Before Tennessee attempted to execute Christa Gail Pike on September 30, 2026, she wrote something that captured an important distinction between death and dying. Pike, who was sentenced to death for the 1995 murder of nineteen-year-old Colleen Slemmer, wrote, “I am not afraid to die. I am only nervous about the process.” What made her nervous was not the fact of death itself, but what she might consciously experience while the state was causing it.
That distinction is at the heart of lethal-injection litigation. The state is deliberately trying to kill someone, so why should it matter whether dying hurts? The answer is embedded in the Eighth Amendment’s prohibition against cruel and unusual punishment. The Constitution does not guarantee a painless execution, and the Supreme Court has recognized that some risk of pain is inherent in carrying out a death sentence. But a sentence of death is not a license to inflict any degree of suffering by any means. The constitutional controversy concerns the path to death and what the state may make a conscious person endure on the way there.
In the federal protocol and in some state protocols, the method at issue is a massive dose of pentobarbital, a barbiturate that depresses the central nervous system. The intended sequence sounds straightforward: The drug produces deep unconsciousness, suppresses breathing, and ultimately causes death. If unconsciousness comes first and remains profound, what happens afterward may never be consciously experienced. That sequence is central to the argument that the method does not subject the prisoner to severe conscious suffering.
But autopsies have repeatedly revealed a disturbing finding after lethal-injection executions: pulmonary edema, in which fluid accumulates in the lungs and interferes with gas exchange. Exactly how pentobarbital produces this finding at execution doses remains unsettled, but the association has appeared repeatedly in post-execution autopsies. What matters for the constitutional debate is not necessarily why the fluid accumulates, but whether it does so before or after the prisoner has lost the capacity to experience it.
Real physician voices, twice a week
Free, and one click to unsubscribe.
An NPR investigation reviewed 216 lethal-injection autopsies that included internal examination of the lungs and found evidence of pulmonary edema in 84 percent. The Justice Department’s January 2025 review noted that 47 of 58 state autopsies after single-drug pentobarbital executions showed signs of edema in the lungs. It also reported that both available autopsies after recent federal pentobarbital executions showed pulmonary edema.
Those numbers are striking, but an autopsy alone cannot answer the question that matters most: Was the prisoner already unconscious, or did pulmonary edema develop while the prisoner could still experience it? Courts have not declared pulmonary edema categorically cruel and unusual punishment, and prisoners challenging execution protocols face a demanding legal burden. Many have lost. Yet whether a prisoner can consciously experience this process has prompted years of constitutional litigation, competing expert testimony, and evidentiary hearings, with autopsy findings playing a central role. Death alone does not answer the Eighth Amendment question. How the prisoner gets from consciousness to death matters.
What does pulmonary edema feel like if someone is still conscious?
The Merck Manual describes acute pulmonary edema as producing extreme breathlessness, restlessness, anxiety, and a sense of suffocation. Yale Medicine similarly notes that patients may struggle for air and describe the sensation as drowning or suffocating. Those descriptions come from ordinary clinical medicine, not death-penalty litigation.
Medicine calls the subjective experience of breathing discomfort dyspnea. One particularly distressing component is air hunger, the intensely unpleasant urge to breathe when ventilation cannot satisfy the body’s respiratory drive. Respiratory physiologist Robert Banzett and colleagues have described air hunger as a primal sensation signaling failure to meet one of the body’s most urgent needs: maintaining gas exchange. Like pain, thirst, or hunger, it demands attention, but the need it signals is immediate: Breathe. As it intensifies, it can dominate consciousness and provoke anxiety, fear, and an urgent drive to escape.
In severe pulmonary edema, that alarm may be intensifying while the lungs become progressively less capable of satisfying it. A person can breathe faster and harder, yet each breath may still feel inadequate. Pulmonary edema is sometimes described colloquially as “drowning from the inside.” It is not literal drowning because the mechanism is different: Fluid accumulates within the lungs rather than being inhaled from outside the body. But the comparison captures what severe pulmonary edema can feel like when it is consciously experienced. The body is demanding air, the person is trying to breathe, and the lungs are increasingly unable to satisfy that demand.
The language becomes even more stark in lethal-injection litigation. Anesthesiologist Gail Van Norman compared the potential conscious experience of rapidly developing pulmonary edema with near-drowning and suffocation and described those sensations as among the “most excruciating feelings known to man.”
A federal court confronted the severity of conscious pulmonary edema in a different lethal-injection protocol in 2019. Ohio’s protocol used midazolam rather than single-drug pentobarbital, but the litigation raised the same underlying question: What might a prisoner experience if pulmonary edema develops before awareness is lost? U.S. Magistrate Judge Michael Merz found that the high dose of midazolam was certain or very likely to cause pulmonary edema. He found that the medical witnesses who addressed the condition agreed that pulmonary edema would be physically and emotionally painful, “inducing a sense of drowning and the attendant panic and terror, much as would occur with the torture tactic known as waterboarding.”
Yet Merz denied the injunction because the prisoner had not satisfied the separate requirement of identifying a feasible and readily implemented alternative method that would significantly reduce the risk. The Sixth Circuit affirmed the denial, but it disagreed with Merz’s conclusion that the asserted suffering satisfied the constitutional threshold. In doing so, the appellate court compared sensations of drowning and suffocation with suffering historically associated with hanging.
That disagreement exposes an important distinction. A court can accept that a physiological experience may involve drowning-like sensations, suffocation, and serious pain while still concluding that the prisoner has not met the legal test required to stop an execution. How terrible an experience may be and whether it satisfies the Eighth Amendment are not necessarily the same question.
When timing becomes the constitutional question
The same issue reached the federal courts in 2020 as the government prepared to resume federal executions using pentobarbital. U.S. District Judge Tanya Chutkan concluded that the scientific evidence before her “overwhelmingly” indicated that the protocol was very likely to cause “extreme pain and needless suffering,” and she temporarily blocked the executions.
The Supreme Court vacated that injunction in Barr v. Lee. The government had presented competing expert evidence that the large pentobarbital dose would render prisoners insensate before pulmonary edema could be consciously experienced. Justice Sonia Sotomayor’s dissent, by contrast, described the prisoners’ evidence that flash pulmonary edema could produce a sensation akin to drowning accompanied by “extreme pain, terror, and panic.” The majority concluded that the prisoners had not shown they were likely to succeed on their Eighth Amendment claim and allowed the executions to proceed. But that ruling did not resolve the underlying question of whether pulmonary edema develops before or after conscious experience ends.
The execution of Wesley Ira Purkey soon made that dispute less abstract. A private autopsy obtained by his family documented severe bilateral acute pulmonary edema and unusually heavy lungs, with frothy pulmonary edema present in the trachea and mainstem bronchi. Van Norman interpreted those findings as evidence that the edema developed before death. She argued that, if Purkey remained conscious while it progressed, he could have experienced profound shortness of breath, suffocation, and sensations comparable to near-drowning. The pathology could be demonstrated. The harder question was whether awareness and that pulmonary process overlapped.
The Justice Department confronted that problem directly in its January 2025 review. It distinguished responsiveness from consciousness and described expert debate over whether a massive dose of pentobarbital produces “disconnected consciousness,” in which the person is unable to experience what is happening, or “connected consciousness,” in which the person may be physically unresponsive yet still retain awareness or experience pain. The review emphasized that lack of responsiveness does not necessarily establish absence of internal or external awareness and concluded that significant uncertainty remained over whether a single-drug pentobarbital protocol could cause unnecessary pain and suffering.
That uncertainty did not produce a permanent policy conclusion. Attorney General Merrick Garland rescinded the federal pentobarbital protocol in January 2025 after the review. In 2026, the Justice Department reversed course, reinstated the protocol, and accepted the position that pentobarbital renders prisoners unconscious before pulmonary edema can be consciously experienced. The policy conclusion changed. The physiological question did not.
What can anyone really know about consciousness?
Pike’s attempted execution brought a different part of the same uncertainty into public view: how difficult it can be to determine exactly when conscious experience ends. Witnesses reported that she remained awake after the execution process had begun and complained of severe discomfort in her arm. Later came prolonged snoring-like breathing and other respiratory sounds before the procedure was abandoned.
Meaningful speech establishes consciousness at that moment. Later respiratory sounds do not establish that consciousness persisted, while subsequent unresponsiveness cannot identify the precise instant at which awareness disappeared. Observers can document what a person says and does, pharmacology can predict what a drug should do, and pathology can show what happened to the body. None can perfectly reconstruct the subjective transition from awareness to unconsciousness.
That uncertainty is why timing matters so much in cases involving pulmonary edema. If pulmonary edema develops only after a prisoner is profoundly unconscious, it may produce striking pathology without conscious suffering. If it develops while awareness remains, the interval may contain the air hunger, suffocation, panic, and terror described by clinicians, physiologists, and execution experts. The question is not simply what ultimately killed the person. It is what the person was capable of experiencing while it was happening.
There is one uncomfortable problem with treating this as a death-row question
Descriptions of air hunger, suffocation, and sensations resembling drowning do not come only from death-penalty litigation. They are also descriptions of what patients experience in ordinary clinical medicine. Pulmonary edema is a familiar medical emergency, occurring with heart failure, kidney disease, critical illness, acute volume overload, and other conditions encountered routinely in hospitals.
The cause may be completely different, and the intention is obviously different. But once fluid is accumulating in the lungs of a conscious person, the physiology of respiratory distress does not change with the setting. The lungs do not know what room they are in.
Medicine also recognizes that respiratory suffering can be both severe and difficult to assess from the outside. A 2025 systematic review of 24 studies found dyspnea in 475 of 1,169 communicative mechanically ventilated patients, or 40.6 percent, and when present it was generally moderate to severe. The finding is particularly striking because these were patients capable of reporting what breathing felt like to them. As critical illness progresses and communication becomes more difficult or disappears, recognizing that suffering becomes harder, not easier.
A 2024 joint scientific statement from the European Respiratory Society and European Society of Intensive Care Medicine is unusually direct: “Dyspnoea ranks among the most distressing experiences that human beings can endure.” The societies also warn that clinicians can underestimate dyspnea, and that critically ill patients may continue to experience it even when they cannot communicate their distress. In other words, inability to communicate does not establish that breathing difficulty is absent. It may mean the patient can no longer report it.
The parallel with the execution litigation is difficult to miss. Courts have spent years asking whether pulmonary edema and conscious experience overlapped before a condemned prisoner became unresponsive. Medicine can face the same biological problem when respiratory failure progresses from a period in which a patient can describe distress to a period in which communication becomes limited or disappears. Losing the ability to report suffering does not establish when the ability to experience it ended.
The comparison is not constitutional. A hospital is not an execution chamber, and the Eighth Amendment does not govern medical care. But if the possibility of consciously experiencing pulmonary edema is serious enough to command years of constitutional scrutiny over what the state may make a condemned prisoner endure, the same human experience should not become less important when it occurs in a hospital.
A diagnosis of pulmonary edema tells us what happened to the lungs. It does not necessarily tell us what happened to the person experiencing it. Unresponsiveness does not prove that the person was spared its worst stages. When the available evidence cannot establish that unconsciousness preceded severe respiratory distress, comfort should not simply be presumed. The purpose is not to presume agony. It is to refuse to presume its absence.
There is a reason these details are difficult to sit with. Severe air hunger, suffocation, and the possibility of remaining conscious while the lungs become progressively less able to satisfy the body’s demand for air are not comfortable things to imagine. Most people encountering those details have the privilege of turning away: A judge can close an opinion, a physician can move on to the next case, a reviewer can stop reading, an attorney can move to the next page, and family members and friends can look away. The person struggling for air could not turn away from any of it.
Pike understood the distinction before anyone attempted to execute her. She was not afraid of death, she wrote. She was nervous about the process. Death is an outcome. Dying is an experience. The prisoner is supposed to die. The patient is not. The law may change with the room. The capacity to suffer does not.
Laurel A. Coons is a scientist with a background in genomics and biomedical research. She completed her doctoral training in pharmacology and cancer biology at Duke University and conducted research at the National Institute of Environmental Health Sciences. Her work has focused on genomic regulation, endocrine signaling, and translating complex scientific data into insights relevant to medicine and patient care.
She shares professional updates on X at laurelcoons.
