Tennessee’s Failed Execution Shows Lethal Injection Needs Doctors It Can’t Have

Tennessee says it followed its protocol when Christa Pike survived two doses of pentobarbital. The failure lies in a method that needs medical skill doctors are ethically barred from providing.

Editor’s note: Joel Zivot, an anesthesiologist and medical ethicist, has served as a medical expert for Christa Pike’s legal team, including providing expert testimony in her challenge to Tennessee’s execution protocol before the Sept. 30 execution attempt.

After Tennessee failed to execute Christa Pike on September 30, the Tennessee Department of Correction issued a statement saying it had followed its execution protocol. It added that the protocol “does not allow for additional procedures beyond what was carried out this evening.” Her attorney Randy Spivey, of the Tennessee Office of the Post-Conviction Defender, witnessed the attempt and documented it minute by minute in a sworn declaration filed Oct. 22. The IV team used approximately 10 needles at several sites on both arms, he wrote, and doubt remains whether working IV access was ever established. Even with a physician overseeing the process and vein-finding devices in use, the team struggled for nearly an hour to place the lines.

The execution attempt went ahead, nonetheless. When it became clear she had not died, a 911 call went out from the prison, but dispatchers were told it was a false call, and the prison’s own control center said it had not placed it. Paramedics reached the building more than half an hour after the first call. Pike was taken to Vanderbilt University Medical Center, where she spent more than a week, several days of it on a ventilator, before she was discharged and returned to prison on Oct. 10. Her lawyers say her recovery will be long and her prognosis is unclear. Pike was sentenced to death for the 1995 murder of 19-year-old Colleen Slemmer.

In a statement dictated to her legal team and released Oct. 30, Pike said, “There hasn’t been a moment since that night when I haven’t been in pain.” She said she still struggles to speak and continues to think about her victim’s family and “the terrible pain and loss they have endured.”

The department’s statement that it followed its protocol had something confessional about it. A woman had survived two doses of a drug meant to kill her, and the state’s first explanation was that its employees had followed the instructions. In litigation, that is a party admission, and it can be used against the state. If employees followed the protocol, the review needs to examine the protocol itself.

Gov. Bill Lee has paused executions and appointed former US Attorney Ed Stanton to lead an independent review, which the governor’s office says “will seek to determine whether the protocol was followed.” The department has already said it followed the protocol. If that account is accurate, the tougher question is why the procedure failed.

Lethal injection is supposed to offer a measure of control over the violence of an execution. The drugs, the intravenous lines, and the clinical setting suggest that medical knowledge can make death orderly and spare the condemned unnecessary suffering. But the procedure depends on a profession whose ethical rules prohibit taking part. The American Medical Association’s Code of Medical Ethics describes the very tasks at issue in Pike’s case as participating in an execution. These include selecting injection sites, starting intravenous lines, and prescribing, preparing, or administering the drugs. States want physicians’ competence and the reassurance their presence provides, while asking them to abandon the ethics that come with it. No major medical society endorses physician participation in executions, yet some physicians still help.

RELATED | ‘I’m Not Incompetent’ Christa Pike’s execution doctor, Mark Fowler, speaks.

Physicians who participate can argue that if the state is going to execute someone anyway, a qualified physician should be there to prevent suffering. A doctor standing aside while an untrained person struggles with a needle is an uncomfortable prospect. But a physician acts within a doctor-patient relationship, and a prisoner does not become a patient because a doctor is in the room. If such a relationship did exist in the execution chamber, the doctor’s duty would be to protect the prisoner by blocking an intervention the prisoner rejects, not to help carry it out. In Pike’s case, a physician’s presence was no guard against the state’s errors. The clinicians who treated her afterward had a duty to care for her, and they did. They “treated me with compassion, dignity, and respect,” she said in her statement.

Saying “the execution will happen anyway” overlooks officials’ responsibility for deciding whether to proceed. Officials can stop. They can decline to proceed when they cannot obtain the expertise they say is necessary. A physician’s refusal does not force the state to use someone else. The state chooses to.

Oklahoma’s 2014 execution of Clayton Lockett involved both a physician and a paramedic. The state’s subsequent investigation identified the viability of the intravenous access as the greatest factor contributing to the difficulty administering the drugs. It also found that the protocol had been substantially followed and that the deviations it identified had not caused the complications.

In medicine, intravenous therapy follows evidence-based protocols designed to prevent bloodstream infections, minimize vein damage, and prevent medication errors. Clinicians use the smallest catheter that can deliver the prescribed therapy, preserving blood flow around it to reduce friction, clotting, and inflammation. Placing a catheter well takes knowledge of anatomy and physiology and real manual skill. Ultrasound and other vein-finding technologies are now standard practice, but the use of these technologies requires their own expertise. Months before Sept. 30, Pike’s lawyers warned in a lawsuit challenging the protocol that her small veins would make inserting a needle difficult.

Intravenous access in an execution chamber is a different activity altogether, performed largely by team members whose identities the state keeps secret, with little outside scrutiny or accountability. Execution teams use medical techniques without the same professional oversight. The failures in Tennessee and other states show why that oversight matters.

Tennessee’s protocol uses a single drug, pentobarbital. The drug’s prescribing information warns that injection outside a vein can damage tissue, including causing tissue death. Pentobarbital is a highly alkaline solution, made more noxious to tissue by injecting it in quantity, and in medicine, highly toxic therapies are kept out of short peripheral IV lines. Spivey’s declaration describes the team cycling through needle sizes—22-gauge, 20-gauge ("It's not long enough; what is the longest you’ve got”), and at one point a 24-gauge, very small and short, the kind that might be placed in a small child. Rapidly injecting a large volume of a caustic drug through small, short peripheral catheters risks serious tissue injury if the drug leaks outside the vein.

Pike’s lawyers said in a court filing that her arms were swollen, burned, and blistered when she reached the hospital. In her statement released a month later, she said, "My arms hurt. My hands hurt.” Clinicians use these drugs and devices to treat patients. Execution teams use them to cause death.

Repeated failure is not simply a shortfall in instruction. Without knowing the skills and training of every member of the execution team, you can’t trace a failure to its source. Hospitals do this routinely through root cause analysis—a structured search for why something went wrong rather than who is to blame. It depends on a culture that a department of correction built on secrecy rather than safety does not have. Root cause analysis needs identifiable practitioners, complete records, and professional accountability, all of which execution secrecy forecloses.

A genuine investigation would begin with a precise definition of the failure. “It did not work” is not a definition. The drug had an effect; the question is why that effect was sedation and respiratory depression rather than death. The most likely explanation is extravasation (the drug leaking out of the vein into surrounding tissue). Other possible explanations include drug degradation, administration error, or some combination of these. The medical team caring for Pike would have documented the needle gauge, the number of attempts, the IV sites, and the pentobarbital level in Pike’s blood when she reached the hospital. On Oct. 7, Davidson County Chancellor I’Ashea Myles, a judge on the county’s Chancery Court, ordered the state to preserve the drugs, syringes, IV lines, recordings, and records from the execution attempt and directed the department to try to recover anything already discarded or destroyed. A court had to order what any hospital quality review would take for granted. And even preserved evidence cannot answer questions about people the law keeps anonymous.

Tennessee can investigate, retrain, and rewrite its protocol. It can find individual physicians willing to take part, as it did on Sept. 30. But none of those measures resolves the conflict between the medical expertise lethal injection requires and the ethical duties of those trained to provide it. That conflict is a reason to abandon the death penalty.

Pike said she does not know why she survived or “what comes next.”

Source: jurist.org, Joel Zivot and Ingrid Burke Friedman, October 30, 2026. Joel Zivot is a practicing physician in anesthesiology and intensive care medicine and a senior fellow in ethics at Emory University in Atlanta, Georgia. Zivot, who also holds a legal master’s degree, is a recognized expert who advocates against the use of lethal injection in the death penalty and is against the use of the tools of medicine as an arm of state power. Follow him on X/Twitter @joel_zivot. Ingrid Burke Friedman is a jurist's Editorial Director, based in Austin, TX.

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

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