In the Matter of Baby K: the Fourth Circuit Stretches Emtala Even Further - Kevin T. Brown

• Publication year: 1996

In the Matter of Baby K: The Fourth Circuit Stretches EMTALA Even Further

In 1994, the Fourth Circuit Court of Appeals reaffirmed its position on the applicability of the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)¹ when it decided In re Baby "K".² Baby K, an anencephalic infant, was born in the hospital in October 1992.³ Anencephaly is a congenital malformation found in a very small number of infants in which a major portion of the brain, skull, and scalp are missing.⁴ One of the missing components of the brain is the cerebrum, which provides cognitive abilities and awareness and allows interaction with our surroundings.⁵ Baby K, therefore, lacked all of these abilities, was permanently unconscious, and could not see, hear, or otherwise interact with her environment.⁶ As a side effect of her anencephaly, Baby K had severe breathing problems at birth. Doctors at the hospital recommended that the infant be given only supportive care in the form of nutrition, hydration, and warmth and that a "Do Not Resuscitate Order" would be a possibility.⁷ The mother, Ms. H, refused these suggestions and demanded mechanical respiration for the infant.⁸ The hospital attempted to transfer the infant to other, more specialized hospitals, but none would accept her.⁹ These breathing problems persisted and required Baby K's readmittance to the hospital on several occasions for further respirator treatment.¹⁰ On the second of these subsequent readmittances, the hospital, joined by the father of Baby K, Mr. K, (collectively "the Hospital") filed this suit for declaratory judgment on whether it must continue to provide such treatment to infants like Baby K.¹¹ The United States District Court for the Eastern District of Virginia ruled that in light of the Rehabilitation Act of 1973,¹² Americans with Disabilities Act,¹³ Child Abuse Amendments of 1984,¹⁴ EMTALA,¹⁵ and Virginia Medical Malpractice Act,¹⁶ the Hospital was not entitled to a declaratory judgment ratifying the discontinuance of such measures with Baby K.¹⁷ The Hospital appealed, contending that the district court erred when it: 1) construed EMTALA to require a particular treatment rather than imposing a prohibition on disparate treatment; 2) ignored the standard of care provided to anencephalic infants as shown by the evidence; 3) failed to recognize that physicians under Virginia state law can refuse to administer treatment the physicians believe to be ethically and medically unwarranted; and 4) ignored relevant language by not applying EMTALA only to patients who, although unstable, are transferred by hospitals.¹⁸ Finally, the Hospital had argued to the district court that further treatment of the anencephalic Baby K was "futile," and it should therefore not be required to continue to incur the expense of treatment which does not help the patient.¹⁹ On appeal, the Fourth Circuit Court of Appeals found these arguments without merit and elected to follow the plain language of the statute.²⁰ The Court affirmed the decision of the district court, holding that EMTALA required the hospital to continue stabilizing respiratory treatment on Baby K when necessary.²¹

The legislative history of EMTALA demonstrates that it was originally enacted by Congress in 1986 to combat the problem of emergency medical treatment facilities "dumping" patients who could not afford the services.²² However, the wording of the statute states that it applies to "any individual."²³ With the selection of the "any individual" language, Congress, maybe unwittingly, expanded the coverage of EMTALA to a much larger group than just those who are economically disadvantaged.²⁴ The problem faced by the courts is whether to apply the provisions of EMTALA according to Congress' original intentions, which only protected against economic dumping, or to interpret EMTALA as protecting all patients, regardless of situation, from discrimination in treatment.²⁵ The Fourth Circuit first addressed the provisions of EMTALA in Baber v. Hospital Corp. of America.²⁶ Baber brought the action against the doctors and hospital for their failure to provide his mentally ill sister with an appropriate medical screening and subsequent failure to provide her with stabilizing treatment, both required by EMTALA.²⁷ The district court granted summary judgment for the defendants, holding that although EMTALA did allow the institution of civil suits against federally-funded hospitals, it did not give rise to a private cause of action against treating physicians nor did it define the appropriate levels of medical screening for malpractice purposes.²⁸ The Court of Appeals for the Fourth Circuit affirmed the decision, finding that EMTALA was not intended to insure proper diagnosis of emergency situations, but only that screening and treatment procedures be given in a nondiscriminatory fashion.²⁹ The Fourth Circuit recognized the true breadth of EMTALA with its decision in

Brooks v. Maryland General Hospital, Inc.³⁰ Brooks brought an action against the hospital under EMTALA based on his contention that delays in diagnosis and stabilization of his conditions caused permanent injury to his spinal column.³¹ The Fourth Circuit held that EMTALA did not protect against misdiagnosis or malpractice in cases like Brooks.³² However, the court continued in dictum to state that obligations of hospitals required by EMTALA were not just to the economically disadvantaged, but to '"any individual' who is presented to an emergency room for examination or treatment of a medical condition."³³ Yet, even before the Fourth Circuit's decision in Brooks, EMTALA had already been interpreted to apply to "any individual" in other jurisdictions.³⁴ Prior to the Fourth Circuit's decision in Baby K, the Sixth, Ninth, Tenth and District of Columbia Circuits had found that EMTALA, according to the statute itself, applied to any individual.³⁵ Other jurisdictions had also previously held that EMTALA guarantees only proper screening and stabilizing treatment and does not...