By Josh Sanburn
December 9, 2016

The drug used to sedate an Alabama death row inmate—who reportedly coughed and heaved 13 minutes into his execution Thursday—is the same one that was at the heart of a Supreme Court case last year and has often been criticized for not properly making inmates unconscious during executions.

On Thursday, Alabama executed Ronald Bert Smith, Jr., a 45-year-old inmate who was convicted in the fatal shooting of Casey Wilson in 1994 in Huntsville, Ala. According to reports, the execution went awry soon after the sedative was administered. Smith reportedly coughed, clenched his fists, and raised his head during the execution, forcing prison officials to conduct two consciousness checks to determine whether Smith was properly sedated before administering the final two drugs, according to the Associated Press.

Read more: Creator of Lethal Injection: ‘I Don’t See Anything That is More Humane’

The first drug used was midazolam, which states have increasingly turned to as previously used execution drugs have proven difficult to obtain thanks to drug shortages and pressure from anti-death penalty groups. But since 2014, a number of states have experienced serious issues in properly sedating inmates, including during the executions of Dennis McGuire in Ohio, Clayton Lockett in Oklahoma, and Joseph Wood in Arizona, all of whom appeared to move and writhe on the gurney after being injected with the drug—just as Smith did on Thursday.

In June 2015, the Supreme Court ruled 5-4 that the use of the drug was constitutional, after considering whether Oklahoma’s drug protocol involving the sedative violated the Eighth Amendment’s ban on cruel and unusual punishment. The court said that the death row inmates who brought the case failed to prove that midazolam could lead to the risk of severe pain.

Read more: Oklahoma’s Lethal Injection Problems Go From Bad to Worse

A number of anesthesiologists have criticized the drug’s use in executions, even in large doses. The problem for the drug’s opponents is that while there’s oftentimes visual evidence that midazolam hasn’t properly made an inmate unconscious—writhing, groaning, coughing—it’s proven difficult to show that its use actually leads to the kind of pain that would violate the constitution, in part because the inmates aren’t around to say so.

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