DAWNELLE BARRIS, Plаintiff and Appellant, v. COUNTY OF LOS ANGELES, Defendant and Appellant.
No. S067733
Supreme Court of California
Mar. 25, 1999.
20 Cal. 4th 101
DAWNELLE BARRIS, Plaintiff and Appellant, v. COUNTY OF LOS ANGELES, Defendant and Appellant.
Kenneth M. Sigelman & Associates, Kenneth M. Sigelman and Penelope A. Phillips for Plaintiff and Appellant.
Shernoff, Bidart, Darras & Arkin and Sharon J. Arkin for Consumers for Quality Care as Amicus Curiae on behalf of Plaintiff and Appellant.
Drivon & Tabak, Laurence E. Drivon; Douglas Devries; Roland Wrinkle; Harvey R. Levine; Robert Steinberg; Thomas G. Stolpman; David Rosen; Moses Lebovits; Bruce Brusavitch; Bruce Broilett; Wayne McLean; Leonard Sacks; Tony Tanke; Stewart Tabak; Rick Simons; David Casey, Jr.; Christine Spagnoli; James Sturdevant; Daniel U. Smith; Deborah David; Joseph Harbison III; and Cynthia Chihak for Consumer Attorneys of California as Amicus Curiae on behalf of Plaintiff and Appellant.
Houck & Balisok, Russell S. Balisok, Steven C. Wilheim; and Peter G. Lomhoff for California Advocates for Nursing Home Reform, Inc., as Amicus Curiae on behalf of Plaintiff and Appellant.
Veatch, Carlson, Grogan & Nelson, Mark Weinstein, William G. Lieb; Greines, Martin, Stein & Richland, Timothy T. Coates and Alison M. Turner for Defendant and Appellant.
Horvitz & Levy, Mitchell C. Tilner and L. Rachel Lerman Helyar for Program Beta Risk Management Authority as Amicus Curiae on behalf of Defendant and Appellant.
Thelen, Marrin, Johnson & Bridges, Curtis A. Cole and Matthew S. Levinson for California Medical Association, California Dental Association and California Healthcare Association as Amici Curiae on behalf of Defendant and Appellant.
MOSK, J.—In this matter, a hospital operated by the County of Los Angeles (hereafter the County) transferred Mychelle Williams to another hospital without providing treatment required to stabilize her emergency medical condition, in violation of
We granted review to address the question whether the award was subject to the $250,000 limit on noneconomic damages under
I
On May 6, 1993, at approximately 5:30 p.m., Dawnelle Barris (hereafter Barris) brought her 18-month old daughter, Mychelle Williams, to the emergency room at Martin Luther King/Drew Medical Center (hereafter King/Drew) by ambulance. Mychelle was a member of the Kaiser Foundation Health Plan (hereafter Kaiser), but was taken to King/Drew because it was the nearest emergency medical facility. She had suffered episodes of vomiting and diarrhea, was lethargic, and was having difficulty breathing. Her temperature was 106.6 degrees, her pulse and respiratory rate were abnormally fast, she had abnormally low pulse oxygenation, and she had infections of the middle ear in both ears.
Mychelle was transferred tо the pediatric emergency room, and examined by Dr. Trach Phoung Dang. He believed her fever might be caused by bacteria in the bloodstream. He noted signs and symptoms consistent with sepsis, a life-threatening bacterial infection that he knew requires prompt treatment with antibiotics. Nonetheless, he did not rule out sepsis or begin antibiotic treatment. Although he concluded that a complete blood culture, which could have detected sepsis, should be done, he did not order it because
On the night of May 6, Brian Thompson, a Kaiser physician, was handling phone calls that came in under the EPRP. At approximately 7 p.m., Dr. Dang spoke by telephone to Dr. Thompson to arrange for possible transfer of Mychelle. Dr. Dang discussed her condition and indicated that he thought blood tests, which would rule out a bacterial infection in the blood, should be performed at King/Drew. Dr. Thompson instructed him not to perform the tests, saying that the blood work would be done at Kaiser. Apparently still concerned about the delay in treatment, Dr. Dang telephoned Dr. Thompson again, and repeatedly suggested starting the blood work at King/Drew. Again, Dr. Thompson instructed Dr. Dang not to do so. Dr. Dang noted in his chаrt that “Dr. Thompson at Kaiser did not want me to do any blood test.”
At approximately 8 p.m., Mychelle suffered a seizure. She became increasingly lethargic and nonresponsive. Dr. Dang treated her symptoms of fever, dehydration, breathing difficulty, and seizure, but did not administer antibiotics.
Shortly after 9 p.m., Mychelle was transferred by ambulance to Kaiser. At 9:50 p.m., within 15 minutes of her arrival, Mychelle suffered a cardiac arrest and was pronounced dead shortly thereafter. A blood culture performed as part of an autopsy was positive for streptococcus bacteria, which is readily treatable by antibiotics. The death certificate listed cardiac respiratory arrest caused by septicemia, or sepsis, that had been present for 10 hours.
Barris brought an aсtion for professional negligence against the County, Kaiser, and Drs. Dang and Thompson, and an action for violation of EMTALA against the County. The EMTALA claim alleged failure to provide appropriate medical screening of Mychelle and failure to stabilize her emergency medical condition before transferring her to Kaiser.
On November 14, 1995, a jury trial began. Dr. Dang testified that he knew sepsis was a possible cause of Mychelle‘s fever. He explained that blood work, which would rule out a bacterial infection in the blood, was not done at King/Drew because Dr. Thompson said that it would be done at Kaiser. He also testified that he did not believe Mychelle had sepsis and thought that she was stable at the time she was transferred.
The County moved for a nonsuit as to the medical screening and failure to stabilize claims under EMTALA. The superior court granted the County‘s motion for a nonsuit as to the medical screening claim only, concluding that Barris presented evidence sufficient for the jury to conclude that Mychelle was treated for an emergency medical condition and was not stable for transfer when she was taken to Kaiser.
The jury returned a special verdict in favor of Barris both on the professional negligence cause of action and the failure to stabilize claim under EMTALA. It awarded noneconomic damages in the amount of $1,350,000 in addition to funerаl expenses of $3,000.
The superior court ruled that the cap on noneconomic damages under
Barris appealed the superior court‘s application of
The Court of Appeal affirmed, concluding that the cap on noneconomic damages under
We granted review. We now affirm the judgment.
II
We begin with an overview of the two provisions at issue here,
EMTALA was enacted as part of the Comprehensive Omnibus Budget Reconciliation Act of 1986 (COBRA). It provides that hospitals that have
Under EMTALA, hospitals with emergency departments have two obligations. First, if any individual comes to the emergency depаrtment requesting examination or treatment, a hospital must provide for “an appropriate medical screening examination within the capability of the hospital‘s emergency department.” (
EMTALA defines the term “emergency medical condition” as meaning “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in . . . [¶] . . . placing the health of the individual in serious jeopardy, [¶] . . . serious impairment to bodily functions, or [¶] . . . serious dysfunction of any bodily organ or part.” (
An individual who “suffers personal harm as a direct result” of a hospital‘s failure to meet the requirements under EMTALA may bring a civil action seeking damages and appropriate equitable relief against the participating hospital. (
In stabilizing a patient, a hospital must, within the staff and facilities available to it, meet requirements that relate to the prevailing standard of professional care: it must give the treatment medically necessary to stabilize a patient and it may not discharge or transfer the patient unless it provides “treatment that medical experts agree would prevent the threatening and severe consequences of [the patient‘s emergency medical condition] while [he or] she was in transit.” (Burditt v. U.S. Dept. of Health and Human Services (5th Cir. 1991) 934 F.2d 1362, 1369; see also id. at p. 1370, fn. 8 [noting that “Congress only mandates treatment ‘within the staff and facilities available at the hospital’ “].)
A plaintiff is not required to establish that failure to provide such treatment was based on an improper motive, such as racial discrimination or financial considerations about payment or reimbursement. As the United States Supreme Court explained in Roberts v. Galen of Virginia, Inc. (1999) 525 U.S. 249, 119 S.Ct. 685, 687, 142 L.Ed.2d 648: “[
A claim under EMTALA for failure to stabilize is thus necessarily “based on professional negligence” within the meaning of MICRA—it involves “a negligent . . . omission to act by a health care provider in the rendering of professiоnal services” (
Congress expressly provided that state law provisions limiting the recovery of damages are applicable to EMTALA claims: “Any individual who suffers personal harm as a direct result of a participating hospital‘s violation of a requirement [under EMTALA] may, in a civil action against the participating hospital, obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate.” (
III
We turn now to the specific question before us: whether damages under EMTALA in a claim based on failure to stabilize are subject to the cap on noneconomic damages under
We discern no conflict between the purposes of providing for a private right to recover damages for violations of EMTALA and state law limits on malpractice damages. “[T]he ends of both the federal and state statutes are to keep medical care accessible.” (Jackson v. East Bay Hosp. (N.D.Cal. 1997) 980 F.Supp. 1341, 1347.) Indeed, the apparent intent of Congress was to balance the deterrence and compensation goals of EMTALA with deference to the ability of states to determine what limits are appropriate in personal injury actions against health care providers. Thus, the legislative history suggests that in drafting EMTALA to incorporate state law limits on personal injury damages, Congress was specifically responding to conсern “regarding ‘the potential impact of these enforcement provisions on the current medical malpractice crisis.’ ” (Power, supra, 42 F.3d at p. 862, quoting H.R.Rep. No. 99-241, 1st Sess., pt. 3, p. 6 (1986).) “Congress apparently wished to preserve state-enacted ceilings on the amount of damages that could be recovered in EMTALA . . . .” (42 F.3d at p. 862.)
Most federal courts that have addressed the point have applied particular state caps on malpractice damages to EMTALA claims. Thus, in Power, the Fourth Circuit determined that a claim under EMTALA based on failure to provide appropriate medical screening was subject to its cap of $1 million on damages for medical malpractice claims. (Power, supra, 42 F.3d at pp. 861-863; see also Reid v. Indianapolis Osteopathic Medical Hosp. (S.D.Ind. 1989) 709 F.Supp. 853, 855-856 [holding that an award under EMTALA was subject to Indiana‘s substantive limitation on the maximum amount recoverable for personal injury from a health care provider]; Diaz v. CCHC-Golden Glades, Ltd. (Fla.Dist.Ct.App. 1997) 696 So.2d 1346, 1347 [Holding that EMTALA “incorporates all the vagaries of the state medical malpractice law in determination of the damages recoverable in an action under the
In determining whether a particular state‘s damages cap applies to an EMTALA violation, federal courts have looked at the underlying conduct challenged and its legal basis to determine whether, if brought under state law, it would constitute a cause of action subject to the cap. Thus, in Power, the Fourth Circuit determined that although the plaintiff alleged disparate treatment, not a breach of the standard of care associated with a traditional medical malpractice claim, damages for the EMTALA violation would nonetheless be subject to Virginia‘s $1 million cap on malpractice damages because the cap applies broadly to ” ‘any tort based on health care or professional services rendered, or which should have been rendered, by a health care provider, to a patient.’ ” (Power, supra, 42 F.3d at p. 861, citing Va. Code Ann. §§ 8.01-581.15, 8.01-581.1 (Michie Supp. 1993).) Power stressed that, as interpreted by Virginia courts, the cap on malpractice damages had not been limited to “traditional medical malpractice claims arising from breaches of the profеssional standard of care,” but also applied to claims of battery and sexual misconduct by a physician. (42 F.3d at p. 861.)
We find the analytical approach of the Fourth Circuit on this point persuasive. Accordingly, the issue here is whether a claim under EMTALA based on failure to stabilize, if brought under state law, would constitute an action subject to
The cap on damages under
To be sure, every claim for professional negligence does not also constitute an EMTALA claim for failure to stabilize. A claim under EMTALA also requires proof that the hospital actually determined that the patient was suffering from an emergency mediсal condition, and a hospital must provide required treatment only to stabilize a patient, i.e., to assure, within its capability, “no material deterioration of the condition” upon transfer or discharge. But an EMTALA claim based on failure to provide medically reasonable treatment to stabilize a patient would, if brought under state law, constitute a claim of “professional negligence” as defined by
Plaintiff urges that we should be guided by the federal district court in Jackson v. East Bay Hosp., supra, 980 F.Supp. at page 1348, which held that MICRA‘s cap on damages is inapplicable to EMTALA claims. We find the holding in Jackson unpersuasive. It relies on the erroneous premise that EMTALA claims “do not rest on any proof that the hospital was negligent or that the hospital failed to . . . provide adequate treatment.” (Ibid.) Moreover, it inсorrectly asserts that EMTALA makes hospitals “strictly liable” and requires proof of the hospital‘s intentional refusal of care: “EMTALA creates a separate cause of action which makes hospitals strictly liable for refusing ‘essential emergency care because of a patient‘s inability to pay.’ ” (Ibid.) As discussed, EMTALA requires hospitals, within the staff and
The County urges that the cap on damages under
The Court of Appeal, adopting the approach urged by the County, extended the broad interpretation of the phrase “arising under professional negligence” in Central Pathology to all MICRA provisions, including the damages cap under
We have not previously held that MICRA applies to intentional torts. Nor does Central Pathology, which involved a non-MICRA provision, so hold.
Because we decide this question on the different grounds discussed, we need not, and do not, adopt the Court of Appeal‘s rationale. Similarly, we need not, and do not, adopt the County‘s suggestion that the scope of MICRA should be viewed expansively as necessarily limiting all awards of noneconomic damages against a hospital for violations of EMTALA, including claims that do not involve conduct constituting “professional negligence.” As discussed, the court‘s task in determining whether
IV
For the foregoing reasons, we conclude that damages awarded to Barris under EMTALA were properly subject to reduction pursuant to Civil Code
George, C. J., Kennard, J., Werdegar, J., and Brown, J., concurred.
BAXTER, J., Concurring.—The question here is whether the $250,000 limit on noneconomic damages under California‘s Medical Injury Compensation Reform Act (MICRA) (
EMTALA imposes two limited duties of care upon hospitals that have both a Medicare provider agreement and an emergency department. First, if any individual comes to the emergency department requesting examination or treatment, the hospital “must provide for an appropriate medical screening examination within the capability of the hospital‘s emergency department . . . to determine whether or not an emergency medical condition . . . exists.”1 (
In my view, a hospital‘s demonstrated failure to act in accordance with EMTALA is, in and of itself, “a negligent . . . omission to act by a health care provider in the rendering of prоfessional services” under the MICRA definition of professional negligence. (
Unlike the majority, then, I conclude, as a general matter, that any action against a hospital for a violation of EMTALA‘s duty of care provisions qualifies as an action based on professional negligence subject to MICRA, without regard to whether the particular claim entails consideration of the prevailing medical standards of care generally associated with a malpractice action. (Cf. Power v. Arlington Hosp. Ass‘n (4th Cir. 1994) 42 F.3d 851, 861 [concluding that an EMTALA claim based on alleged disparate medical screening by a hospital was subject to Virginia‘s cap on medical malpractice damages even though the claim did not allege a breach of the prevailing standard of care].)
Chin, J., concurred.