Written: June 2021 by Jakob Mertz

USA was the first country to introduce the “medical execution” (lethal injection) in 1979, and within a few years this execution method spread from Oklahoma to all US-states using the death penalty.


In 1979 Oklahoma as the first US-state introduced lethal injection in its legislation using a 3 drugs protocol (Pentothal, Pancuronium and Potassium). However, Texas was the first state to use this method of execution, when Charles Brooks in 1982 was executed in Huntsville Prison with a lethal injection. Since then, 1338 people (June 2020) have been executed in the United States by lethal injection (1).

During the past 20 years a constant decline in the number of states using the death penalty and the number of executions, peaking in 1999 with 98 executions, has taken place. During the past years 20-30 people have been executed every year (1,2).

Lethal injection

When introduced, the method was seen as a “human” and cheap way of carrying out an execution, but since its introduction several obstacles have turned up:

  • It became increasingly difficult to find qualified personnel willing to assist with the executions. Medical technicians must necessarily be educated as doctors and nurses denied participation. National and international doctors and nurses’ associations adopted resolutions against participation in executions.
  • During the past 10 years an increasing number of pharmaceutical companies have opposed the use of their drugs for executions. In 2011 the Danish pharmaceutical company Lundbeck introduced a very restrictive sales policy preventing Lundbeck drugs to be sold to correctional facilities (3). A significant number of other pharmaceutical companies have adopted similar restrictions since 2011, and during the following years it became increasingly difficult for correctional facilities to obtain drugs for executions. Several states have tried with varying success to buy from dubious wholesalers and compound pharmacies.
  • Due to this a number of states have introduced untested drugs for executions, sometimes as single-dose.

Partly due to the difficulties mentioned above, a significant number of botched executions have taken place, causing significant suffering for the executed prisoner. A few states have returned to previous execution methods as the gas chamber.

Intellectual disability and mental disease

A significant percentage of prisoners on death row in the US has intellectual disability in varying degrees or/and psychiatric diseases (4,5)

According to the US Supreme Court it is unconstitutional to execute prisoners with intellectual disability, but it is also unconstitutional to have a strict IQ cut-off for the diagnose. Consequently, prisoners with varying and sometimes severe intellectual disability are executed.

Legislation varies in different states regarding execution of prisoners with severe mental illness. A few states prohibit execution of prisoners with severe mental illness. However, there are numerous examples of execution of prisoners with psychotic symptoms (6,7).

The effect of the steps taken by the medical profession and the pharmaceutical industry

Due to the above-mentioned difficulties in carrying out executions, many executions have been postponed or cancelled. Executions have been set on hold in a number of states, and an increasing number of states have given op the death penalty.

Contributing to this development is the increasing number of death row prisoners being released because new DNA tests have proved them innocent.

In addition, an increasing number of American citizens oppose the use of the death penalty.

Once the United States hopefully stops the use of the death penalty, this will without any doubt have a great impact on the use of the death penalty worldwide.

  1. Death Penalty Information Center. Execution Database. June 2020.
  2. Amnesty International. Death Sentences and Executions 2020, Amnesty International Global Report, ACT 50/3760/2021. 21April
  3. The Guardian. “Lundbeck and pentobarbital: pharma takes a stand”. 1 July 2011.
  4. Amnesty International. “United States of America. The execution of mentally ill offenders”, ACT AMR 51/003/2006. January 2006.
  5. Death Penalty Information Center. Policy Issues, Mental Illness. June 2021.
  6. Death Penalty Information Center. Recent Legislative Activities. June 2021.
  7. Amnesty International USA. Death Penalty and Mental Illness. 18 May 2017.