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This story describes a lethal injection procedure used in state executions.

In May, a group of healthcare workers spent about an hour trying to establish complete IV access so they could inject Tony Carruthers, an inmate at the Riverbend Maximum Security Institution in Nashville, Tennessee, with a lethal dose of sedative.

Maria DeLiberato, an attorney for Carruthers, was in the room. She said the workers stuck his arms and feet with needles, to no avail. A doctor then tried to insert a central line through his collarbone and shoulder. That didn’t work, either.

Carruthers groaned in pain and blood oozed from puncture wounds, DeLiberato said in a news briefing.

After more than an hour, Gov. Bill Lee called the warden, ordering him to halt the execution attempt. He later granted Carruthers a one-year reprieve.

Now, as another approaches, doctors and nurses in the state say they want medical professionals removed from the execution process. They’ve also joined defense attorneys and nine Republican state lawmakers in demanding a moratorium on the death penalty and an overhaul of the state’s execution methods.

The doctors’ arguments echoed those the American Medical Association has made and in its code of ethics.

Tennessee is where the death penalty is legal, according to the Death Penalty Information Center, a nonprofit that offers data and analysis on issues surrounding capital punishment.

Governors in four of those states have halted all executions, citing and , such as being unable to obtain lethal injection drugs amid pharmaceutical companies’ refusal to sell them for use in executions. Lethal injection is still the primary nationwide, but some states may use , a , or .

Since the beginning of 2020, 170 people have been executed in 17 states, with most occurring in Florida, Texas, and Oklahoma. In that time, six states have had , according to the , which defines those as executions that include a departure from the protocol because of unanticipated problems and that cause more pain for the prisoner than anticipated, whether they ultimately end with a death or not. Several of the stories read like Carruthers’ — protracted but ultimately failed attempts to establish IV access.

Tennessee Health Workers’ Concerns

The IV team gave up on trying to place a typical line into Carruthers after several failed attempts, according to DeLiberato’s account. , physician Mark Fowler, a contractor for the state’s prison system, then tried to place a central line in a deeper vein. That’s a quasi-surgical procedure in which a plastic tube is inserted in the chest, groin, or neck. Fowler used a series of syringes, trying to insert the tube under Carruthers’ collarbone and then through his shoulder.

In an , Fowler said he hadn’t done such a procedure in the 12 years since he had stopped working in an emergency room, and didn’t know that placing a central line could be among his execution duties.

Fowler told NPR by phone on Sept. 24 that “the doctor does not participate in the execution. The only thing the doctor does is declare the person dead.” He did not have further comment.

Two months after the halted lethal injection, more than 40 doctors and nurses to Lee, calling on the Republican governor to pause executions and redesign the protocol to omit health workers from the process.

The letter said that Tennessee’s rules requiring the participation of pharmacists, physicians, and other healthcare workers in executions are at odds with medical ethics, as well as guidelines explicitly laid out by groups such as the American Medical Association. The doctors are to preserve life when there is hope of doing so and bars participation in executions.

“This means that the health care professionals who agree to take part in Tennessee’s executions are those willing to set aside their professional ethics,” the letter to Lee reads. “The problems that we have seen, such as in Mr. Carruthers’s case, are the predictable result of working with such unscrupulous actors.”

John Greer, a retired Nashville hematologist, said in a news conference about the letter that he wasn’t surprised the central line placement went awry.

“Placing a central line is not just sticking a needle in a person’s arm,” he said.

Greer said the doctor has to tap a large vessel above the heart. He said that it’s a risky procedure in which an error could cause a collapsed lung or heavy bleeding — and that only those with specific training and routine practice should attempt.

“And I cannot imagine that there would be someone who’s doing these routinely who would be involved in this procedure,” Greer said.

Some Republican state senators also hold on executions and an overhaul of the process, saying that “incompetent administration” of capital punishment gives its critics more ammunition.

This summer, Lee said he didn’t want a pause.

“The Department of Correction did exactly what they should,” he said. “It should not affect executions in the future.”

“It’s one of the most difficult things that we do in this state,” Lee said later. “But I am committed to making sure that it is done in the way that it should be.”

The state’s lethal injection protocol orders the prison to keep a curtain over the media witnesses’ viewing window until the IVs are established, so none of them could offer a visual account of the failed execution attempt.

A has been filed has been filed by the Reporters Committee for Freedom of the Press and news outlets including NPR member station WPLN. The lawsuit argues the lack of transparency during the IV placement process obscures problems like the ones that happened in Carruthers’ case.

There’s a broad understanding in the U.S. that the medical establishment doesn’t participate in executions, said , director of the Center for Bioethics and Humanities at the University of Colorado’s medical school.

“We came out of World War II with a whole bioethics and medical ethics enterprise that is really strongly opposed to medicine serving as an arm of the state and using specialized medical skills to hurt people or kill people,” Wynia said.

A history of medical abuses by government doctors — such as and unethical studies of in the U.S., and in Nazi Germany — forged that consensus, he said.

Wynia mentioned other nations where medical professionals still participate in executions.

“But they are, you know, Iran and Saudi Arabia and Russia, sort of authoritarian states, where medicine is an arm of the government,” Wynia said. “Medical involvement in executions ends up happening because medicine is unable to say, ‘No, we don’t do that.’”

Upcoming Execution

On Sept. 30, Tennessee is scheduled to execute Christa Pike, who was 18 years old when she and her boyfriend killed Colleen Slemmer.

Pike’s attorneys this year raised several concerns that the state’s lethal injection protocol would violate her rights. Among them is their contention that because she suffers from a platelet disorder, it’s likely she will need a central line placed. They also argued that she was at risk of needless suffering, alleging Carruthers’ execution showed that Fowler — who has that he will oversee Pike’s execution — is incompetent at placing central lines.

In June, they put all of those concerns to the Tennessee Supreme Court, asking for a special investigator to collect evidence and hold hearings to determine whether they warranted an order to delay her execution and design a method for only her.

The court did appoint a special investigator, Senior Judge Mark Ward. He held a series of hearings in Knoxville last month. Ward said he didn’t believe Pike’s rights would be violated by the process and submitted to the court.

On Sept. 23, the Tennessee Supreme Court , agreeing with Ward, saying none of the concerns amounted to a constitutional violation. On Sept. 28, Lee announced he would not grant her clemency.

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