Risk, Care, and Compliance: How Does Race Continue to Legally Permeate These Definitions?

In the early 1990s, after a traumatizing and emotional experience, a woman in a South Carolina public hospital labored and gave birth to a baby. She was promised and expected to receive support from modern medicine; instead, she was met with the shackles of cold steel handcuffs, hours after her delivery, while she was still recovering in her hospital bed. This was a result of her participation in a secret drug test without the consent of the pregnant mothers, something that was tested and authorized by the hospital's own "neutral" policy to protect fetal health. Not even days after giving birth, she was forced to leave the maternity ward in shackles and transported to a jail cell. In that moment, the boundary between the clinic and the prison had vanished, and she transformed from a patient to a suspect. The doctor, bound by the Hippocratic Oath to do no harm and the confidential promises they make when presuming the job, had been transformed into an advocate and agent of the state [1].

This shift from victim to accused reveals how the system is logically structured to disguise racial control as a neutral administrative process. Healthcare law is universally understood as a system meant to protect its people and ensure equal access to care. It is presented as a neutral system grounded in policies meant to promote fairness and improve health outcomes for all. However, this understanding becomes blurred when examining how, since its inception, Black women have experienced disproportionate amounts of harm when attempting to receive care. From unequal access to care to harmful medical interventions, there is a clear gap between what healthcare law claims to do and what it produces. This raises an important question: if the US healthcare law is truly neutral and protective, why does it consistently result in unequal outcomes for Black women?

Although the healthcare law claims to ensure equal protection and access, the policies governing medical standards, insurance, and clinical decision-making systematically disadvantage Black women by embedding racial bias into definitions of “risk,” “compliance,” and “care,” transforming legal protection into institutional harm. By examining legal cases and healthcare policies, this paper argues that these categories are not neutral but operate to reinforce existing inequalities rather than resolve them.

To understand the modern clinic, engaging with Michel Foucault’s concept of the "medical gaze" from The Birth of the Clinic is crucial. Foucault describes a power shift where a physician’s role, when attempting to heal a patient, is to observe, map, and categorize the body within a hierarchy of health and deviance in order to reach clinical conclusions [2]. This gaze is a form of biopower: the state's practice of regulating and monitoring biological processes to manage populations. Although this may seem objective in theory, it becomes evident that the American legal system fails to achieve true neutrality. Because the system is rooted in the dehumanization of Black bodies, the gaze is never fully neutral; notably, 54% of Black women have reported experiencing at least one form of discrimination within the past year [3]. For many black women, the clinic has become a place of intense surveillance, where their health is treated as a matter of public concern and state security. This theoretical framework suggests that the hospital is no longer a sanctuary, but a transparent space where biological “risk” is recorded and potentially weaponized by the state.

When examining the case of Ferguson v. City of Charleston, the concept of “risk” becomes crystallized. In this case, a public hospital in South Carolina partnered with law enforcement to secretly drug test pregnant women, most of whom were Black, for cocaine use without receiving their consent [4]. When the results came back positive, these women were not offered treatment or support but were instead arrested after giving birth. While the policy was framed as a way to protect fetal health, the Supreme Court ultimately discovered that these actions executed by the hospital violated the Fourth Amendment, as they constituted unconstitutional searches. Through this procedure, the hospital developed a chain of custody for the urine samples. According to the National Institute of Health, chain of custody is defined as “the sequential documentation or trail that accounts for the sequence of custody, control, transfer, analysis, and disposition of physical or electronic evidence.” [5]. With this understanding the hospital, “[r]equired that a chain of custody be followed when obtaining and testing patients' urine samples; provided for education and treatment referral for patients testing positive; contained police procedures and criteria for arresting patients who tested positive; and prescribed prosecution for drug offenses and/or child neglect, depending on the stage of the defendant's pregnancy” [6]. In medicine, you only need a chain of custody when you are planning to use that urine as evidence in court. This implies that the hospital was planning to be an institutional support for law enforcement from the very beginning. The worst part is that after the hospitals identified which patients had used cocaine, “the policy made no mention of any change in the prenatal care of such patients, nor did it prescribe any special treatment for the newborns” [7]. If this process was meant to “help” the newborn babies, why did the babies not receive any special treatment from the hospital that is supposed to take care of them, especially after knowing they would need extra care due to the extreme developing circumstances under which they were developed? This ruling reveals something deeper about the operation of healthcare systems. The concept of “risk” was not treated as a medical issue requiring care, for either the mother or the baby, but rather as a form of criminalization justified by surveillance and punishment. Rather than offering support, resources, or adequate treatment, the system reframed the mother’s drug use as a threat to society, turning concern into suspicion. In doing so, healthcare spaces began to function less as places of care and more as sites of monitoring. This shift transforms healthcare from a sanctuary into something closer to a secondary system of control, where the focus moves away from healing and toward surveillance. Once a patient is labeled as a “risk,” she is no longer simply cared for, but watched, reported, tested, and potentially criminalized: the opposite of what the healthcare system promises to provide.

According to Ferguson v. City of Charleston, “In affirming without reaching the consent question, the Fourth Circuit held that the searches in question were reasonable as a matter of law under this Court's cases recognizing that ‘special needs’ may, in certain exceptional circumstances, justify a search policy designed to serve non-law-enforcement ends” [8]. The logic behind this is that police need a warrant to search, but under this doctrine, an individual can be searched without a warrant “outside law enforcement" (such as drug testing for an athlete's safety). The court ruled that this was the hospital's way of generalizing evidence or policy, which is just ordinary law enforcement, not special needs. This shows how the hospital tried to use legal means to hide behind the special needs doctrine, pretending they were helping. Although the court saw through this, it demonstrates how healthcare law transforms medical spaces into extensions of law enforcement, especially for Black women. Instead of being treated as patients, they were viewed and treated as criminals, without even having prior reasons to be deemed as such. This assumption highlights how the definition of risk is not neutral, but is shaped in ways that disproportionately target marginalized groups. As a result, what appears to be a protective policy instead continually reinforces systemic harm by embedding racial bias into how risk is identified and addressed.

Initially, the Fourth Circuit Court of Appeals attempted to justify the hospital's actions by applying the special needs doctrine, arguing that the searches were reasonable because they served a non-law-enforcement goal: public health. By doing so, the court avoided the question of where the patentee had truly consented, effectively using a health-based excuse to bypass constitutional protections against warrantless searches. In a 6-3 opinion, Justice Stevens delivered the majority opinion clarifying that a legitimate special need must be divorced from the state's general interest in law enforcement [9]. The Court saw through the hospital’s defense, noting that if the law allowed the state to justify searches based solely on an “ultimate purpose” like health, then virtually any unconstitutional intrusion could be “immunized” from legal challenge [10]. This ruling is a direct indictment of the “neutrality” my thesis challenges; it proves that the legal system often attempts to use the language of care to bypass the constitutional rights of marginalized patients." [11]. 

This transformation of the patient into a suspect in Ferguson is not an isolated legal anomaly, but rather a manifestation of what Dorothy Roberts describes in Killing the Black Body as a systemic effort to regulate Black reproduction. Roberts argues that this regulation is rooted in the era of chattel slavery, where Black procreation was treated as a tool to sustain the institution of slavery [12]. Because slave masters held an economic stake in the labor of the children born to enslaved women, the American legal system was essentially founded on the dehumanization of African women’s reproductive lives. As Roberts notes, the 1662 Virginia statute, which decreed that children followed the status of their mothers, marked Black women from the beginning as “objects whose decisions about reproduction should be subject to social regulation rather than their own will” [13]. This historical domination laid the foundation for the American legal system that continues to justify the state’s intrusion into the reproductive autonomy of Black women today. 

From the era of slavery framed black women as a procreative vessel for economic gain, to the contemporary era of today, the world has used this as a means to shift toward treating women as a social burden that must be eliminated. The Thai transition from forced procreation to forced sterilization becomes extremely exemplified through the case of Relf v. Weinberger (1973). Where the social regulation that is described by Roberts has moved to the federally funded clinic and exposes another violent stage of this transition: the use of state-funded medical protocols to strip Black women of their biological rights and future [14]. In the case of Relf, two young sisters in Alabama were surgically sterilized without their or their mother’s consent [15]. While the younger sisters were subjected to the producer, the eldest, Katie Relf, only escaped the same fate by successfully resisting and locking herself in her room to hide from the medical staff. The sisters were unaware that they were test subjects in a project funded by federal dollars, intended to guide “family planning.” This was not a medical necessity, but rather a manifestation of a scholarly problem deeply embedded within US healthcare policy: the assumption that poverty and Blackness contain a “risk” to the social fabric that must be managed through the permanent removal of reproductive capacity [16]. By framing sterilization as a service for people experiencing poverty, intended for them not to bear additional financial burdens, the healthcare system utilized a veneer of administrative neutrality to execute a project that Judge Gesell noted sat on a “murky” line between eugenics and planning a family [17]. This undoubtedly blurs the line between the legal categories of care and control, raising questions about how a system meant to benefit all produced a procedure funded by the same government claiming to uplift marginalized communities.

What this case does is force us to recognize the legal infractions placed on women of color and how certain definitions, such as compliance, become intertwined within the world of legal healthcare. In the logic of the federal programs that funded the Relf sisters’ sterilization, “compliance” was not about a patient agreeing to treatment for their benefit, but rather about controlling a woman’s body so that it conforms to the social demographic goals of the state. The coercion was explicit, and the report found that a large number of poor people were improperly coerced into sterilization under the“threat that their welfare benefits would be withdrawn.” Those under Medicaid during childbirth were the most frequent target of this benefit ransom, which was seen in the experience of Mrs. Waters, who was actually not able to receive medical assistance from her physician during labor unless she submitted to a tubal ligation. When the court later found that an estimated 100,000 to 150,000 low-income people had been sterilized through similar processes annually, it became clear that care offered to Black women is often predicated on a belief that they are unfit for motherhood [18]. This connects back to Ferguson, where the law did not see Black women as sovereign individuals with rights to privacy and bodily autonomy. Rather, the state viewed women as a social harm that must be mitigated by either policing their pregnancies or, in this particular case, ending their ability to have children. Consequently, the supposed neutrality of federal healthcare becomes a tool of biopower, ensuring that “equal access” to care is, in reality, equal access to state-sanctioned erasure.

Although cases such as Ferguson and Relf illustrate the state’s active intrusion into the lives of black women, the case of Bryan v. Koch (1980) reveals how the legal system tends to justify the systematic withdrawal of care through a veneer of administrative necessity. In this case, New York City moved to close several public hospitals in Harlem, most notably Sydenham Hospital. This hospital was located within a predominantly low-income minority community that was approximately 98% Black and Hispanic [19]. When the case went to court, the plaintiffs argued that the closure would have a “disparate impact,” disproportionately stripping resources away from marginalized communities [20]. Despite this understanding, the court’s opinion dismissed this characterization of the lawsuit as an attempt to use the federal courts to delay a painful but purely political decision. The framing of a law that views health care closures as a political choice rather than a civil rights violation reinforces the notion that the court continues to effectively not hold the city accountable. 

This ruling further accelerated the creation of legal barriers for those affected by the hospital closures and resulting institutional harm. By strictly adhering to "discriminatory intent," as established in Washington v. Davis, Sofaer noted that even if a racially adverse impact is foreseeable, it is "insufficient in itself to prove discriminatory purpose." The ruling highlighted how, even when discrimination is clearly present, without sufficient legal evidence of intent, courts tend to uphold those in power rather than those without a strong voice. Legal scholar Charles Lawrence III describes this as the “Id, Ego, and Equal Protection” problem, arguing that because most racial bias is unconscious, the “intent” requirement acts as a barrier that protects systemic racism rather than dismantling it [21]. Under this legal framework, disparate impact alone is insufficient to prove a constitutional violation; instead, plaintiffs must prove "discriminatory intent." This requires showing not just that a policy harms a specific racial group, but that it was designed with the "explicit purpose" of doing so. By prioritizing intent over outcome, the court allows the state to hide behind "fiscal responsibility" and "budgetary efficiency" as neutral justifications for actions that ultimately result in racialized harm. This legal avoidance transforms Black communities into mere "accounting calculations," demonstrating that framing healthcare solely as a matter of administrative policy ultimately jeopardizes the survival of marginalized patients, as they are treated as secondary to financial considerations within the state’s logic. 

The cases of Bryan v. Koch, Ferguson v. City of Charleston, and Relf v. Weinberger are not isolated failures of a well-intentioned system, but rather they represent conscious expressions of a legal framework that treated black bodies as objects for the state to manage rather than subjects of care. Through such legal precedents, the veneer of neutrality in the US healthcare law is stripped away, revealing a machinery of biopower. An example of this is when the courts in Bryan v. Koch prioritized discriminatory intent over the reality of community abandonment, sanctioning the withdrawal of life-saving resources guided by fiscal logic. When hospitals in Ferguson are transforming medical exams into a site of surveillance, it codifies the patient as a suspect. Furthermore, when federal protocols in Relf permanently erase reproductive capacity, the law moves from passive abandonment to active elimination. 

In the end, these policies show how the legal definitions of risk, compliance, and care are structurally meant to harm rather than benefit black women. By embedding racial bias into these administrative categories, the healthcare system can produce unequal outcomes while maintaining a facade of objectivity. To move toward a system that truly protects and ensures equal access, the law must move beyond the narrow requirement of proving individual “intent” and begin to account for the measurable "impact" of its policies. The only way this can be achieved is through dismantling this false neutrality, so that healthcare can be reclaimed as a human right rather than a tool of institutional harm. The survival of marginalized patients depends on a legal evolution that views them not as fiscal burdens or criminal risks, but as sovereign individuals entitled to the sanctuaries that modern medicine once promised.

Endnotes

[1] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[2] Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A. M. Sheridan Smith (New York: Pantheon Books, 1973).

[3] Nambi Ndugga, Latoya Hill, Alisha Rao, Akash Pillai, and Samantha Artiga, "Key Data on Health and Health Care by Race and Ethnicity," Kaiser Family Foundation–KFF, December 16, 2025.

[4] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[5] Ashish Badiye et al., "Chain of Custody (Chain of Evidence)," StatPearls, February 13, 2023.

[6] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[7] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[8] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[9] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[10] Ferguson v. City of Charleston, 532 U.S. 67 (2001).

[11] Oyez, “Ferguson v. City of Charleston.”

[12] Dorothy E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York: Pantheon Books, 1997).

[13] Roberts, Killing the Black Body.

[14] Relf v. Weinberger, 372 F. Supp. 1196 (D.D.C. 1974).

[15] Southern Poverty Law Center, “Relf v. Weinberger,” November 30, 2024. 

[16] Katherine Gillespie, “Defining Reproductive Freedom for Women ‘Living under a Microscope’: Relf v. Weinberger and the Involuntary Sterilization of Poor Women of Color,” Digital Georgetown, January 24, 2000.

[17] Relf v. Weinberger, 372 F. Supp. 1196 (D.D.C. 1974).

[18] Liana Woskie and Kimberly Turner, "From Relf v. Weinberger to Drive-through Delivery: Unpacking Democratic Responsiveness and Administrative Levers in U.S. Sterilization Policy," Journal of Health Politics, Policy and Law (December 2026).

[19] Bryan v. Koch, 492 F. Supp. 212 (S.D.N.Y. 1980).

[20] Bryan v. Koch Brief for Plaintiffs-Appellants, May 27, 1980, Brief Collection, LDF Court Filings, LDF Archives, Thurgood Marshall Institute.

[21] Charles R. Lawrence III, "Unconscious Racism Revisited: Reflections on the Impact and Origins of ‘The Id, the Ego, and Equal Protection,’” Georgetown Law Faculty Publications, 2008.

Works Cited 

Badiye, Ashish, et al. “Chain of Custody (Chain of Evidence).” StatPearls. February 13, 2023. https://www.ncbi.nlm.nih.gov/books/NBK551677/.

Bryan v. Koch, 492 F. Supp. 212 (S.D.N.Y. 1980). https://law.justia.com/cases/federal/district-courts/FSupp/492/212/2308767/.

Bryan v. Koch Brief for Plaintiffs-Appellants. Brief Collection, Legal Defense Fund Court Filings. LDF Archives, Thurgood Marshall Institute, May 27, 1980. https://ldfrecollection.org/archives/archives-search/archives-item/50d1b670-9608-40dd-ac80-d64f47ee3a67/bryan-v-koch-brief-for-plaintiffs-appellants. 

Ferguson v. City of Charleston, 532 U.S. 67 (2001).

Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception, (New York: A. M. Sheridan Smith, 1973).

Gillespie, Katherine. “Defining Reproductive Freedom for Women ‘Living under a Microscope’: Relf v. Weinberger and the Involuntary Sterilization of Poor Women of Color.” Digital Georgetown, January 24, 2000. https://law.digital.georgetown.edu/handle/10822/1051142.

Lawrence III, Charles R. “Unconscious Racism Revisited: Reflections on the Impact and Origins of ‘The Id, the Ego, and Equal Protection.’” Georgetown Law Faculty Publications, 2008.https://scholarship.law.georgetown.edu/facpub/339/ 

Ndugga, Nambi, Latoya Hill, Alisha Rao, Akash Pillai, and Samantha Artiga. "Key Data on Health and Health Care by Race and Ethnicity." Kaiser Family Foundation–KKF, December 16, 2025. https://www.kff.org/racial-equity-and-health-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity/

Oyez. “Ferguson v. City of Charleston.”
 https://www.oyez.org/cases/2000/99-936.

Relf v. Weinberger, 372 F. Supp. 1196 (D.D.C. 1974).

Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon Books, 1997.

Southern Poverty Law Center. “Relf v. Weinberger.” November 30, 2024.
 https://www.splcenter.org/resources/civil-rights-case-docket/relf-v-weinberger/.

Woskie, Liana, and Kimberly Turner. “From Relf v. Weinberger to Drive-through Delivery: Unpacking Democratic Responsiveness and Administrative Levers in U.S. Sterilization Policy.” Journal of Health Politics, Policy and Law (December 2026): 12461787. https://doi.org/10.1215/03616878-12461787.