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Drug companies refuse to supply states with execution medications. Not sure if it’s liability, legality or ethics (probably not the latter). I’d think states could synthesize their own or use drugs they confiscated, though.
Also, the AMA and state medical boards punish doctors who agree to supervise executions, because to do so violates the Hippocratic oath.
Often doctors have travelled to the prison in secret, and go to great lengths to remain anonymous. Kinda like the hooded axe man of old.
Some of the drugs are not manufactured in the US. There has been an EU wide ban for selling drugs used in executions to the US without making sure they're not used for executions. Which also is the reason why medical organizations were very unhappy few years ago when states lied to them in an attempt to get those drugs - as they risk getting cut off for legitimate medical use.
Reason for the EU ban is simple: We consider executions a human rights violation over here.
The appearance of having ethics matters for drug companies because of liability concerns.
The other thing that matters to big multinational pharma companies is when Italian prosecutors start charging their executives with murder. That's definitely a "liability concern."