After checking to see whether the new Reference Manual on Scientific Evidence[1] attended to some long overdue corrections, I turned my attention to the substance of the chapter on epidemiology. A cursory comparison between the third[2] and fourth[3] editions of the epidemiology chapter in the Reference Manual a lot of carry over from the third edition, some change in authorship, and at least one interesting change.
The two lawyer authors, Steve Gold and Michael Green, remain, but the authors with reasonable pretense to subject-matter expertise have changed. Gold and Green are both law professors with a long history of commenting on American tort and evidence law. Both are aligned with the lawsuit industry. Previous epidemiology authors, Daryl Michal Freedman and Leon Gordis are now gone from the chapter. Leon Gordis, who had been a chairman of the department of epidemiology, in the Bloomberg School of Public Health, Johns Hopkins University, died in September 2015, after the third edition was published. Daryl Michal Freedman, who been the other subject-matter expert on the third edition’s chapter on epidemiology, has been an epidemiologist with the Biostatistics Branch of the National Cancer Institute, for many years. It is not clear why he left the project.
Replacing Gordis and Freedman are Jonathan Chevrier and Brenda Eskenazi. Chevrier is an associate professor on the faculty of medicine, in the department of epidemiology, in McGill University. The focus of his work is on “common environmental contaminants,” and the role in the development and health of children. Brenda Eskenazi is professor emerita, in the University of California Berkeley School of Public Health, where she is the Director of the Center for Environmental Research and Children’s Health. Eskenazi is a member of a dodgy group known as the Collegium Ramazzini, which was responsible for staging an ex parte presentation of plaintiffs’ expert witnesses to judges presiding in asbestos litigation.[4] Eskenazi was not, however, a member of the Collegium at the time the group conspired with the late Irving Selikoff to pervert the course of justice in American asbestos litigation.
The second significant change is substantive; the fourth edition has added a new subsection to the epidemiology chapter. Comparing the texts of the third and fourth editions of this chapter reveals a new subheading in the new edition:[5]
Genetic and Molecular Epidemiologic Studies
Alas, there is not as much substance to the new subsection, which is less than four pages. Lawyers in the trenches might well have hoped for more substantive treatment of genetic epidemiology, and genetic causation. The chapter’s authors explain their abbreviated treatment with the comment:
“Although commentators have long forecast that the output of genetic and molecular epidemiology would revolutionize causal proof, as of this writing few judicial opinions have addressed these types of studies, and it is far from clear that a revolution is in the offing.”[6]
The chapter authors are correct that some authors in the past proffered unrealistic predictions of how genetics would supplant correlational studies. Nonetheless, this area has not been as quiescent as the authors’ parsimonious treatment would suggest.
On the question of how prevalent are genetic causation issues, whether raised by plaintiffs or defendants, the chapter might have benefitted from the contributions of a practicing lawyer. Genetic issues come up with some frequency in the litigation of cases involving mesothelioma. The days of plaintiffs who had 30 years of amphibole asbestos exposure in the workplace are largely over. Today’s cases involve little to no exposure, and it stands to reason that the origins of the recently diagnosed cases are different from those diagnosed in the 1970s and 1980s.[7] Genetic cause of mesothelioma is a salient current issue that is passed over in this new Reference Manual.
The authors acknowledge a single birth defects case in which genetic causation was litigated,[8] which was already old news when the last edition of the Manual was published. There are now many more reported cases that cry out for discussion in this under-covered area of the Manual.[9] There are also many cases not reported that have turned on genetic issues. For instance, in some cancer and birth defect cases, the existence of a highly penetrant genetic mutation that could explain the occurrence of a disease completely raises a serious question whether the plaintiff who fails to test for the mutation can possibly have carried his burden of proof.[10] And then there are myriad cases in which the parties have engaged in motion practice, sometimes extended, over access to genetic testing materials.
Genetic issues have arisen in the litigation of high-profile general causation disputes. For instance, the failure to control for genetic effects in epidemiologic studies was a significant issue in the acetaminophen-autism litigation, with both sides presenting geneticists to explain whether the relevant studies were undermined by failure to control for genetic effects.[11]
In the Manual’s epidemiology chapter’s new section on genetics, the authors describe some basic terms and explain that genetic epidemiology may provide evidence for, or against, claims of health effects. The authors’ views come through most clearly in the following short passage:
“Alternatively, genetic epidemiology may reveal associations between genetic variations and a plaintiff’s disease, raising the issue of whether or not a genetic variation may be a competing cause of the disease. This requires assessment of whether the gene–disease association is causal in a general sense, whether it acts independently of the exposure, and whether it is a competing cause in the plaintiff’s specific instance. The extreme, though not typical, example would be a health outcome or disease entirely determined by genetics, 55 as is the case with sickle cell anemia.56”[12]
The authors never explain or defend their claim that cases involving diseases caused entirely by genetics are “extreme” and “not typical.” At several points, the authors emphasize that gene-environment interactions are the more prevalent determinants of diseases.[13] If we were to catalog the currently known genetic determinants of diseases, the authors may be correct on a percentage basis, but the issue in any given case is whether the disease or harm claimed by the plaintiff is one of the “extreme” cases of complete genetic causation, or an instance of genetic susceptibility. The authors’ generalization, even if it were correct, would not be very helpful or informative for any specific case.
Perhaps even more important for lawyers, there is a substantive issue on which the new chapter manages to provide confusing guidance. The epidemiology chapter appears to create a false dichotomy between rare, highly penetrant genetic mutations that are uncommon causes of certain diseases, and the more prevalent genetic mutations and polymorphisms that leave persons more susceptible to the deleterious effects of exogenous exposures to toxic chemicals.[14] There is, however, another scenario omitted in the chapter’s discussion of genetic causation. Genetic mutations and polymorphisms may leave persons susceptible to normal, endogenous chemicals, stochastic cellular events, and biological processes that result in diseases such as cancers. In other words, the knee-jerk reflex to invoke exogenous, external toxic chemical exposures promotes a false dichotomy and obscures the obvious implication that susceptibility mutations and polymorphisms may lead to cancer without environmental exposures to harmful chemicals.[15]
The number of endogenous events leading to DNA alterations is enormous, and requires us to rethink the mantra that attributes chronic diseases to gene-environment interaction. At the very least, we need to stop thinking of “environment” as chemical exposures from without ourselves. The epidemiology chapter authors, like many writers, point to external chemical exposures as the culprits in gene-environment reactions, but they ignore the normal, endogenous events that lead to DNA damage, for which genetic susceptibility may be relevant. Mutations that result in increased susceptibility to cancer may affect DNA alterations from both endogenous and metabolic factors as well as from exposures to external chemicals.
Ignorance is never a good thing, and the chapter does the bar and bench a disservice in not adequately exploring genetic susceptibility in view of both exogenous and endogenous exposures that may be responsible for chronic diseases, such as cancers.
[1] National Academies of Sciences, Engineering, and Medicine & Federal Judicial Center, REFERENCE MANUAL ON SCIENTIFIC EVIDENCE (4th ed. 2025) (cited as RMSE 4th ed.)
[2] Michael D. Green, D. Michal Freedman & Leon Gordis, Reference Guide on Epidemiology, 549, in RMSE 3rd ed.
[3] Steve C. Gold, Michael D. Green, Jonathan Chevrier, & Brenda Eskenazi, Reference Guide on Epidemiology, in RMSE 4th ed.
[4] See In re School Asbestos Litigation, 977 F.2d 764 (3d Cir. 1992). See also Cathleen M. Devlin, Disqualification of Federal Judges – Third Circuit Orders District Judge James McGirr Kelly to Disqualify Himself So As To Preserve ‘The Appearance of Justice’ Under 28 U.S.C. § 455 – In re School Asbestos Litigation (1992), 38 VILL. L. REV. 1219 (1993); Bruce A. Green, May Judges Attend Privately Funded Educational Programs? Should Judicial Education Be Privatized?: Questions of Judicial Ethics and Policy, 29 FORDHAM URB. L. J. 941, 996-98 (2002).
[5] Steve Gold, et al., Reference Guide on Epidemiology, at 914, in RMSE 4th ed.
[6] Id. at 916.
[7] ToxicoGenomica, The Litigator’s Guide to Using Genomics in a Toxic Tort Case (2018).
[8] Id. at 917 & n.55 (citing Bowen v. E.I. Du Pont de Nemours & Co., No. CIV.A. 97C-06-194 CH, 2005 WL 1952859 (Del. Super. Ct. June 23, 2005), aff’d, 906 A.2d 787 (Del. 2006) (discussing the importance of a test for a genetic mutation, which was the defense’s alternative causation theory to plaintiff’s claim that a toxic exposure caused the birth defect at issue). The authors fail to mention that the Bowen case was actually dismissed.
[9] See, e.g., Oliver v. Sec’y Health & Human Servs., 900 F.3d 1357 (Fed. Cir. 2018); Ortega v. United States, 2021 WL 4477896, 2021 U.S. Dist. LEXIS 188969 (N.D.Ill. Sept. 30, 2021); Vanslembrouck ex rel. Braverman v. Halperin, 2014 WL 5462596 (Mich. App. 2014).
[10] See, e.g., Halter v. Boehringer Ingelheim Pharms. Inc., no. 2023-L-001382, Cir. Ct. Cook Cty., Illinois, jury verdict (Aug. 27, 2025) (defense verdict in colorectal cancer case in which plaintiff failed to test for genetic mutation); see also Lauraann Wood, Boehringer Wins Another Zantac Cancer Trial In Illinois, LAW360, Chicago (Aug. 27, 2025).
[11] See, e.g., In re Acetaminophen – ASD-ADHD Prods. Liab. Litig., 707 F.Supp.3d 309, 320 (S.D.N.Y. 2023).
[12] Id. at 916-17 (emphasis added).
[13] Id. at 915.
[14] See, e.g., id. at 967n.190, citing McMillan v. Dep’t of Veterans Affairs, 294 F. Supp. 2d 305, 312 (E.D.N.Y. 2003) (“It is generally accepted that genetic susceptibility plays a key role in determining the adverse effects of environmental chemicals. . . . [I]f polymorphisms of the gene encoding the AhR [protein] exist in humans as they do in laboratory animals, some people would be at greater risk or at lesser risk for the toxic and carcinogenic effects of TCDD [dioxin].”).
[15] See Edward J. Calabrese, Changing the paradigm: The biggest polluter and threat to your health is your body, J. OCCUP. & ENVT’L HYG. (2025), published on-line, ahead of print.
