Christa Pike, 50, has been hospitalized for almost a week after receiving two injections that allegedly contained lethal pentobarbital. On Tuesday, her lawyers said she had regained consciousness and speech, though her prognosis remains uncertain. The state of Tennessee had attempted to execute her for the 1995 murder of a fellow student, but Pike survived and was taken to hospital. If she stabilizes and is discharged, the state could send her back to death row and try to execute her again.

There is still no official account of what happened last Wednesday afternoon when the execution was briefly halted before the Supreme Court authorized it hours later, but experts say the pentobarbital may have leaked into the tissues around the vein, causing injuries that authorities have not yet confirmed. Because of what occurred during the failed execution, and the medical care required to save her life, Pike’s case raises ethical dilemmas about the obligations of the doctors and caregivers treating her and about the state’s responsibility for her condition.

Dr. Arthur Caplan, a bioethics expert and emeritus professor of medicine at New York University, says there is “no place for doctors, nurses, or any health worker in executions.” “That violates their oath not to cause harm. An execution is not intended to benefit the person,” he adds.

Caplan argues that even when a doctor’s presence at an execution is presented as a way to reduce suffering, there is a boundary between punishment and medicine. “Doctors have no role in executions. Even when someone says, ‘Well, if better-prepared doctors had been present, this execution wouldn’t have gone wrong’ — you don’t need doctors, you need better-trained executioners,” he says.

“Some argue that in parts of the world doctors help terminally ill people end their lives. But remember that is meant to relieve the suffering of someone who is dying. The patient is the focus. An execution is something the judicial system seeks to carry out,” Caplan explains.

Pike was sentenced to death 30 years ago for the murder of Colleen Slemmer, a 19-year-old fellow student, when Pike was 18. On September 30, after last-minute appeals that delayed the execution for several hours, she was given two injections of pentobarbital and, because she remained alive, was taken to a Nashville hospital. Over the weekend, her lawyers said she was unconscious and on a ventilator.

Caplan says the question of who legally represents a person who cannot communicate is fundamental. If there is no designated decision-maker to represent and defend her interests, a court must appoint someone. “I don’t think it should be the state of Tennessee, the prison warden, or any official involved in the execution attempt” who decides what care she should receive, he argues.

“Another question is who is in charge of her care. Doctors, absent other instructions, will try to improve her condition. But she may have a mother or other relative who wants to intervene and say, ‘I don’t want that. Let her die. She will be left with disabilities and I don’t think she would want to live like that,’” the expert adds.

Stephen Ferrell, one of Pike’s defense lawyers, said Pike signed a power of attorney naming someone else to make her medical decisions, according to The Associated Press.

The dilemma has precedents in cases of inmates with mental illnesses who do not understand they will be executed, Caplan notes. “Doctors have encountered situations where psychiatrists and psychologists treat someone on death row who has severe schizophrenia or many other mental health issues, and some have refused to restore that person’s competence to be executed so they cannot be put to death,” he explains.

Until the extent of Pike’s injuries — both physical and cognitive — after the failed execution is clear, it will not be known whether the defense will raise this kind of argument. It is also not yet known what steps the state of Tennessee will take in Pike’s case.

“Lending the prestige of medicine to execution”

The American Medical Association has declared it ethically incompatible for a physician to participate in a legally authorized execution because the profession is “dedicated to preserving life when there is hope of doing so.”

Caplan says the presence of healthcare personnel amounts to “lending the prestige of medicine to the execution,” giving the impression that “it is more humane because it is supervised by doctors.”

However, the presence of doctors does not by itself guarantee humane treatment. “We know that throughout history there have been doctors who participated in torture. The presence of doctors does not make things better,” he says.

Dr. Joel Zivot, an anesthesiologist and critical care physician who advised Pike’s lawyers, wrote in an essay in The New York Times over the weekend that authorities have “tried to make executions appear like medicine,” with stretchers, intravenous lines and cardiac monitors, but that it is a “sinister impersonation of the medical profession” without consent or therapeutic purpose.

The Tennessee Department of Correction has said that all protocol steps were followed.

“We have laws, judges and courts so society does not descend to the level of brutality of its criminals,” Caplan adds. “We try to set punishments that have a rationale and objectives, such as rehabilitation, deterrence — preventing others from doing what she did — or, in some cases, retribution, that you will pay for what you have done. But we also try to remain, so to speak, civilized and mindful of the ethical need for punishment not to reproduce the same cruelty as that of the criminals.” Pike’s case shows that this is not always achieved.

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The U.S. midterm elections will not only determine who will occupy the Congressional seats and governorships up for grabs in November. In several states, voters will also find ballot measures seeking to amend laws, approve tax changes, or add new provisions to state constitutions.

These measures allow certain public policy decisions to be put directly to voters, either through initiatives introduced by state legislatures or through citizen-led processes. From voting rules to taxes, housing, immigration, and reproductive rights, these are some of the most relevant initiatives that voters will consider in the midterms.

California: Voter ID and taxes on the wealthy

California will vote on 14 ballot measures. Five were placed on the ballot by the legislature, while nine came from citizen initiatives.

The most contested is Proposition 39, which would require voters to present an official ID to vote in person and provide the last four digits of one of those IDs on mail-in ballots. The initiative would also provide free identification cards and require annual reports on the percentage of voters with verified citizenship in each county. The state currently requires identification and a Social Security number to register to vote, but not at the polling place. The measure is opposed by the American Civil Liberties Union (ACLU), Common Cause, the League of Women Voters, and the California Democratic Party.

The other major battle is over taxes. Proposition 3 would make permanent the tax on high incomes approved in 2012 and extended in 2016, with 89% of the revenue going to public schools and 11% to community colleges. Proposition 40, better known as the billionaires’ tax proposal, would impose a one-time tax of up to 5% on people with assets exceeding $1 billion.

Housing is another major area. Proposition 1 would authorize a bond for affordable and veterans’ housing, costing state coffers between $500 million and $600 million annually for about 25 years, according to the Legislative Analyst’s Office. Proposition 37 would create loans for middle-income buyers of newly built homes, while Proposition 45 would expedite environmental reviews for housing, water, transportation, and clean energy projects.

Florida: ‘Save Our Homes’

In Florida, voters will decide on three amendments, all proposed by the legislature, which require 60% of the vote to pass.

One of them, known as Save Our Homes, is the most controversial. It seeks to substantially increase tax exemptions for primary residences and halve the annual cap on increases in the assessed value of nonresidential properties. It is controversial because, while supporters say it would provide much-needed, significant economic relief in response to inflation, critics and public safety agencies warn that the measure would create a severe shortfall in local budgets, putting funding for essential public services such as police, fire departments, and education at risk.

Immigration enters the ballot box

The American Immigration Council, an organization that advocates for immigrants’ rights, is tracking nine state measures affecting these communities. Most concern who can vote.

Arkansas, Kansas, South Dakota and West Virginia will put amendments to a referendum specifying that only citizens may vote; Alaska and Arizona are considering similar initiatives, while Arizona’s would also require identification and ban foreign contributions to political campaigns. There are recent precedents: in 2024, eight states approved measures of this kind. Supporters present them as a matter of common sense; opponents point out that federal law already prohibits noncitizens from voting and that, according to available data, such cases are extremely rare.

Another major measure is Colorado’s Amendment 81, which would require local police to notify the Department of Homeland Security, within 72 hours, when a person who is unlawfully in the country or whose immigration status cannot be determined is charged with certain crimes. Opponents argue that it would apply to people who have been charged but not convicted and could even affect someone with a prior felony who is charged with a minor offense, such as a traffic violation.

Idaho, meanwhile, will vote on an amendment to establish English as the official language in its Constitution. If approved, and unless required by federal law, English would be the only language used in the state’s public proceedings and documents, affecting Spanish-speaking communities.

Other initiatives

In Missouri, Amendment 3 proposes an almost total ban on abortion, with exceptions for rape, incest, and medical emergencies, and would enshrine in the state Constitution a ban on gender-affirming care for minors. It will be the first time voters decide whether to repeal an abortion right they themselves approved at the ballot box. The state will also hold a referendum on the congressional map, although the state Supreme Court ordered the 2022 map to be used in these elections.

Virginia will vote on reproductive freedom, the removal of the ban on same-sex marriage, and the restoration of voting rights after completing a sentence. Nevada, meanwhile, will vote again on its abortion amendment, which would establish abortion as a fundamental right.

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