America’s Continuing Experiment with Lethal Injection Executions

The state of Oklahoma executed Richard Rojem in June 2024. In 1984, he abducted and sexually assaulted his seven-year-old stepdaughter.

In May 2024, Oklahoma executed Michael Dewayne. Dewayne was convicted of killing two people. He was high on drugs at the time of the killings. That was in 2002.

Oklahoma killed Rojem and Dewayne with “lethal injections.” Proponents say this is the most humane way of killing condemned prisoners. With lethal injection, the prisoner is restrained on a gurney and “chemicals” are administered via an intravenous line to cause death.

I first heard about lethal injection executions when I was a medical student in the late 1980s. I was unsettled then. It seemed that medical science was being used to affirmatively harm people. Today, I am a medical school professor and scientist. I remain troubled by capital punishment in general, and the lethal injection method in particular.

In the United States, the government has executed condemned prisoners by hanging, firing squad, and electric chair as well as the gas chamber. The French have previously used the guillotine. The last execution in France was in 1977, and capital punishment there has since been abolished.

Although the Nazis contemplated lethal injection execution, the first jurisdiction to authorize this method of execution was Oklahoma. This was in 1977.

William Wiseman, a brilliant and charismatic Oklahoma state legislator, made lethal injection executions happen. He was elected while still a law student and wrote the statute that authorized lethal injection.

Wiseman wanted a less violent approach of carrying out executions. He was shown photographs of prisoners who were previously executed with the electric chair by the state’s chief medical examiner, Dr. A. Jay Chapman. The burned and disfigured corpses horrified Wiseman. Wiseman wrote, “When the lever is pulled, the body twists and shudders violently, cooks and sizzles obscenely, and emits horrible noises from the nose, mouth and anus. The smell of cooking flesh mingles wretchedly with the reek of voided bowels and bladder.”

Wiseman’s father and grandfather were prominent protestant ministers.

Proponents of lethal injection executions present a progressive and compassionate narrative. As Mark Inch, who served as Florida’s secretary of corrections, put in a 2021 letter to Governor Ron DeSantis, lethal injection executions are “compatible with evolving standards of decency that mark the progress of a maturing society, the concepts of the dignity of man, and advances in science, research, pharmacology, and technology. The process will not involve unnecessary lingering or the unnecessary or wanton infliction of pain and suffering.” Ricky Dixon, the current Florida secretary of corrections, repeated this characterization, verbatim, in 2023. Dixon made his remarks in a letter to DeSantis. Inch is a graduate of Wheaton College, which is at the forefront of the evangelical movement. Billy Graham was an alumnus. Inch majored in “biblical archeology.” He was previously the director of the Federal Bureau of Prisons. Inch retired from full-time military service as a major general.

Wiseman, with the assistance of Chapman, convinced the state legislature to adopt the following statute: “The punishment of death must be inflicted with the continuous intravenous administration of a lethal quantity of an ultra-short acting barbiturate in combination with a chemical paralytic agent until death is pronounced by a licensed physician according to the accepted standards of medical practice.”

Fast forward to 2024. Lethal injection, by far and away, is the most common method of execution. In the United States, about 1,600 prisoners have been executed since 1976. About 1,400 executions have been carried out with lethal injections. In this time period, the electric chair has been used about 150 times.

To proponents, lethal injection executions have all the trappings of a medically supervised treatment. But the reality is different.

The killing of prisoners does not fall within the domain of medical practice. Condemned prisoners are not patients. The Hippocratic oath—do no harm—forbids doctors from administering lethal injection executions. Medical treatment is supposed to be therapeutic. This is not the case in executions, whose intended goal is death. Drugs given to patients have been rigorously tested in a process supervised by the Food and Drug Administration (FDA). The “sponsor” must, typically, test the drug on people who are healthy and then on people who are sick. Clinical trial participants are methodically polled about side effects. With regard to the chemicals that are used in lethal injection executions, there are no clinical trials evaluating the use of midazolam or pentobarbital at the administered doses. There are several practical reasons for this. In the first instance, by design, the prisoners receiving the chemicals are not expected to survive after administration. As such, the recipients cannot be polled regarding side effects. Clearly, the therapeutic benefit is a non sequitur in these circumstances. Without regulatory approval, there is no “package insert” to guide the administration of these chemicals. The package insert is the official guidance related to how a drug is to be used in people.

Drs. Joel Zivot, Mark Edger, and David Lubransky stepped into this scientific vacuum. Zivot is an anesthesiologist in Atlanta; Edger, a pathologist at the Mayo Clinic; and Lubrasky, an anesthesiologist at the University of California at Davis. They painstakingly reviewed the autopsy findings of 43 prisoners killed by lethal injection protocols in eight states. The authors found that 76 percent of the prisoners had autopsy findings of “pulmonary edema,” which is often associated “with froth filling airways.” The authors say that froth in the airways “suggests physical or chemical injury as seen in death by drowning, electrocution, inhalation of toxic gas, or heroin overdose.”

“The death here is akin to death by drowning where their lungs are filled with fluid, and they choke, and they may have awareness of this and that’s how they die. They die of suffocation,” Zivot said in a video interview with Al Jazeera in 2021.

The study has not been published in any peer-reviewed journal. However, it is readily available as a “preprint.” The authors acknowledge that they only personally conducted an autopsy on one of the 43 prisoners. In all the other cases, they reviewed the autopsy reports—the written assessment of other pathologists.

I have thoroughly searched the medical literature. There is no other scientific article that thoroughly reviews the pathological findings.

In this context, although not perfect, this is the best science available. As a scientist, I would say that paper is very well drafted. I interviewed Zivot and Edgar and they were able to cogently articulate their findings and conclusions. Nevertheless, detractors would discount the study conclusions as an overreach—a mostly paper exercise, not based on an actual review of the actual pathological specimens.

Zivot, in addition to his medical training, has two graduate degrees—one in medical ethics and another in law. He says that he is “agnostic” on the probity of capital punishment. But he also says that “medical science should not be used to carry out punishment on prisoners.” He has testified as an expert witness on behalf of death row inmates.

So where does the truth lie? Are lethal injection executions an awful way to kill prisoners? Alternatively, when properly administered, is this method a painless and humane method to effectuate a judicially sanctioned homicide?

Absent clinical trials of lethal injections, we are left to make physiological and mechanistic inferences based on the clinical experience in patients, where the desired goal is for the patient to survive.

At the current time, the most common death-effectuating cocktail incorporates three chemicals. Rojem and Dewayne were executed with the three-drug cocktail. The first is a sedative chemical that makes the prisoner unconscious. Currently, midazolam is the drug most used. It is important to understand that midazolam causes people to “go to sleep.” It does not stop a person from experiencing pain.

The second chemical stops the muscles from moving—a “paralytic” in medical jargon. Once this chemical is injected into the blood system, the prisoner cannot move their chest to breathe. Air cannot be sucked into the lungs. The entire body is chemically paralyzed. At this point, the prisoner may not be able to signal perceived pain or anxiety to the witnesses attending the execution.

It is important to understand paralytic chemicals do not stop people from experiencing pain or distress.

The final drug is supposed to stop the heart from beating.

The other common approach in lethal injection executions is to give one chemical—an intravenous injection of pentobarbital. This chemical suppresses lung and heart function. Pentobarbital has many legitimate uses. Veterinarians use this drug to euthanize animals. Physicians use it to treat seizures in human beings.

If everything goes as planned, a lethal injection execution should result in the death of a prisoner in less than an hour. However, there are no published studies on the actual length of time from first chemical injection to time of death.

As an aside, there are many cases where not everything goes as planned. According to Austin Serat, a professor at Amherst College, seven percent of lethal injection executions are “botched.” The most common problem is not being able to find a suitable vein. This is because many of the condemned prisoners used intravenous drugs in the past. As such, many of the veins have been damaged and are not usable.

As a physician, here is my assessment of science.Midazolam is typically used in clinical practice to sedate patients at the beginning of a surgical or diagnostic procedure—not only does it make the patient go to sleep, but it also makes patients forget the procedure. It is not a painkiller, so patients can still experience pain, even though they are asleep. If pain control is required, the physician will administer other medications. Midazolam is part of the benzodiazepine class of drugs—Valium and Xanax are within the class. Midazolam is an acid. It is one of the many drugs used to anesthetize patients prior to surgery.

Phenobarbital is a chemical that is used to treat seizures in some patients. It is part of the barbiturate class of drugs. Unlike midazolam, phenobarbital is an alkaline compound. Household bleach is an example of an alkaline compound.

When midazolam or pentobarbital is administered intravenously as a medication to patients, a subset will experience an uncomfortable burning sensation in the arm at the time of infusion. This is, in part, related to the acidic or alkaline nature of the medications.

Some patients develop “thrombophlebitis.” This is akin to a chemical burn in the veins. This can result in a painful blockage in the vein. The vein may feel rubbery when feeling the skin over the damaged vein. With midazolam, thrombophlebitis is estimated to occur in 4 to 10 percent of patients. In patients, this is minimized by inserting the intravenous line in a larger vein and infusing the medications slowly over a period of minutes. Thrombophlebitis is usually a self-limiting side effect and typically resolves with supportive treatment.

In lethal injection executions, the prisoner, typically, receives a midazolam dose typically 50 to 100 times the dose administered to patients. The pentobarbital dose is typically 10 times the dose administered to patients. The chemicals are “pushed” by the executioner, which means that the syringe is emptied quickly. The body has about five liters of blood and the total volume of fluids and chemicals administered can exceed 10 percent of the blood volume.

Given all of this, it only follows that the veins are likely to be damaged. This is key to evaluating the conclusions presented by Zivot and his colleagues.

We all need oxygen to live. The lungs, heart, and blood vessels play a key role in extracting oxygen from the air. Air is inhaled from the nose, and it travels through the large windpipe. The chest and surrounding muscles are like bellows, making sure that human beings can inhale and exhale air. The windpipe branches many times, and ultimately the air reaches the alveoli. These are delicate structures replete with blood vessels. This is where oxygen is extracted from the air and transferred to the blood.

With lethal injection executions, Zivot and his colleagues hypothesize that the large dose of chemicals damage the cells in the alveoli. Blood and other fluids enter the part of the alveoli that should only contain air. This is what causes the frothing found on autopsy—the technical term is pulmonary edema.

People with pulmonary edema suffer—they suffer a lot. Shortness of breath is a terrible anxiety-provoking experience. I can tell you this as someone who has treated patients with pulmonary edema, and from personal experience as a patient in the emergency department. Could the froth in the lungs have occurred after death? This hypothesis, if true, would refute the argument that prisoners were suffocating before death. But this is not likely. To have this autopsy finding, the bellows function of the lung has to work—meaning that the pulmonary edema occurred before the person was dead.

So, I think Zivot and colleagues’ conclusions are correct. In many cases, lethal injection executions result in a painful and distressing death. However, the lethal injection method may be less painful for the policymakers to the extent that it may appear to be less gruesome than the other methods. But the truth is that lethal injection executions are more akin to ongoing human experimentation and a well-managed medical procedure.

But there is also a second question. So, what if the prisoner suffers? After all, executions are a form of “punishment.”

Deborah Denno, a professor of law at Fordham University, says that the Constitution prohibits cruel and unusual punishment. However, it does not have a blanket prohibition against painful punishment.

If the Supreme Court allows capital punishment, then it only follows that it must also allow a method of carrying out the punishment. Arguably, even with all the problems with lethal injection executions, is a less painful method than the electric chair or gas chamber.

In 2003, Wiseman became an Episcopal priest, following in the footsteps of his father and grandfather. He publicly disavowed capital punishment and expressed remorse in bringing the lethal injection bill to the legislature. Wiseman wrote an article in the Christian Century magazine where he disclosed that he was always opposed to capital punishment. He candidly stated that retaining his seat, at that time, was more important than standing up for his moral beliefs.

Wiseman crashed his private plane in 2007. He died. The crash also killed his passengers. Dr. Rhonda Lunn, his girlfriend, as well as her three teenage children, was killed. He was the pilot in control.

Wiseman, in an article in the Christian Century, said he wanted executions with “no pain, no spasms, no smells or sounds—just sleep.” Since then, we have experimented with this method on about 1,400 people—experiments with little scientific oversight. The evidence tells us the lethal injection executions are not consistent with Wiseman’s goals.

Rev. Wiseman had a change of heart. Hopefully, the Supreme Court might change its mind.