EMTALA's Financial Incentives Cause Conflict between Compassion and Limited Resources

By Seth Chandler

The headline today reads, "Just outside hospital, teen lay bleeding to death." The article recounts how an innocent bystander who was shot by gangs at a basketball game was dragged by friends within 30 feet of an emergency room but no further after ER workers refused to help despite the pleas of friends, neighbors and police. By the time the police took matters into their own hands and wheeled the boy into the ER, it was too late. Christopher Sercye, age 15, was dead.

This story may sound like a macabre tale of callous behavior by medical professionals or a lament about gang violence, which not only threatens many residents of urban America but causes even well intentioned doctors to cleave to a rigid code of cloister rather than respond with an occasional foray into the perceived killing fields outside. For the medical professionals in the ER were not acting on whim, but pursuant to a hospital policy (now, of course, rescinded) that prohibited them from going outside the confines of the building to help. The policy was apparently based on a concern for the safety of hospital personnel entering "danger zones," but the unseen hand of a federal law, the Emergency Treatment and Active Labor Act (EMTALA), and its interpretation in the courts may be responsible for simlilar policies at other hospitals. And this policy was likely optimal financial behavior in light of EMTALA.

EMTALA, a federal law enacted in 1986, modifies the common law rule announced in cases such as Hurley v. Eddingfield, 59 N.E. 1058 (Ind. 1901) that accords medical professionals the same freedom as other Americans: the right not to enter into contractual relationships with people even when "morality" might suggest that they do so. Under EMTALA, however, most hospitals with emergency rooms are obligated to screen patients and treat those found to have emergencies without inquiry into whether the patient can pay. Since many patients entering the ER are indeed indigent, and perhaps now enter the ER precisely for this reason, EMTALA’s obligation shifts the financial burden of modern health care away both from the individual and the conventional redistributive mechanisms of the government (like the income tax) and places it on hospitals. But in order for the EMTALA "tax" to kick in, the patient must physically enter the emergency room, according to cases such as Miller v. Medical Center of Southwest Louisiana, 22 F.3d 626 (5th Cir. 1994). Thus, the hospital, seen by some as a center of caring professionals, actually has a strong financial incentive, to ensure that those likely to be indigent, such as those bleeding to death from gang violence, never make it through the front door. And hence, perhaps, the "don’t go outside" policy.

The case of Christopher Sercye is a reminder that EMTALA is a bizarre response to the problem of our unequal capacity to finance medically beneficial treatment. To condition freedom from financial incapacity on an ability to pierce the emergency room doors while providing incentives for hospitals to guard those doors against just such unwanted intrusions is a stupid response to the real conflict raised by our significant compassion and our limited resources. Until we come up with a better resolution than EMTALA, however, to that real problem, society perhaps as much as the professionals who just followed orders while a young boy bled to death on their doorstep, should stop feeling surprised when Christopher Sercye’s story is told, but instead feel a sense of shame.

05/22/98