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Health Law
University of Iowa School of Law
Kurtz, Sheldon F.

PART 1: The Provider and the Patient
 
Chapter 2: The Treatment Relationship: Formation and Termination
2.5 hours
 
A.   The Duty to Treat: pg. 105-143
1.     The Duty to Accept Patients: pg. 106
Doctor
Hurley v. Eddingfield
Rule: In obtaining the state’s license to practice medicine, the state does not require, and the licensee does not engage, that he will practice at all or on other terms than he may choose to accept. 
 
Facts: Eddingfield (D) was decedent’s family doc and refused to go to his aid when summoned. Although no other patients were requiring (D) immediate services (D) refused the messenger’s tender of a fee for his services when told of decedent’s violent sickness for no reason. When death ensued, Hurley (P) sued, claiming that (D) wrongfully failed to meet his obligation to the public.
 
Holding: (D) refusal to enter into a contract of employment did not violate the law regulating the practice of medicine, which is a preventive, and not a compulsive, measure. Hurley’s (P) analogies drawn from the obligations to the public on the part of innkeepers, common carriers, and the like, are beside the mark. Affirmed. 
 
Analysis: The patient-healthcare provider relationship is normally a consensual one. A physician may refuse a patient for any reason, or for no reason.
1.      Further Analysis:
a.                  Licensing Statutes: Only determine, according to court, whether you are allowed to practice medicine. Act of licensing does not impose an obligation to treat.
b.                  Criticism of the Rule:
                                                        i.Discrimination against certain groups: groups of patients might not be treated, or might only be treated for a high price (e.g., malpractice attorneys).
                                                      ii.Reliance: patients rely on competent medical care from a professional, especially in case of emergency. If there is no other doctor available, the cost of refusal to treat can be very high.
                                                    iii.Public Profession: Certain professions (e.g., doctor, fireman, police officer) are qualitatively different and should confer certain ethical requirements, including the duty to treat.
1.                  Counter: Having an obligation to take all comers may affect decision-making about what profession to pursue in a way that might be harmful to the people we are trying to help.
Hospital (pre EMTALA)
Wilmington General Hospital v. Manlove                
Rule: Liability on the part of a hospital may be predicated on the refusal of service to a patient in case of an unmistakable emergency, if the patient has relied upon a well-established custom of the hospital to render aid in such a case. 
 
Facts: The Manloves’ (P) infant son had been ill for several days the nurse at (D) ER said that the Hospital (D) could not give any treatment because the child was under the care of a physician. She did not examine the child at all. The child died later that day.
 
Holding: In this case, the mere recitation of the infant’s symptoms was not in itself evidence of an emergency sufficient to present a question for the jury. Before such an issue could arise there would have to be evidence that an experienced nurse should have known that such symptoms constituted unmistakable evidence of an emergency. If the Manloves (P) cannot adduce evidence showing some incompetency of the nurse, or some breach of duty or some negligence, their case must fail.
 
Anlysis: The court below had decided that the Hospital (D) was public and therefore could be held liable. The appellate court, however, decided that the hospital was private, but reasoned that it could still be held liable. The judge analogized to a case of negligent termination of gratuitous services, which creates a tort liability. A refusal to see a patient might result in a worsening of the condition because of the time lost in a useless attempt to obtain medical help. 
1.      Further Analysis:
a.                  Detrimental Reliance Theory:
                                                        i.In the “case of an unmistakable emergency,” where the patient has “relied” on the “well-established custom of the hospital to render aid in such a case…” then the hospital cannot refuse to treat.
b.                  Other potential theories
                                                      ii.Note: not used by the court in this case
                                                    iii.Common Carrier / Innkeeper:
2.                  Generally: certain institutions that have a monopoly over a service are obliged to serve all paying customers that present, or provide a good reason for rejection.
 
Hospital (post EMTALA)
                    i.EMTALA Triggering Requirements
1.      Hospitals are subject to EMTALA if…
a.                  …you accept Medicare funds…AND you operate an Emergency Room
2.      Patients trigger EMTALA duty to treat if…
a.                  They exhibit an “emergency medical condition”…OR they are in “active labor”
3.      Note: What counts as an “emergency room” has been broadly defined.
a.                  The patient does not need to be “present” in the actual ER.
b.                  The ambulance (if hired by the hospital) is OK, elsewhere in the hospital is OK (e.g., birth with complications), etc. Hospitals not required when they are specialty service clinic or equivalent.
                  ii.EMTALA Compliance Requirements
1.      Step One: Conduct Screening
a.                  If screening shows an emergency medical condition or active labor (see above) then there is an obligation to either stabilize or treat the patient.
                                                              i.      If not, then EMTALA is not triggered
2.      Step Two: Stabilize or Treat the Patient
a.                  Stabilization: required prior to transfer or discharge. WHAT IS THIS REQUIREMENT?
                                                        i.Exceptions to stabilization: You can also transfer a non-stable patient if…
                                                      ii.(1) the patient consents OR (2) the doctor certifies, based on a risk analysis, that transfer is a medically reasonable course of action (doctor tried in Burditt, court rejected the validity of the order).
b.                  Treatment: if you are planning to treat (i.e., admit) the patient, then there is no stabilization requirement.   
                                                    iii.MedMal vs. EMTALA: stabilization requirement is unnecessary in this case because, on admission, a treatment relationship has been established and ordinary MedMal liability then applies, not EMTALA.
                                                    iv.Rationale: Congress didn’t want to federalize Medical Malpractice, which is why EMTALA liability ceases at the point of admission.
                iii.EMTALA Penalties:
1.      Generally:
a.                  Hospitals and responsible physicians are subject to civil money penalties.
b.                  Also, a private right of action for the patient against the hospital (but not the doctor).
2.      Note Damages Rarely Awarded: EMTALA rarely leads to damages or penalties. Fines tend to be relatively small, Medicare licenses are rarely revoked, and enforcement overall is generally quite weak.
3.      Note: Doctor vs. Hospital Liability:
a.                  Query: Why does EMTALA provide a right of action only against hospitals?
b.                  Rationale: If Doctors were liable they might not practice in the ER
c.                   Result: Hospitals contract with doctors to provide care for ER patients who need it
                                                        i.EMTALA hospital liability forces hospitals to contract with doctors to provide care.
                                                      ii.Rationale: There are several doctors working in the ER, but only one hospital. It is easier for the law to hold the hospital liable for failures to treat
 
Constitutional Right to Treatment (or, Constitutional Duty to Treat)?
Wideman v. Shallowford Community Hospital                         
Rule: There is no general right to medical care or treatment provided by the state. 
 
Facts: Ambulance took Wideman (P) to a different hospital than she had requested. After delay, the doc at Shallowford (D) hospital spoke to (P) physician at Piedmont and had her transferred there. (D) physician was unable to stop her labor and Wideman (P) gave birth to a premature baby who survived only four hours.  She claimed her constitutional right to medical care and services of her choice had been violated. 
 
Holding: A constitutional duty can arise only when a state or municipality, by exercising a significant degree of custody or control over an individual, places that person in a worse situation than he would have been had the government not acted at all. In the present case, DeKalb County did not exercise a degree of coercion, dominion, or restraint over (P) sufficient to create such a special relationship. Her physical condition cannot be attributed to the county therefore the county was under no affirmative constitutional duty to provide medical services at all. 
 
Analysis: In this case, the court held that even if the alleged policy of the county to transport patients only to certain hospitals were proved, no constitutional right would be violated.
2.       Further Analysis: “Negative Liberties” vs. “Positive Liberties”
a.                   The Constitution protects “negative liberties,” (e.g., free from unreasonable search and seizure) but does not provide “positive liberties” or affirmative rights (e.g., healthcare).
b.                   Exceptions: Custodial Relationships: If the government places you in a situation where they exercise “coercion, dominion, or restraint” (e.g., prison, mental hospital, etc.) then there is a Constitutional obligation to provide healthcare.
3.       Right to Choice (Alternative Interpretation of Wideman):
a.                   Argument: The patient isn’t asking for a right to healthcare; she is simply asking for the right to choose where she is taken once in the ambulance.
b.                   Response: Patient chose to enter the ambulance voluntarily, so this is a different situation from prison or mental institution (“coercion, dominion, or restraint”).
c.                    Counter [Reliance]:
                                                         i.The right to choose argument might be buttressed with a reliance argument (show reliance on a custom that ambulances take patients

e surgery. 
 
Holding: The “otherwise qualified” determination requires an individualized inquiry and appropriate findings of fact. Based on the evidence, facts are certainly available to warrant the conclusion that (P) was “otherwise qualified” for surgery. Moreover, (D) has not produced any evidence that reasonable accommodations could not have been made. A strict rule of deference to a doctor’s medical judgment would completely eviscerate § 504’s function of preventing discrimination against the disabled in the healthcare context. (P) must be given an opportunity to prove that the reason given by (D) that made him unqualified was a pretext or encompassed unjustified consideration of the handicap itself. 
 
Analysis: This case set forth the proper evidentiary approach to be taken in § 504 cases. The plaintiff must first make out a prima facie case that he was otherwise qualified for surgery, and only then does the burden shift to the defendant to show that the plaintiff’s handicap made him unqualified. Then, in order to prevail, the plaintiff must prove either that the reason given by the defendant is a pretext or that the reason encompasses unjustified consideration of the handicap itself.
a.       Further Analysis:
                                                         i.Efficacy Issue: If the treatment is not as effective for the handicapped person that can be a sufficient reason to deny. Patient is not “otherwise qualified.”
                                                       ii.But Reasonable Accommodations:
1.                   In this case the Doctor (defendant) did not receive summary judgment, despite the general rule that handicaps can be considered in medical treatment.
2.                   Why? “The defendants have not produced any evidence that reasonable accommodations could not have been made”
                                                     iii.Risk to Doctor?
1.                   From handicap (e.g., HIV), as distinct from risk to patient. Can this be considered?
2.                   Yes, and treatment can be denied only if reasonable accommodations could not be made.
                                                     iv.Risk to Patient from Doctor
1.                   Query: Can a doctor’s handicap be considered by a patient refusing to receive treatment? E.g., does a Doctor have to reveal that he has HIV before performing invasive surgery?
2.                   Held: Yes. The doctor must disclose disability and the patient may use that as a reason to opt out, even if reasonable accommodations can (and would) be made.
Walker v. Pierce                    
Rule: A physician may condition care on a personal economic philosophy publicly announced to his patients. 
 
Facts: Pierce (D) was a physician who had a policy of requesting, as condition for his care, that all patients who were unable to financially support themselves voluntarily submit to sterilization following the delivery of their third child. (P) later agreed to sign the consent form for sterilization. Following the delivery of her fourth child, (P) signed two more consent forms and a tubal ligation was performed. Walker (P) and another patient (P) sued Pierce (D), alleging constitutional violations and race discrimination.  
 
Holding: There is no judicial precedent or statute inhibiting Pierce (D) from establishing and pursuing the policy he has publicly and freely announced. At no time is he shown to have forced his view upon any mother. In this case, not just one, but three formal written consents were obtained. Moreover, since Pierce (D) was not a state actor, he could not be found to have violated his patients’ constitutional rights. 
 
Analysis: Under the South Carolina Medicaid plan, the patient-physician relationship is one of free choice for both parties. The physician, under no contract with the state, simply submits his bill when treatment is concluded to the Medicaid insurance carrier instead of the patient. Thus he could not be found to have been a state actor for constitutional analysis purposes. 
 
C.   The Structure of the Treatment Relationship: pg. 143-170
1.     Forming a Patient-Physician Relationship: pg. 146
Clanton v. Von Haam                       
Rule: There is no rule of law that requires a p