The second episode of HBO’s Emmy-winning series, The Pitt, included a storyline where paramedics bring in a woman they describe as “drug-seeking,” “uncooperative,” and “combative” after she was removed from the city bus “for disrupting and disturbing passengers.” After a tense scene in the Emergency Department, where the patient was threatened with a police call, she excruciatingly noted that her pain medicine was not working, and she has sickle cell anemia. Dr. Mohan, unlike the other healthcare professionals that the patient encountered, quickly recognizes a vaso-occlusive crisis and changes the trajectory of the patient’s treatment for the better, while informing fellow healthcare providers of the symptoms of sickle cell anemia.
Hopefully, this episode raises awareness, as shockingly, even today, reports indicate that health care providers and others remain unfamiliar with sickle cell disease, and those with the disease or trait often face mistreatment and racism in the healthcare space, increasing health disparities. Similar to The Pitt episode, Professor Britney Wilson’s article, Predisposed: Race, Disability, and Death Investigations, draws attention to a related context where those with sickle cell and other diseases face discrimination—death investigators’ use of the trait and other related conditions “as a justification for the deaths of Black people who die due to state violence or neglect” even when such a justification is not convincing.
The first part of the article provides a theoretical background that situates the paper within the literature of racism, ableism, state violence, and state neglect. The terms “state violence” and “state action” are broadly defined and encompass phenomena like deaths in police custody and even the impacts of neglect during natural disasters, including Hurricane Katrina, the subject of numerous documentaries, with the hurricane landfall’s 20th anniversary occurring last year.
Part II “explores the history of the death investigation system.” Part II (A) provides information on the colonial origins of the death investigation system in the United States, and Part II (C) discusses the current roles of coroners and medical examiners. Part II.B briefly explains how legal causation, which “consists of two primary elements: actual cause and proximate cause,” connects to the decisions of coroners and medical examiners to cite “disability” in death investigations. Sections D and E of Part II, as well as Part IV, briefly describe the procedures governing autopsies and proposed reforms, which often focus on insulating death investigators from political pressure, hopefully, to facilitate a neutral determination of cause of death.
Part III, “Disability, Underlying or Preexisting Conditions as Causes of Death” addresses many specific examples from recent history in which death determinations have specifically referenced health conditions or genetic conditions that do not seem to have actually caused the death. Current law provides inadequate protections for individuals with genetic conditions like sickle cell anemia, Tay-Sachs, and Huntington’s disease. While the law provides some protections of individuals’ genetic information with respect to health insurance and employment, it does not adequately address the use of that information in death investigations.
Notably, as Professor Wilson’s article shows in Part III, simply having a genetic trait but not the genetic condition can impact causation in a death investigation, even when it should not. In turn, this can reduce the liability of an actor, especially a state actor. Despite the prevalence of sickle cell anemia, many individuals have the sickle cell trait, meaning one copy of the gene, not the two required for the disease. Moreover, generally, “people with sickle cell trait enjoy normal life spans with no medical problems related to sickle cell trait. Sickle cell trait can never become sickle cell disease.” For this reason, citing the mere existence of the sickle trait in death investigations is often unexpected and insufficient in articulating clear causation in a death investigation.
Similarly, in Part III, Professor Wilson’s article contributes to the environmental justice and disability literatures by noting that “people of color and people with disabilities are both disproportionately affected by the hazardous consequences of natural diseases…[and] are disproportionately likely to have preexisting or underlying conditions, such as heart disease or diabetes, to which death investigators often attribute their deaths even in the wake of natural disasters.” This observation should give everyone pause as the American Heart Association’s annually issued reports continue to indicate that “[h]eart disease kills more people than any other cause.” The Centers for Disease Control and Prevention note that “[h]igh blood pressure, high blood cholesterol, and smoking are key risk factors for heart disease.” Nearly half of all Americans have high blood pressure, and at least 10% of the American population either has high blood cholesterol or is a smoker, meaning many Americans have pre-existing conditions that investigators could inaccurately deem to be their causes of death. Moreover, climate change is expected to increase the number of natural disasters, which could harm individuals and property, with a disparate impact on minorities. It is worth noting that when including the Great Lakes and U.S. territories, “more than 129 million people, almost 40% of the nation’s total population, live in coastal counties.”
While poor health outcomes can clearly result from genetic conditions, as deaths of individuals, whether due to actions in state custody, natural disasters or simply poorer health outcomes continue (or possibly increase), Professor Wilson’s article reminds us of how important it is to be aware of how the legal system will ultimately allocate liability, whether in investigations, civil lawsuits, or criminal proceedings.
