Hickson v. St. David’s Healthcare: Disability-Discrimination Liability for Adverse Medical-Treatment Decisions When Denial of Care Is “Solely” Because of Disability

1. Introduction

Parties. Plaintiffs-Appellants are Melissa Hickson (individually, as administrator of Michael Hickson’s estate, and as next friend of minor children) and Marques Hickson. Defendants-Appellees include St. David’s Healthcare Partnership, L.P., L.L.P. d/b/a St. David’s South Austin Medical Center, Dr. Devry Anderson, Hospital Internists of Texas, Dr. Carlye Mabry Cantu, and Dr. Viet Vo.

Factual backdrop (as pleaded). Michael Hickson, a quadriplegic man with an anoxic brain injury, was hospitalized in June 2020 with serious infections and suspected COVID-19. Plaintiffs allege that despite a hospital risk tool reflecting a “70% chance of survival,” physicians pursued hospice and DNR status, discontinued antibiotics, and ordered withdrawal of life-sustaining treatment including food and fluids—allegedly because Michael could not walk or talk and was judged to have a low “quality of life.” Michael died. Plaintiffs also allege severe restrictions on family access and later public disclosure of protected health information by the hospital’s Chief Medical Officer.

Procedural posture. The district court dismissed multiple claims at the pleading stage and later granted summary judgment on remaining state-law claims. On appeal, the Fifth Circuit affirmed in part but vacated and remanded in part—most importantly restoring the federal disability-discrimination theories based on allegedly disability-based denial of treatment, and reviving certain state-law tort theories due to improper “with prejudice” dismissal.

Core issues on appeal. (1) Can an adverse medical treatment decision support disability discrimination claims under § 504 of the Rehabilitation Act and § 1557 of the ACA? (2) Were the hospital and physicians state actors under 42 U.S.C. § 1983? (3) Were dismissal rulings on informed consent and intentional infliction of emotional distress (IIED) proper—particularly dismissal “with prejudice” without leave to amend?

2. Summary of the Opinion

  • Disability discrimination (Rehabilitation Act § 504 / ACA § 1557): The court rejected a categorical rule that medical treatment decisions cannot constitute disability discrimination. It held such claims are cognizable where allegations plausibly show treatment was denied solely, in the “pejorative” sense, because of disability. The district court’s dismissal of these federal claims was vacated and remanded.
  • Section 1983: The court affirmed dismissal, holding neither the temporary guardian nor the private hospital and physicians were state actors; “parens patriae” and “acting in concert” theories were not plausibly alleged on these facts.
  • Informed consent (Texas law): The pleaded allegations were too conclusory to state a claim, but the district court plainly erred by dismissing with prejudice without giving an opportunity to cure potentially curable factual deficiencies. Vacated and remanded as to the with-prejudice dismissal.
  • IIED (Texas law): Applying plain-error review due to failure to object below, the court nonetheless held the alleged conduct—starvation/dehydration in hospice despite improvement, family exclusion, delayed notification of death, and public disclosure of health information—could qualify as “extreme and outrageous.” Dismissal with prejudice was vacated and remanded (as to the hospital).

3. Analysis

A. Precedents Cited

1) Pleading and review standards

  • Teeuwissen v. Hinds County and Meador v. Apple, Inc.: Used to restate de novo review of Rule 12(b)(6) dismissals and the requirement to accept well-pleaded facts as true while viewing them favorably to plaintiffs.
  • Harmon v. City of Arlington and Ashcroft v. Iqbal: Reinforced the line between plausible factual allegations and conclusory labels—central to why the informed-consent pleadings were found insufficient.
  • Dobbin Plantersville Water Supply Corp. v. Lake (citing Club Retro, LLC v. Hilton): Provided the abuse-of-discretion framework for reviewing dismissal “with prejudice.”
  • Boone v. Rankin Cnty. Pub. Sch. Dist.: Supported forfeiture/waiver principles for issues not adequately briefed on appeal.

2) Disability discrimination in medical treatment

  • Carter ex rel. Carter v. City of Shreveport: The district court relied on the notion that disability statutes do not “typically” remedy negligent care. The Fifth Circuit clarified that “typically” is not “never,” rejecting a categorical bar.
  • Francois v. Our Lady of the Lake Hosp., Inc.: Supplied the Fifth Circuit’s prima facie elements for Rehabilitation Act/ACA disability claims (qualifying disability; denial/exclusion by covered entity; denial “by reason of” disability).
  • Cummings v. Premier Rehab Keller, P.L.L.C.: Emphasized the Rehabilitation Act’s Fifth Circuit requirement that disability be the “sole” reason for denial—an analytical fulcrum in distinguishing malpractice from discrimination.
  • Johnson ex rel. Johnson v. Thompson: Quoted for the interpretive force of “solely”—“the discrimination must result from the handicap and from the handicap alone”—supporting the Fifth Circuit’s “pejorative sense” approach.
  • McGugan v. Aldana-Bernier (quoting United States v. Univ. Hosp., State Univ. of N.Y. at Stony Brook), Lesley v. Hee Man Chie, Reed v. Columbia St. Mary's Hosp., and McDaniel v. Syed: These decisions shaped the court’s framing that treatment choices can be “discriminating” in a neutral medical-judgment sense, yet unlawful in a “pejorative” bias-based sense when grounded in improper criteria unrelated to legitimate medical judgment.
  • Contrary-categorical statements were expressly rejected as inconsistent with text and common sense, including: Dinkins v. Corr. Med. Servs., Burger v. Bloomberg, and Schiavo ex rel. Schindler v. Schiavo. The Fifth Circuit treated these as overbroad categorical propositions that could immunize disability-based refusals of ordinary care.

3) State action and § 1983

  • Polk Cnty. v. Dodson: Used by analogy: just as public defenders do not act “under color of state law” when representing clients, guardians represent individuals—not the State.
  • Crank v. Crank: Fifth Circuit support for the proposition that guardians (including guardians ad litem) are not state actors.
  • The court also cited multi-circuit authority in footnote 6 consistent with that conclusion: Milan v. Wertheimer, Kirtley v. Rainey, Long v. Pend Oreille Cnty. Sheriff's Dep't, and Meeker v. Kercher.
  • Thomas S. v. Morrow: Distinguished because that guardian coordinated with state officials; here the alleged coordination was with private providers.
  • Bass v. Parkwood Hosp.: Reiterated that private hospitals do not become state actors merely due to regulation or participation in proceedings such as commitments; applied to foreclose § 1983 against these private defendants.
  • Lindke v. Freed and Lugar v. Edmondson Oil Co.: Anchored the constitutional/statutory “state action” requirement: § 1983 targets conduct attributable to the State, not private conduct.
  • T.L. v. Cook Children's Med. Ctr.: Plaintiffs invoked “parens patriae” reasoning, but the Fifth Circuit held it inapposite because T.L. involved the sovereign’s prerogative in disputes against parents of a minor; here, a temporary guardian existed and plaintiffs did not plausibly allege withdrawal of treatment contrary to the guardian’s wishes.

4) Informed consent, amendment, and plain error

  • Ortiz v. City of San Antonio Fire Dep't, United States v. Huerta, and Puckett v. United States: Established plain-error review after failure to object to a magistrate recommendation.
  • Ferrer v. Chevron Corp. and Sw. Bell Tel., L.P. v. City of Houston: Reinforced that arguments in briefs cannot substitute for missing allegations in the complaint on a Rule 12(b)(6) review.
  • Great Plains Tr. Co. v. Morgan Stanley: Provided the rule that dismissal with prejudice is generally reserved for incurable defects or where plaintiffs cannot/will not amend—supporting remand to allow potential amendment on informed consent.

5) IIED under Texas law

  • Hoffmann-La Roche Inc. v. Zeltwanger (citing Standard Fruit & Vegetable Co. v. Johnson) and Twyman v. Twyman: Set out IIED elements and the “extreme and outrageous” standard—conduct beyond all possible bounds of decency.
  • Elliott v. Methodist Hosp. and Escalante v. Koerner: Demonstrated Texas appellate willingness to treat certain medical and death-related misconduct as “extreme and outrageous,” supporting plausibility of the pleaded IIED claim here.

B. Legal Reasoning

1) A new Fifth Circuit rule: medical-treatment decisions are not categorically immunized from disability-discrimination scrutiny

The opinion’s central doctrinal move is textual and limiting: § 504 reaches discrimination “solely by reason of” disability, and § 1557 incorporates that framework for disability claims. The court drew a boundary between:

  • Malpractice / negligence / ordinary medical judgment (not typically the target of disability statutes), and
  • Denial of medical benefit “solely” because of disability—i.e., where disability itself (or a bias-laden “quality of life” assessment untethered from medical prognosis) is the operative reason care is withheld.

The Fifth Circuit endorsed the “pejorative sense” of discrimination (per Reed and McGugan) and held that adverse medical treatment decisions can be actionable when the pleaded facts show the decision was based solely on disability rather than legitimate medical criteria. The court illustrated the danger of categorical immunity with common-sense hypotheticals (refusing flu medication solely because of blindness; refusing to set a broken arm solely because of diabetes).

2) “Solely” functions as a gatekeeper—and narrows the claim

By insisting on “sole cause” (via Cummings and Johnson ex rel. Johnson v. Thompson), the court cabined the new rule: plaintiffs must plausibly allege that disability—standing alone—drove the denial, not mixed motives such as independent medical futility, resource constraints, or clinical contraindications.

This framing simultaneously (a) prevents the disability statutes from becoming general medical-malpractice codes and (b) preserves them as a remedy for disability-based rationing or exclusion masquerading as clinical judgment.

3) § 1983 rejected: no state action via guardianship or “parens patriae” on these facts

The § 1983 analysis is conventional but significant for healthcare litigation strategy. The court held:

  • A temporary guardian appointed under Texas Estates Code acts for the ward, not the State (analogy to Polk Cnty. v. Dodson; Fifth Circuit support in Crank v. Crank).
  • Private hospitals and physicians remain private actors notwithstanding regulation and involvement in end-of-life decisions (per Bass v. Parkwood Hosp.).
  • Plaintiffs’ reliance on T.L. v. Cook Children's Med. Ctr. failed because T.L.’s parens patriae concept concerned state-type intervention overriding parents of a minor; here, plaintiffs did not allege the withdrawal of treatment was contrary to the temporary guardian’s position, and the care was delivered by private actors.

4) Remedial/procedural correction: with-prejudice dismissal was improper for potentially curable pleadings (informed consent) and for a plausibly pleaded IIED claim

Even under plain-error review (Ortiz; Puckett), the Fifth Circuit treated “with prejudice” dismissal as a serious remedial step requiring futility or refusal to amend (Great Plains Tr. Co. v. Morgan Stanley).

  • Informed consent: allegations were too thin to satisfy Texas’s disclosure standard (Tex. Civ. Prac. & Rem. Code § 74.101), but the defect was factual and potentially fixable; therefore, “with prejudice” was error.
  • IIED: the alleged constellation—withdrawal of food/fluids despite improvement, severe access restrictions, delayed notice of death, and public disclosure of protected health information—could meet Texas’s “atrocious, utterly intolerable” threshold (Hoffmann-La Roche; Twyman), so dismissal at the pleading stage (and with prejudice) was improper.

C. Impact

1) Disability discrimination claims in healthcare: Fifth Circuit joins a non-categorical approach

The opinion establishes that, in the Fifth Circuit, providers cannot rely on a categorical “medical treatment decisions are not discrimination” defense at the motion-to-dismiss stage. Plaintiffs may proceed when they plausibly allege that disability itself—rather than medical contraindication—was the sole reason for denial of beneficial treatment.

2) Litigation consequences: discovery may now focus on “why” treatment was withdrawn

Because the dividing line is motive/criterion (medical vs. disability-as-disqualifier), future cases will likely probe: clinical notes, palliative/hospice consult communications, ethics consult documentation, prognostic scoring tools, and statements reflecting “quality of life” judgments untethered to survival prospects.

3) End-of-life decision-making: quality-of-life language becomes legally risky when it substitutes for medical prognosis

The court did not hold that palliative care, hospice, or DNR orders are discriminatory per se. But it signaled that “walk/talk” rationales and disability status may not lawfully operate as categorical disqualifiers for treatment where survival and benefit are plausible.

4) § 1983 remains a steep hill against private healthcare actors

The decision reaffirms that even high-stakes end-of-life decisions do not, without more, transform private hospitals and physicians into state actors. Plaintiffs seeking constitutional pathways must plead concrete state attribution beyond guardianship involvement or general parens patriae rhetoric.

4. Complex Concepts Simplified

  • Rehabilitation Act § 504 / ACA § 1557: Federal laws that forbid disability discrimination by covered healthcare entities (e.g., recipients of federal funds). The ACA’s § 1557 imports the Rehabilitation Act’s disability framework.
  • “Solely by reason of” disability: A strict causation requirement in § 504—disability must be the only reason for denial/exclusion. If denial is due to an independent medical reason, the disability statute typically will not fit.
  • Medical malpractice vs. discrimination: Malpractice is substandard care; discrimination is unequal care because of an improper criterion like disability. A bad outcome does not itself prove discrimination; disability must be the reason for the adverse decision.
  • State action / “under color of state law” (§ 1983): A constitutional tort requires conduct fairly attributable to the State. Private hospitals/doctors usually are not state actors, even if heavily regulated.
  • Parens patriae: The State’s protective authority (often invoked in child welfare). It does not automatically apply to private end-of-life decisions for an adult under guardianship.
  • Rule 12(b)(6) dismissal: A case can be dismissed early if the complaint does not plead enough concrete facts to make the claim plausible.
  • Dismissal “with prejudice”: The claim is ended and cannot be refiled/amended; appropriate only when defects are incurable or amendment would be futile.
  • Plain error review: A demanding standard applied when a party did not properly preserve an argument in the trial court; relief is granted only for clear, outcome-relevant mistakes.

5. Conclusion

Hickson v. St. David’s announces a key Fifth Circuit principle: adverse medical treatment decisions are not categorically exempt from disability-discrimination liability. A plaintiff may proceed under § 504 and § 1557 where the pleaded facts plausibly show that the denial (or withdrawal) of beneficial treatment occurred solely because of disability, as distinct from medical judgment or negligence.

At the same time, the opinion leaves conventional boundaries intact: § 1983 claims generally fail against private hospitals and physicians absent true state attribution. And procedurally, the court reinforces that with-prejudice dismissal is a severe remedy not suited to potentially curable pleadings (informed consent) or plausibly pleaded emotional-distress torts (IIED) arising from alleged end-of-life misconduct.