Lethal injection has come under fire as less than the peaceful, painless death it appears. Reevaluation of the process has sparked examination of the role of doctors in state-sponsored executions. Physicians helped design the lethal injection protocol. Seventeen death penalty states require physician involvement and all practicing jurisdictions employ medical personnel. Doctors have signed death warrants, rendered inmates competent, provided intravenous access, monitored vital signs, administered lethal injections and declared death. Remarkably, lethal injections are administered remotely and neither physicians nor other execution personnel assess depth of anesthesia prior to injection of the painful lethal drugs. Recently physicians have helped precipitate an unprecedented public and judicial review of lethal injection through expert testimony in litigation and by publishing evidence of potential awareness in execution. In response, judges have ordered protocol modifications to extend further the tools and expertise of medicine into the execution chamber in order to ensure anesthesia. Physician involvement created and perpetuates the seriously flawed protocol of lethal injection. Physicians and particularly anesthesiologists now have the opportunity to redress the mistakes of the past, and inform the growing debate over whether and potentially how medicine should be used to kill.