Case and Commentary
Jun 2001

Emergency Treatment for Patients Who Cannot Pay

Kayhan Parsi, JD, PhD
Virtual Mentor. 2001;3(6):183-184. doi: 10.1001/virtualmentor.2001.3.6.hlaw1-0106.


Dr. Burnett arrived at DeFrancis to examine Mrs. Raphael. He confirmed her blood pressure to be the highest he had ever seen, 210/130, and he assumed that she had been hypertensive throughout her pregnancy. He estimated that Mrs. Raphael's baby weighed 6 pounds—less than normal weight. After stabilizing Mrs. Raphael's blood pressure, Dr. Burnett arranged for her transfer to David Ward Hospital, a perinatal facility better equipped than DeFrancis to care for underweight infants.

Ms. Harper then showed Dr. Burnett the DeFrancis Hospital guidelines regarding the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA requires that patients diagnosed with an "emergency medical condition" or in "active labor" be treated at the emergency department where they present or be transferred, if they are in stable condition, to an emergency department better prepared to handle their medical emergency. Dr. Burnett refused to read the guidelines. He told Ms. Harper that Mrs. Raphael represented more risk than he was willing to accept from a malpractice standpoint. Moreover, he was concerned about reimbursement for taking care of Mrs. Raphael. Ms. Harper explained that Mrs. Raphael could not be transferred unless Dr. Burnett signed a form entitled "Physician's Certificate Authorizing Transfer." Dr. Burnett signed the form, and Mrs. Raphael was transferred.

On route to the hospital Mrs. Raphael delivered a healthy baby in the ambulance approximately 40 miles into the 170-mile trip. There were no outcome complications.

  1. Did Dr. Burnett fulfill his ethical obligation concerning treatment of indigent patients such as Mrs. Raphael?
  2. Does the fact that Mrs. Raphael was a potentially high-risk patient make any difference in his ethical obligation?
  3. In the absence of universal health insurance, EMTALA has become a safety net for uninsured patients who present at an emergency room. How well does this legal measure address inadequate care for the poor? What unintended adverse consequences can you foresee to this safety net role for EMTALA?


Virtual Mentor. 2001;3(6):183-184.



The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.