Since its advent more than 40 years ago, lethal injection has become by far the most common method of enacting capital punishment in the United States, accounting for the vast majority of executions since the penalty was reinstated in 1976.
The US government and 27 states reserve the death penalty for those deemed the worst of the worst. Convicted of particularly heinous crimes, inmates are typically put to death after their appeals run out, often a yearslong process that regularly reaches the US Supreme Court – which has found lethal injection constitutional and not a violation of Eighth Amendment protections against cruel and unusual punishment.
Even so, workplace ethics dictate medical professionals “should have no part in this charade,” the American Medical Association wrote in a 2018 brief to the US Supreme Court in the case of the planned lethal injection of Missouri death row inmate Russell Bucklew. “Society wants to delude itself into a belief that capital punishment no longer represents a weighted moral choice, but is now somehow scientific – nearly antiseptic,” the group wrote. “This delusion, however, cheapens life and makes its extinction easier.”
In a common lethal injection protocol, a trio of chemicals is administered in three steps: First, an anesthetic renders an inmate unconscious; then a second drug paralyzes them; and finally, a third stops their heart.
Since losing access in 2009 to the anesthetic sodium thiopental — European pharmaceutical firms banned it in executions and the sole US producer stopped making it — some states have used pentobarbital in a single-drug protocol to execute death row inmates, while others have adopted midazolam as the three-drug method’s anesthetic.
Midazolam, however, has become the focus of lawsuits by inmates who claim it’s not effective at inducing unconsciousness, potentially exposing them to pain caused by the other two drugs. Indeed, those can have a highly painful effect, even in clinical settings — and they’re used in much larger doses for an execution, experts told CNN.
So far, courts have ruled midazolam sufficiently shields inmates from pain and does not violate the Constitution. And US Supreme Court Justice Neil Gorsuch last year in denying one death penalty appeal ruled the Eighth Amendment “does not guarantee a prisoner a painless death.”
Perhaps nowhere has midazolam’s use been as heavily litigated as in Oklahoma, the first jurisdiction in the world to adopt lethal injection — in 1977 — as its preferred execution method and the state that’s carried out more executions per capita than any other.
Here’s what happens in Oklahoma during a typical three-drug lethal injection of anyone who weighs less than 500 pounds, according to state documents — confirmed by a corrections spokesperson who declined further comment — and medical experts who spoke to CNN.
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