Eight times, a medical team in an Idaho prison tried to establish an intravenous line to deliver a lethal injection to condemned inmate Thomas Creech. But their attempts failed, giving Creech an unsettling reprieve. The incident last week raised sharp questions, such as: Who serves on the medical team used for executions by the Idaho Department of Correction?
"They're all volunteers," Creech's legal team said in a message sent to NPR, citing Idaho's execution protocol.
That detail may come as a surprise. But other states have similar arrangements — and in Idaho and elsewhere, it's also routine to protect the identities of people on an execution medical team.
Here's a rundown of questions about how lethal injections work in Idaho and other states that have recently carried out executions:
What are Idaho's rules for executions?
Idaho's official policy requires candidates for an execution medical team to have at least three years of experience in jobs such as an emergency medical technician, nurse, military corpsman or physician's assistant.
As of late 2022, Creech's lawyers said, the Idaho Department of Correction said its medical team had six members: four EMTs and two registered nurses. Their identities were not revealed.
The names of people on the medical team "will be treated with the highest degree of confidentiality," according to the state's rules, which list only a handful of officials as knowing the team members' identities.
Members of the medical team are required to attend at least 10 training sessions each year, although officials have the ability to revise that number. Team members receive a "small honorarium," a department spokesperson said.
Last year, Idaho became the fifth state to provide for a firing squad to execute prisoners, an option that states have adopted as they face difficulties in acquiring lethal injection drugs.
But that alternative comes with its own complications. The state wants to "retrofit F Block, our current execution chamber, and accommodate a firing squad," Idaho Department of Correction Director Josh Tewalt said in an update to his staff.
"Those initial efforts were unsuccessful because contractors who would engage in this type of work have expressed their unwillingness to work on a project related to executions," Tewalt added, "but efforts are ongoing."
Do doctors help perform executions?
"A physician must not participate in a legally authorized execution," the American Medical Association says in its Code of Medical Ethics.
"When physicians participate in capital punishment, they are being utilized to intentionally inflict harm by using their medical knowledge and skills to forcibly cause death," AMA media relations manager R.J. Mills told NPR. "Physicians who participate in capital punishment take an active role as agents of the state, not as advocates for the condemned, even if their intent is to minimize suffering."
Still, it's common for states' execution protocols to include a physician, and doctors have attended executions.
In Idaho, for instance, the protocol requires a licensed physician to be present, but it also adds that the doctor "will not be a member of any execution specialty teams ... and will not participate in the execution in any way."
How do states differ on executions in the U.S.?
Capital punishment has increasingly been criticized for disproportionately harming people of color; opponents also say exonerations of people on death row expose dangerous flaws in the way states administer the ultimate penalty.
"Since 1973, more than 195 people have been released from death row with evidence of their innocence," according to the Death Penalty Information Center.
In 2023, only five states carried out executions and seven imposed new death sentences — numbers that are tied for the lowest in 20 years, the center said in its annual recap.
"The majority of states, 29, have now either abolished the death penalty or paused executions by executive action," the center said.
Alabama recently became the first state to use nitrogen gas to perform an execution, with inmate Kenneth Smith, 58, attended by two execution workers. A physician then declared him dead.
As for who carries out such tasks, it varies by state, from prison staff to volunteers.
"It is difficult to land on a precise number of states that use volunteers for their executions because of the prevalence of secrecy statutes," the center said in a statement to NPR, "which usually protect the identity and information of/about the execution team members."
Florida, which conducted six executions last year, uses an "execution team" composed of correctional staff and others to put inmates to death. Its lethal-injection policies call for a warden to select "personnel with sufficient training and experience to perform the technical procedures needed to carry out an execution by lethal injection," listing professions such as paramedics, EMTs, nurses and physicians.
Texas executed eight people in 2023. Its execution policies designate a "drug team," who are not employees of the Texas Department of Criminal Justice.
"All members of the drug team are paid for the services they provide," Amanda Hernandez, the agency's director of communications, told NPR.
Qualifications for Texas drug team members call for the group to include at least one person with medical training. That person must be "certified or licensed as a certified medical assistant, phlebotomist, emergency medical technician, paramedic, or military corpsman," the rules state.
The Texas policy also calls for new team members to shadow the group for two executions, and then to be supervised on their first two executions, in turn.
In Oklahoma, where four people were executed in 2023, "The identity of our team is protected by state statute," Oklahoma Department of Corrections public relations chief Kay Thompson told NPR.
"However, team members are asked and cannot volunteer to participate," Thompson added. "They also can choose to leave the team at any time."
What happened with Idaho's lethal injection attempt?
In Creech's case, the team was made up of three people, clad in blue scrubs with white cloth covering their heads, Scott McIntosh, who witnessed the process as the opinion editor of the Idaho Statesman, told member station Boise State Public Radio.
Creech, 73, who was sentenced to death and convicted of multiple murders decades ago, was strapped to a metal-framed bed in the execution chamber. The medical team then began looking for a vein to deliver lethal drugs to the inmate's bloodstream.
"They started in his right arm and they went to his right hand and then they moved to his left arm" and then his left leg and ankle, McIntosh said. Each time, he added, the team applied a local anesthetic and alcohol wipe. But each attempt was unsuccessful, and the process stretched to more than 45 minutes.
"At one point, the lead execution team member left the room to get more supplies," McIntosh said. "We were told that he went to get smaller catheters to see if that would work in finding a vein and establishing an IV."
It didn't work. After consulting with Tewalt, the Department of Correction director, the execution was called off and the death warrant for Creech was allowed to expire that night.
It was an abrupt turnaround for Creech, who had eaten what he thought would be his last meal — fried chicken and mashed potatoes with gravy, along with corn, rolls, and ice cream, the state reported — and said farewell to his wife.
"We are angered but not surprised" that the execution failed, Creech's lawyers at Federal Defender Services of Idaho wrote in a statement. "This is what happens when unknown individuals with unknown training are assigned to carry out an execution."
The next steps in Idaho's quest to execute Creech are unclear. McIntosh reported that the state spoiled some of its lethal-injection chemicals in its failed attempt, and it must now acquire more of the drugs before attempting another execution.
Creech was sentenced to death in 1983 — just one year after Texas conducted the first execution by lethal injection in the U.S. in late 1982. A separate death sentence for him was overturned on appeal.
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