohr testified that he construes the functions described in this core component to be medical functions. He is incorrect. There is no adjective modif