02/16/2016 06:22 pm ET Updated Feb 16, 2017

Questions About the Death of Justice Scalia

Supreme Court Justice Antonin Scalia died quietly in his sleep on the night of February 12-13, 2016 at age 79. The death was at a private hunting ranch in West Texas where he had arrived by chartered plane less than 24 hours before his death. Without examining the scene or the body, a justice of the peace declared death from a presumed heart attack, despite a lack of any specific symptoms of a heart attack. No autopsy was done.

Was "heart attack" the most likely cause of death?

Our research shows that 29% of men in this age group suffered from sleep apnea, as defined by at least five apneas per hour of sleep. Sleep apnea means cessations of breathing during sleep. The rate and likely severity of sleep apnea is elevated among men with obesity, and pictures of Justice Scalia show a massive double chin, one of the best predictors of sleep apnea. He also had hypertension, which is associated with sleep apnea. The altitude of the Cibola Creek Ranch is approximately 4,400 feet. Sleep apnea usually grows worse at higher altitudes because blood oxygen drops. It appears likely that Justice Scalia suffered from sleep apnea, but we do not know if he had been treated. No mention was made that he was seen to be using a treatment for sleep apnea when he died.

News coverage stated that Justice Scalia had recently suffered a rotator cuff injury to the shoulder that could not be treated surgically. An MRI had been done the day before, and rehabilitation was yet to be organized. Upon arriving at the ranch, Justice Scalia attended a quail hunt but apparently did not pick up a gun, perhaps a hint that his shoulder was hurting badly. Returning to the ranch, the Justice attended a cocktail party and then dinner. It would not be surprising if alcohol were served during or after the meal at such an elegant resort, but news stories did not mention if Justice Scalia had any alcohol to drink. This might be of interest because alcohol in the blood makes sleep apnea worse.

It took some time for U.S. Marshals to arrive at the scene of death, but news accounts did not describe what was found in the bedroom. People in acute pain from shoulder injuries are sometimes prescribed sleeping pills or opiates or both. Both sleeping pills (such as the hypnotic zolpidem) and opiates make sleep apnea worse, and the combination of opiates, a sleeping pill, and alcohol is believed to be particularly lethal. A benzodiazepine-like drug such as a sleeping pill is present in blood in over one third of opiate overdose deaths. Sleeping pills carry double the risk for obese patients. Were any sleeping pill or opiate bottles or open liquor bottles found in the room?

In Justice Scalia's case, we wonder if the sudden death in bed might have been due to sleep apnea, made worse by the combination of obesity, thinner air at high altitude, and possible use of alcohol, sleeping pills, or opiates.

When a high government official with many enemies dies unexpectedly, our national security demands that reasonable attention be given to investigating the cause of death.