On the evening of Sept. 30, Tennessee gave Christa Pike a dose of pentobarbital, then a backup dose. She did not die. Witnesses heard her breathing behind the curtain for close to an hour, and she left the prison in an ambulance instead of a hearse. A week later, her lawyers say she is conscious in a Nashville hospital, still shackled to her bed.
The Department of Correction’s first response was that it followed every step of its approved protocol. I spent my career in research and development, and I have read sentences like that in failure reports. When a process follows its procedure exactly and still fails, the procedure is the defect.
Whatever one thinks of capital punishment, a state that carries it out owes the public one thing without exception: competence.
A failure that reverses the message
An execution is meant to close a case and declare that certain crimes lie beyond tolerance. Pike was convicted in the 1995 torture and murder of a 19-year-old classmate, Colleen Slemmer. That crime should be the story. Instead, the headlines are about a failed injection, a moratorium, and an investigation. The condemned becomes the sympathetic figure, the victim’s family loses the finality it was promised, and a nation that condemns torture abroad looks careless at home.
This was no freak event. Legal scholar Austin Sarat found that about 7% of lethal injections between 1890 and 2010 went wrong, the worst record of any method. The Economist counts 148 executions since 2021, 11 of them botched and four that failed to kill. Tennessee has now failed twice in four months. In May, executioners spent more than an hour trying and failing to place an IV in Tony Carruthers. In manufacturing, Six Sigma allows 3.4 defects per million. A plant running at 7% would be shut down. In the death chamber, “good enough” has quietly become the standard. For outcomes that cannot be undone, I have proposed what I call the Thirteen-Sigma Standard: The goal is not fewer failures but a system designed so that failure effectively stops occurring. Nothing a government does is less reversible than an execution.
The warnings were on the record
Pike’s lawyers warned courts and prison officials that her medical conditions and difficult veins would make lethal injection agonizing. A physician involved in Tennessee’s failed May attempt was set to oversee hers. Hospitals do not discover difficult veins on the operating table. They assess and plan in advance. And a 2022 independent review had already found that Tennessee broke its own execution rules every time since 2018. This is not a mystery. It is a failure to listen.
American medicine already knows how to induce deep unconsciousness reliably. Anesthesia-related deaths fell from about 64 per 100,000 procedures in the early 1950s to a few per million through standards, training, and open investigation of every failure. Execution chambers have none of that culture: secret protocols, vanishing drug suppliers, and no shared failure data. The American Medical Association’s ethics code bars physicians from taking part, and even having a doctor present in Tennessee did not save the process.
These obstacles were made by people, and people can remove them. Congress cannot dictate state procedures, but it can fund an independent body to develop and validate a model protocol for every authorized method, and require that each failure be investigated as openly as a plane crash. Flying became the safest way to travel because the industry treated every accident as a design problem. This country reached the moon within a decade of deciding to. Carrying out a sentence without torment is not a harder problem, only a less glamorous one.
TENNESSEE EXECUTED CHRISTA PIKE BY THE BOOK. SHE SURVIVED
There is a second cruelty, too: decades of waiting. Pike spent nearly three decades on death row, and on the day itself, a court paused her execution for hours. Appeals must stay rigorous, because innocent people have been sentenced to death. But idle years of backlog are not review. Trim the waiting, never the scrutiny.
Even the condemned deserve a humane farewell. So do victims’ families, who deserve finality instead of another headline. We should demand from the state what we demand from every aircraft and every car brake: a system designed to work, not merely to look as if it works.
Meda Parameswara Reddy, Ph.D., is the director of the Reddy Center for Critical and Integrated Thinking. A former R&D executive holding 30 U.S. patents, he specializes in interdisciplinary research and public policy analysis and originated the Thirteen-Sigma Standard for zero-failure systems. His writing has appeared in Proc. Natl. Acad. Sci., RealClear platforms, Washington Examiner, the Fulcrum, the Humanist, AFRO American, and South Asia Monitor, where he serves on the editorial board. He also hosts the interview show “SAM Dialogues with Dr. M. P. Reddy.”