Tennessee | The Medical Dilemma at the Heart of Byron Black's Execution

Physicians should never have a role in making a prisoner more fit to be killed

On August 5, 2025, the state of Tennessee executed prisoner Byron Black by intravenous injection of a large dose of pentobarbital. Witnesses to his execution reported that he was visibly in distress or discomfort. Before he died, he reportedly said, "I can't do this," and that it was hurting "so bad."  We cannot know specifically what he felt.

Black was not a healthy man. According to his lawyer, he had an ischemic cardiomyopathy with an estimated ejection fraction of 15-20%. He had undergone hip replacements despite being advised that his operative mortality risk was very high. In May 2024, Black underwent an implantation of an implantable cardioverter-defibrillator (ICD)-dual chamber pacemaker set at a backup rate of 60 beats per minute and a shock heart rate threshold of 220.

In anticipation of his lethal injection execution, Black asked the court to deactivate his ICD/pacemaker to avoid shocks and pacing, so that his dying would not be painfully and cruelly prolonged. (Essentially, the device may have prevented his heart from slowing down before shocking the heart.) No doctor or healthcare facility that was asked was willing to do this. The court therefore decided to proceed.

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The lamentable circumstances of Black's execution are not unique to his case but involve recurring problems at the intersection of medical ethics and law. It is therefore especially important for physicians to learn the right lessons from this unfortunate episode.

The Eighth Amendment and Cruel and Unusual Punishment

According to the plain language of the Eighth Amendment of the Constitution, punishment can't be cruel and unusual. This concept represents the balance between torture and justice. Execution is a form of punishment. 

To be constitutional, it must not be cruel. The prevention of cruelty in punishment is the absolute duty of any state government in charge of its carceral system.

A lawful execution has not occurred by simply producing a corpse. In the case of Black, it appears to me that his execution was likely cruel and, if so, unlawful. In the legal lead-up to Black's execution, I believe his preexisting health conditions and the role of doctors to address his health needs were central to the cruelty.

Execution Impersonates a Medical Act

I am a practicing physician who has worked as an expert witness in post-conviction death penalty defense. Lethal injection, still the most common method of execution in the U.S., impersonates a medical act; the impersonation can be so convincing that sometimes doctors are fooled into thinking physicians should participate in a medical capacity.

I have testified and written against this unethical impersonation for more than 10 years. In my capacity as an expert witness, I have testified that, in certain circumstances, a state's method of execution will be cruel. In reply, I have been asked to provide an alternative method of execution that I believe would not be cruel. I have informed the court that the physician's code of medical ethics prevents me from answering.

The American Medical Association has supported my position -- it is unethical for physicians to participate in capital punishment. Execution is not a medical act in need of further medical refinement. Some physicians believe a prisoner facing execution is like a patient with a terminal illness. This is wrong. An impending execution is not a terminal illness, for which an appropriate treatment might be palliative sedation. An execution is a deliberate act by the state that the legal system can prevent from happening. Physicians are not providing healthcare when they facilitate it. They are acting as assistant executioners.

Black Sought the Help of Physicians

Black wanted his ICD/pacemaker deactivated before his execution. The court requested the medical community perform this task. The medical community refused.

This refusal to deactivate Black's ICD was medically and ethically the right thing to do. Deactivation of his ICD/pacemaker would allow the state to execute Black unencumbered, without the risk of pacing or a defibrillating shock, as he died. The practice of medicine should never be used to make a prisoner medically more fit to be killed.

Even those who do not support abolishing capital punishment altogether are likely to agree that execution should be free of avoidable pain.

Because the state could not reasonably address or satisfy Black's request, the only available option should have been to abandon lethal injection to avoid the real risk of cruelty. A trial court judge had ordered Black's ICD to be deactivated, but the Nashville General Hospital refused, and ultimately, the Supreme Court overturned the decision that the ICD had to be deactivated. Ordering the medical community to deactivate Black's ICD shifts the duty away from the state to ensure execution is not cruel.

Prisoners Need to Pick an Alternative Execution Method

The real problem, however, was what the state did when confronted with that medical refusal. The court determined that if Black believed his execution would kill him in a cruel manner, it was his duty to name a method that would not be cruel.

Prior legal decisions demand that if a prisoner makes a method-based cruelty claim, the prisoner must name another readily available execution method for that claim to succeed. According to a syllogism now held by a majority of the Supreme Court, "because it is settled that capital punishment is constitutional, '[i]t necessarily follows that there must be a [constitutional] means of carrying it out.'"

Of course, as Supreme Court Justice Sonia Sotomayor has written, this syllogism is plain wrong. It transforms a fundamental restraint on state power into a capital prisoner's burden.

Ethical physician practice demands that we provide the best care for our patients, regardless of who they are. The same can be said for any prisoner executed by the state. We must test justice on the people we despise; otherwise, no one is safe.

The answer is that in the upside-down legal world that governs executions, the burden is on the prisoner to come up with a non-cruel method of execution, not on the state to provide one. Physicians must be cautious to avoid the state's assertion that this is within their power to rectify. None of it is.

(Ultimately, the initial post-execution data from the ICD suggested that Black was not shocked by his implanted defibrillator, yet that doesn't negate the risk of cruelty. The ends don't always justify the means.)

Medicine Is Not a Punishing Arm of State Power

The solution, then, is not to change medical ethics but to change the law. Supreme Court rulings interpret the Constitution as a floor, not a ceiling. Even those who do not support abolishing capital punishment altogether are likely to agree that execution should be free of avoidable pain.

In our polarized America, many have little sympathy for Black's cruel death. Ethical physician practice demands that we provide the best care for our patients, regardless of who they are. The same can be said for any prisoner executed by the state. We must test justice on the people we despise; otherwise, no one is safe.

Source: medpagetoday.com, Joel Zivot, August 8, 2025. Joel Zivot, MD, MA, JM, Contributing Writer, MedPage Today

"One is absolutely sickened, not by the crimes that the wicked have committed,
but by the punishments that the good have inflicted."

— Oscar Wilde