The death penalty: How we kill

Illustrations by Sam Ward for Al Jazeera America

Lethal injection is by far the most common method of execution in the U.S., and, because it is the most frequently used, it is the most botched. There are four other methods of executions on the books in several states, used either by inmate choice or when drugs needed for lethal injection are unavailable.

The U.S. executed 35 people in 2014, all by lethal injection. This is down from the peak of 98 executions in 1998. While the number is not as high as in some other countries — according to Amnesty International, China executed at least 1,000 people in 2014 — the U.S. ranks fifth worldwide for the number of executions.

“It’s devastating to have the United States [be] the only Western developed country that executes people — and the only country in the Americas to do so,” Ivan Simonovic, the U.N.’s assistant secretary-general for human rights told Al Jazeera.

Still, the death penalty has supporters in the U.S., especially among some victim’s rights groups,  whose members back the death penalty as a form of  restorative justice. Detractors, however, say its application is unconstitutional.

According to the Death Penalty Information Center, the U.S. has executed 1,408 people since 1976, when the death penalty was reinstated after it was suspended in 1972 because of a landmark Supreme Court case, Furman v. Georgia.

The petitioners in the case claimed that the implementation of the death penalty was cruel and unusual and violated the Eighth and Fourteenth amendments. They showed that only 15 to 20 percent of those who committed crimes eligible for the death penalty were sentenced to death. In other words, the fact that some would be put to death and some would not for committing identical crimes constituted a random, cruel and unconstitutional system.

The U.S. Supreme Court ruled 5 to 4 that the death penalty was “unfair” and “arbitrary.”

Justice Potter Stewart wrote in his concurring opinion, “death sentences are cruel and unusual in the same way that being struck by lightning is cruel and unusual.” He concluded that, “the Eighth and Fourteenth amendments cannot tolerate the infliction of a sentence of death under legal systems that permit this unique penalty to be so wantonly and so freakishly imposed.”

“The point is, if they committed a capital, eligible murder, and to avoid the arbitrariness prong of the Furman complaint, you’d want to be able to have something be systematic and predictable … you don’t want it to be the case that this person was somehow a loser in a nasty or fatal lottery,” said Jeffrey Fagan, who teaches courses on criminal law and capital punishment at Columbia University Law School, explaining the argument that led to a de facto moratorium on executions in the U.S.

“It’s an issue of infrequency,” he said.

“There aren’t enough executions for us to be convinced that they are being carried out in a fair and predictable manner. … If you have 10 people who have committed an identical crime and execute one of them, that’s the essence of unfairness,” said Fagan.

Still, 35 states reinstated the death penalty, restricting juries’ discretion in imposing the sentence, and in 1976 the Supreme Court ruled that Georgia could execute Troy Leon Gregg without violating the U.S. Constitution.

As of the start of 2015, there were 3,109 inmates on death row in the U.S. If they lose their legal appeals or do not die of other means while incarcerated, they will likely be put to death by one of the means below.

While it’s impossible to ask a person what it felt like to die in any particular manner, Al Jazeera sought to find out, clinically speaking, what happens to a body when it is killed via the legal methods in the U.S.

Note: Al Jazeera interviewed these medical experts on the methods of execution: Dr. Mark Heath, an anesthesiologist at the Columbia University College of Physicians and Surgeons; Dr. Jonathan Groner, a professor of clinical surgery at the Ohio State University College of Medicine; and Dr. Nizam Peerwani, the chief medical examiner for Tarrant County, Texas. None of them participate in executions in any way.

Also, lethal injection is the primary method of execution in the states that have the death penalty. In some, alternate methods are allowed under certain circumstances, such as a shortage of the drugs required for a lethal injection or by the inmate’s choice.

Authorized in 31 states (Colorado and New Mexico have abolished the death penalty but have previously sentenced inmates on death row) as well as by the U.S. military and the federal government, according to state data from Death Penalty Information Center

Two methods, typically: one- or three-drug protocol.

Lethal injections are administered via intravenous tube, not syringe.

First drug: Pentobarbital or midazolam, a sedative and an anesthetic. It is intended to render the inmate unconscious, unarousable even by extreme pain (e.g., surgery). Administered in the high doses used — as much as 20 times the therapeutic dose — this drug alone will stop breathing and collapse the circulatory system, putting an inmate to death within 10 minutes. This is the drug that is currently in short supply in the U.S.

Second drug: Pancuronium bromide (or other drugs in the -uronium family), a paralytic. It gives the inmate a placid appearance, paralyzing almost all muscles (except the heart).

Third drug: Potassium chloride, which stops the inmate’s heart. (It is used in low doses to treat potassium deficiency.)

How it’s supposed to work: In the one-drug protocol, the inmate is injected (via IV) with enough of a sedative to cause death by overdose, knocking him or her out within a couple of minutes, depending on the person’s circulation and heart rate. The other drugs are not required.

In the three-drug protocol, the first drug, if administered properly, renders the inmate unconscious. After five minutes, during which a rigorous depth-of-anesthetic test determines that the inmate is fully unconscious, the second and third drugs are administered within minutes of each other.

The inmate should be dead within about 10 minutes.

What can go wrong: There are dozens of cases in which inmates were subjected to a painful, bloody process of inserting the IV needle. In other cases, the first drug was not injected properly, resulting in the anesthetic being delivered into soft tissue rather than the circulatory system, rendering it ineffective. If the sedative is improperly administered, the inmate, conscious but paralyzed, suffocates slowly from the second drug.

Example of botched case: Clayton Lockett, April 29, 2014, Oklahoma: It took 51 minutes for the paramedic and physician to place the IV for the first drug, the sedative. The insertion of the IV proved problematic, and it was ultimately inserted into a vein in Lockett’s groin. He writhed and breathed heavily after the other drugs were administered. He remained paralyzed and awake, effectively locked in his own body, suffocating for several minutes before his heart finally stopped. It took him 43 minutes to die.

Authorized in Alabama, Arkansas, Oklahoma, South Carolina, Tennessee, Florida and Virginia

How it’s supposed to work: A strong electrical current from the head to a leg through the heart causes ventricular fibrillation, a cardiac rhythm disturbance. The heart quivers and stops pumping blood to the brain, rendering an inmate unconscious within 30 seconds. An inmate may be declared dead within three to five minutes.

What could go wrong: Brine-soaked sponges are used to conduct the current between electrodes and the inmate’s skin. If the sponges, typically placed on the head, are over- or undersoaked, they can either cause a short circuit or resist the current. Ventricular fibrillation (which is, on its own, excruciatingly painful) is not always reliably achieved, since the electric current could pass around the heart, requiring additional jolts of electricity to bring about death. Loss of control over bodily functions usually occurs — vomiting, urination and defecation. Exposure to additional shocks can have gruesome consequences, including combustion, cooked organs (while the inmate is still conscious), burst eyeballs and split skin due to the extremely high temperatures.

Example of botched case: Allen Lee Davis, March 25, 1999, Florida: Media reports and witnesses indicated that Davis bled profusely from his nose or mouth, with burns on his leg, groin and head, crying out twice before he died. He was electrocuted for two minutes and was declared dead eight minutes later.

Authorized in Utah (if lethal injection drugs are unavailable) and Oklahoma (if electrocution and lethal injection are found to be unconstitutional  by the courts)

The inmate is strapped down with a target pinned over his or her heart. Five riflemen fire, with one firing a blank, ostensibly so no one knows with certainty who is responsible for the killing, which is perhaps less traumatic for the executioners. By the time the inmate hears gunfire, the bullets have already hit the heart. The inmate probably feels something like a punch in the chest before losing consciousness a few seconds later.

How it’s supposed to work: The high-caliber bullets rip open the heart, causing it to cease pumping, very quickly cutting off blood to the brain. The inmate loses consciousness almost immediately and dies quickly, although it’s unclear exactly how many minutes it takes.

What could go wrong: One or more shooters could miss or have their firearms malfunction, potentially leading to a painful death caused by blood loss.

Example of botched case: Eliseo J. Mares, Jan. 10, 1951, Utah. Two of the four bullets fired missed. One hit him in the abdomen, the other in the hip. It took several minutes before he was declared dead, with a witness telling The Salt Lake Tribune years later that he died “silently and horribly.”

Authorized in Arizona, Califonia, Missouri, Wyoming and Oklahoma

The inmate is trapped to a chair in an airtight chamber. Under the chair is a bucket of sulfuric acid, into which sodium cyanide crystals are dropped via a switch outside the chamber, producing hydrogen cyanide, a poisonous gas. Oklahoma has approved a new protocol, using only nitrogen gas, which is odorless, resulting hypoxia and a loss of consciousness within seconds. It is the first state to do so and has not yet executed anyone using this method.)

How it’s supposed to work: Once inhaled, the toxic gas destroys the mitochondria, tiny structures in cells that generate energy. Hydrogen cyanide inhibits this process, resulting in cardiac arrest and, within a minute, death.

What could go wrong: Much depends on how rapidly an inmate is breathing and the correct preparation of the gas. An inmate might breathe shallowly or hold his or her breath, resulting in a slower death, the loss of bodily functions and spasms.

Example of botched case: Donald Eugene Harding, April 6, 1992, Arizona: It’s unclear what went wrong, but he gasped and thrashed for nearly 11 minutes before he died, with his execution described as so gruesome that it prompted Arizona to change its primary method of execution to lethal injection for all inmates sentenced to death after November 1992.

Authorized in New Hampshire (if lethal injection drugs are not available), Washington (by inmate’s choice) and Delaware (where it remains on the books but the gallows have long been dismantled)

A noose is tied around the inmate’s neck, and he or she is dropped from an appropriate height for his or her weight.

How it’s supposed to work: The noose occludes the carotid arteries, blocking blood flow to the brain, resulting in loss of consciousness. In addition, the noose breaks the spinal cord at the second cervical vertebra (aka hangman’s fracture), which also results in a loss of consciousness. Death likely takes longer, but the inmate is probably unaware of what is happening.

What could go wrong: Hanging is far more complicated than it looks. The inmate’s weight must be factored in to determine the height from which he or she is dropped. Inmates with more muscular necks or lower body mass can pose complications. If the calculations aren’t correct, an inmate can suffocate slowly, spinal cord intact and totally conscious, or at the other extreme, the noose can decapitate him or her.

Example of a botched case: Raymond Lisenba, May 1, 1942, California. He was the last man to be hanged in the state, in San Quentin Prison. The rope used to hang him was the wrong length. It took him about 13 minutes to die. Local media at the time deemed Warden Clinton Duffy’s description of Lisenba’s hanging too graphic, but many ran Duffy’s comment: “Maybe it would help if you could [print what I said]. It would do the people good to know exactly how their mandate was carried out … I have nothing more to say except that this was the most terrible experience of my life and I pray to God that I shall never have to repeat it.” He witnessed 90 executions in the course of his career.