Dr. Mark Fowler knew something was wrong after 45 minutes passed without word from the warden. In most cases, executions take no more than ten minutes. When he was summoned from his waiting room to the chamber next door, he saw 50-year-old Christa Pike, who’d received two lethal doses of pentobarbital that night, strapped to a gurney, gasping for air. “She’s not dead,” Fowler recalls the warden saying. “I thought, Well, in human beings there’s a spectrum of responses to medications and we’ll give it a few more minutes,” he says. Another half-hour passed. Fowler worried she might survive with irreversible brain damage. “She’s going to be in a permanent vegetative state with a quarter-million dollars in medical expenses.” He came back in and diagnosed her as comatose. The deputy commissioner ordered the execution to stop. Now, instead of taking part in Pike’s death, Fowler’s job was to bring her back to life.

He ordered an oxygen tank and an ambulance arrived to take Pike to the Vanderbilt University Medical Center in Nashville, where she was put on a ventilator and treated for severe burns and blistering in her arms. Later, it would become clear that the IV hadn’t been properly inserted into her veins. Sometimes the thin plastic sheath can clog or dislodge, or the push of medication can cause it to fold, Fowler says. Whatever happened in this case, “it was delivering medicine to the subcutaneous tissue” of her arms, he says, rather than her bloodstream. After ten days, she regained the ability to walk and talk before returning to the Tennessee women’s prison.

In the machinery of an execution, each participant is a cog performing a compartmentalized task, diffusing responsibility and obscuring their individual complicity. The paramedics who set the line wouldn’t have known that something went wrong with it because protocol instructs them to leave the room before the injection team enters. In turn, the Department of Corrections employees who inject the drug leave before the physician comes in. (A similar psychological ritual takes place among firing squads, where one randomly assigned gunman shoots blanks, shielding each from knowing if he delivered the fatal bullet.) Fowler’s role on the execution team that day was to pronounce Pike’s death, though in more complex cases, he is sometimes called on to place IV lines himself.

Tennessee’s lethal-injection protocol may help absolve culpability, but it can make executions faultier. Participants may be EMTs with limited medical training, or they may be prison guards with none at all. Physicians almost never agree to take part, and when they do Tennessee prohibits them from observing the full procedure. Pike’s attorneys have cited more than a half-dozen other cases in recent years of excruciating, drawn-out executions caused by failed IVs as well as the use of untested chemicals from unnamed suppliers.

It is extremely unusual that Fowler, a 69-year-old grandfather and Sunday-school teacher in Union City, Tennessee, is known to us at all. He was publicly outed, accidentally, by a warden last year. The identities of execution participants are meant to be kept secret to protect them from social stigma, legal liability, and professional consequences. “Doctors are not lining up to do this,” says Fowler, who otherwise spends his days monitoring opioid prescriptions for chronic-pain patients and writing conservative op-eds for the Union City Daily Messenger. The American Medical Association prohibits physicians from taking any part in executions, including monitoring vital signs, inserting IVs, and declaring death, on the grounds that it violates the oath to “do no harm.” Fowler, who receives $3,000 per execution according to a deposition he gave last year, doesn’t see a contradiction between that pledge and the seven or so lethal injections he’s participated in over the past........

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