Florida’s 100th inmate to be executed in the modern era is scheduled to die today by lethal injection, using a drug that no other state uses and through a process that is being challenged in federal court.
When Donald Dillbeck’s execution begins, he will be given three drugs: a sedative, followed by a paralytic, then a drug that will stop his heart. It’s a process that is being challenged in federal court by a group of death row prisoners who argue the process is a violation of the Eighth Amendment prohibition on cruel and unusual punishment.
Here’s what to know about Florida’s lethal injection protocol ahead of the state’s first execution in three years.
What is the three-drug protocol?
Etomidate, a sedative, is the first drug administered in a three-drug cocktail for Florida’s execution process. Florida is the only state to use the drug and has used it since 2017, when it changed its protocol without explanation. Seven Florida inmates have been executed using cocktails that include etomidate.
Some advocates have raised concerns about the use of that drug in executions. But even before the state moved to etomidate, lawsuits challenged the state’s lethal injection process as unconstitutional.
“I believe there are problems with using etomidate, and major problems with the three-drug protocol,” said Maria Deliberato, executive director of Floridians for Alternatives to the Death Penalty and previous legal counsel for the federal lawsuit brought by the death row prisoners.
Because the second drug in the cocktail, rocuronium bromide, paralyzes the person being executed, the people administering it would not be able to tell if the sedative wears off, she said. The complaint argues that the paralytic only serves to “create the appearance of a serene death.”
Deliberato pointed out that Florida statutes prohibit such neuromuscular blocking agents from being used when euthanizing dogs or cats.
“We don’t put our animals down that way,” Deliberato said.
Along with challenging the use of the paralytic, the lawsuit also argues that etomidate, which is short-acting, fails to produce a proper level of anesthesia; that it does not effectively make the condemned unresponsive to the pain of the second and third drugs; and that etomidate itself is extremely painful upon injection.
Florida uses potassium acetate as the third drug; it’s used to stop the inmate’s heart.
Johnson & Johnson, the original manufacturer of etomidate, put out a statement in 2017, ahead of Florida’s first scheduled execution with the drug, to say it doesn’t support its use for executions and does “not support the use of our medicines for indications that have not been approved by regulatory authorities.” Other drug manufacturers have also put out statements discouraging the use of their products in lethal injections.
How is the execution process supposed to work?
According to the Department of Corrections protocol, the inmate set to die will be given etomidate through an IV line. At that point, the warden will assess, “after consultation,” whether the person is unconscious. The protocol does not specify what that assessment requires, but it does call for “sufficient” training before the execution to include a simulation addressing what happens if an inmate is not rendered unconscious.
If the person is not unconscious, the warden will announce that the execution is suspended until they find a new vein to use to again inject the inmate with etomidate.
If the person is unconscious, the executioner will then inject rocuronium bromide, the paralytic, and then potassium acetate, which stops the heart. Authorized witnesses, which include family members of the victim, a nurse, members of the media and others, can watch the administration of the drugs through a gallery window.
An open telephone line to the governor’s office is established about a half-hour before the execution, and when a physician pronounces the inmate dead, the governor will be notified.
In Florida, recent executions have had measures that advocates like Deliberato fear are a way to stop witnesses from seeing any breathing activity or signs of consciousness among the condemned.
When Michael Lambrix, for example, was executed in 2017, Lambrix’s attorney said that Lambrix was covered with a sheet, his hands and fingers were wrapped up into a “giant mitten” and his feet were pointed toward the gallery so his face was farthest away, according to court records.
What do autopsies show?
In 2019, Mark Edgar, a neuropathologist and Emory University professor at the time, provided expert testimony for the federal case challenging the state’s three-drug protocol. He examined autopsies and records for four inmates whom the state executed using etomidate. At the time of his research, five inmates had been executed using the method, and the most recent autopsy was not made available to him.
Of those examined autopsies, three showed documented pulmonary edema, which is the movement of fluid from blood vessels in the lungs into air spaces, and which can cause a sensation similar to drowning, according to Edgar’s report.
Edgar said the other two drugs used in Florida’s lethal cocktail would not cause pulmonary edema because the paralytic stops all muscular activity and leads to “a picture that’s locked in time” of the lungs at their last moment before the second drug.
Edgar said he can’t testify to whether the inmates whose autopsies he examined were awake when they developed pulmonary edema, or whether the sedative worked. But he said if they were awake, it would have been a horrific experience.
“It is my expert opinion that acute pulmonary edema is a terrifying, horrific and painful condition in a sensate individual that causes great suffering as the person struggles to breathe without being able to exchange air because of the compromised lungs,” he said in his testimony.
Pulmonary edema has been found in a majority of people who died by lethal injection, including by drugs other than etomidate, according to an NPR report.
What do other states do to execute people?
Georgia, North Carolina, Missouri and Texas all use a one-drug protocol of pentobarbital for their lethal injections.
Utah is the only state to carry out execution by firing squad in the last century, according to The Marshall Project, though South Carolina, Mississippi and Oklahoma also have it as an authorized method.
Deliberato said death by firing squad can be instantaneous.
“We’ve sort of gone away from the more visibly gruesome methods, which may in fact actually be more humane,” she said.
How have courts ruled?
Richard Dieter, executive director of the Death Penalty Information Center, said the U.S. Supreme Court has ruled that if the death penalty is constitutional, there must be a way to carry it out, and that lethal injection is not inherently unconstitutional.
But it’s impossible to ethically test the most effective way to kill a human being, Dieter noted.
He said even when it appears the lethal injection process goes smoothly, autopsies show there may be issues.
One challenge to lethal injection was decided last year in a federal court in Oklahoma. Plaintiffs in that case argued that Oklahoma’s three-drug lethal injection cocktail — which included the sedative midazolam, a paralytic and a third drug to stop the heart — was cruel.
Medical experts in Oklahoma pointed to pulmonary edema as evidence that the executed inmates suffered. A federal judge ruled that though the sedative was not the drug of choice for prolonged anesthesia, it could be relied upon to make the inmate not feel pain for the minutes required for execution.
