561 F.3d 573 (2009)
Johnella Richmond MOSES, Personal Representative of the Estate of Marie
Moses Irons, deceased, Plaintif-Appellant,
v.
PROVIDENCE HOSPITAL AND MEDICAL CENTERS, INC. and Paul Lessem, Defendants-Appellees,
Christopher Walter Howard, Third-Party Defendant.
No. 07-2111.
United States Court of Appeals, Sixth Circuit.
Argued: December 5, 2008.
Decided and Filed: April 6, 2009.
ARGUED: Mark Granzotto, Mark Granzotto, P.C., Royal Oak, Michigan, for
Appellant. Susan Healy Zitterman, Kitch, Drutchas, Wagner, DeNardis,
Valitutti & Sherbrook, Detroit, Michigan, for Appellee.
ON BRIEF: Mark Granzotto, Mark Granzotto, P.C., Royal Oak, Michigan, for
Appellant. Susan Healy Zitterman, Kitch, Drutchas, Wagner, DeNardis,
Valitutti & Sherbrook, Detroit, Michigan, for Appellee.
Before: CLAY and GIBBONS, Circuit Judges; STAMP, District Judge.[1]
OPINION
CLAY, Circuit Judge.
Plaintiff Johnella Richmond Moses, as representative of the estate of
Marie Moses-Irons ("Moses-Irons"), brings claims against Defendants Providence
Hospital and Medical Centers, Inc. (the "hospital") and Paul Lessem ("Dr.Lessem")
pursuant to the Emergency Medical Treatment and Active Labor Act ("EMTALA"),
42 U.S.C. § 1395dd, and common law negligence. Plaintiff alleges that
Defendants violated EMTALA by releasing Moses-Irons' husband from the
hospital ten days before he murdered Moses-Irons. Plaintiff appeals the
district court's decision to grant Defendants' motion for summary judgment
and dismiss Plaintiff's claims. For the following reasons, we REVERSE
the district court and REMAND for further proceedings with respect to
the hospital, but AFFIRM with respect to Dr. Lessem.
BACKGROUND
I. Factual Background
On December 13, 2002, Moses-Irons took Howard to the emergency room of
Providence Hospital in Southfield, Michigan because Howard was exhibiting
signs of illness. Howard's physical symptoms included severe headaches,
muscle soreness, high blood pressure and vomiting. Howard was also experiencing
slurred speech, disorientation, hallucinations and delusions. Moses-Irons
reported these symptoms to the emergency room staff, and also informed
them that Howard had "demonstrated threatening behavior, which made her
fearful for her safety." (Joint Appendix ("J.A.") at 31-32.) The emergency
room physicians decided to admit Howard to conduct more tests. Among
the physicians who evaluated Howard during his stay at the hospital were
Mark Silverman ("Dr. Silverman"), a neurologist; Dr. Lessem, a psychiatrist;
and Djeneba Mitchell ("Dr. Mitchell"), an internist.
Dr. Silverman examined Howard on December 14, 2002. Dr. Silverman determined
that Howard "was acting inappropriately" and "appeared to be somewhat
obtunded," but had "no overt outward signs of trauma." (J.A. at 153.)
In addition to informing Dr. Silverman of Howard's symptoms, Moses-Irons
also told him that Howard had told her that he "had bought caskets." (J.A.
at 150.) Dr. Silverman learned from Moses-Irons that Howard had recently
tried to board a plane with a hunting knife. Dr. Silverman ordered a
magnetic resonance imaging exam, though it is unclear from the record
whether the exam ever took place. Dr. Silverman also "felt that a psychiatric
evaluation would be warranted," as well as a "lumbar puncture." (J.A.
at 154, 158.) His notes from the evaluation indicate his belief that "an
acute psychotic episode [must] be ruled out." (J.A. at 153, 158.)
Dr. Lessem examined Howard several times during Howard's stay at the hospital.
On December 17, 2002, Dr. Lessem determined that Howard was not "medically
stable from a psychiatric standpoint," and decided that Howard should
be transferred to the hospital's psychiatric unit called "4 [E]ast" to "reassess
him." (J.A. at 165.) According to Dr. Lessem, 4 East is intended for
patients "who are expected to be hospitalized and stabilized and who
are acutely mentally ill." (J.A. at 165.) Dr. Lessem felt Howard could
be more closely observed at 4 East, and planned to conduct "reality testing" of
Howard there to determine the extent of Howard's delusions. (J.A. at
168.) Dr. Lessem's order notes from December 17, 2002 state, "will accept
[patient] to 4 [E]ast if [patient]'s insurance will accept criteria" and "please
observe carefully for any indications of suicidal ideation or behavior." (J.A.
at 172.) Under the heading "orders for 4 [E]ast," Dr. Lessem wrote, "suicide
precautions." (J.A. at 173.) The notes also indicate that Dr. Lessem
believed Howard had an "atypical psychosis" and "depression." (J.A. at
172.)
Howard was never transferred to the psychiatric unit, and instead was
informed on December 18, 2002 that he would be released. A hospital clinical
progress report signed by Dr. Mitchell that day stated that "[patient]
declines 4 [E]ast, wants to go home. His affect is brighter. No physical
symptoms now. [Patient] wishes to go home, wife fears him. Denies any
suicidality." (J.A. at 219.) Howard stated in a deposition that he never
declined going to 4 East. In Howard's discharge summary form filled out
on December 18, 2002, the hospital's "final diagnosis" of Howard, written
by a resident, was that he had a "migraine headache" and an "atypical
psychosis [with] delusional disorder." (J.A. at 178.) A report dated
December 19, 2002, signed by Dr. Mitchell, indicated that Howard would
be "[discharged] home today ... cannot stay as he is medically stable
and now does not need 4E." (J.A. at 89.) Howard was released on December
19, 2002, and on December 29, 2002, Howard murdered Moses-Irons.
On December 14, 2004, Plaintiff filed a federal suit against the hospital
and Dr. Lessem, alleging a violation of EMTALA and various negligence
claims. On January 5, 2005, Defendants filed a motion to dismiss the
complaint, on the ground that EMTALA only provides a right of action
for a plaintiff who sought treatment as a hospital's patient. On February
28, 2005, the district court denied Defendants' motion from the bench,
stating, inter alia, that "the plain language of the statute
does not preclude a lawsuit by the injured third party." (J.A. at 181.)
Plaintiff filed an amended complaint on September 29, 2005. On January
6, 2006, Defendants filed a third-party complaint against Howard.
II. Motion for Summary Judgment
On May 14, 2007, Defendants filed a motion for summary judgment. In their
brief supporting their motion, Defendants raised two arguments: (1) that
Plaintiff does not have standing to sue, because only the individual
patient who seeks treatment at the hospital has standing under EMTALA;
and (2) that EMTALA imposes no further obligation on a hospital once
the hospital has admitted a person as an inpatient. Defendants' motion
did not refer to any factual record, and they attached only the EMTALA
statute and applicable regulations to their motion.
At oral argument before the district court on July 30, 2007, Defendants
argued for the first time that the hospital physicians, after conducting
the proper screening, did not diagnose Howard as having an emergency
medical condition. At oral argument, Defendants referred in general terms
to the testimony and documentation of the hospital physicians who attended
to Howard to support this third argument, without producing the evidence
they were referencing. Neither the December 18, 2002 progress report
stating that Howard had no physical symptoms and denied "suicidality," nor
the December 19, 2002 progress report in which Dr. Mitchell stated that
Howard was stable, was attached to Defendants' summary judgment motion;
however, both documents were attached to Defendants' response to a separate
motion to compel discovery filed on April 13, 2007. During oral argument,
Defendants also referred to letters from Howard's insurance company indicating
that the insurance company did not deny coverage for Howard's treatment
until January 2003, after Howard had been released; those letters were
not submitted with Defendants' motion papers, nor are they included in
the record on appeal.
Following oral argument, the district court granted Defendants' summary
judgment motion from the bench, dismissing the EMTALA claim and choosing
not to exercise jurisdiction over the negligence claims. In dismissing
the EMTALA claim, the district court stated that summary judgment must
be granted "regardless of the standing issue." (J.A. at 216.) The entirety
of the district court's reasoning for granting summary judgment was as
follows:
First of all, the EMTALA statute was not designed or intended
to establish guidelines for patient care or to provide a suit for medical
negligence or malpractice. Under the clear and unambiguous language of
the statute, the Plaintiff's claim must be dismissed. The hospital admitted
Howard and did not turn him away, as was required by the Sixth Circuit
in Cleland [v. Bronson Health Care Group Inc., 917
F.2d 266 (6th Cir. 1990)]. The patient was undisputedly completely screened,
as the statute requires, even if on the basis of a wrong diagnosis; and
he was thereafter admitted to the Defendant hospital, and no emergency
medical condition was recognized on the screening. So, for all of those
reasons ... the motion of the Defendants must be granted.
(J.A. at 216.) Plaintiff timely appealed.
On appeal, Plaintiff asserts that she did not receive fair notice that
during oral argument Defendants would rely on evidence that the doctors
believed Howard did not have an emergency medical condition. Had Plaintiff
received proper notice, she asserts, she would have filed with her pleadings
an expert report by Harold J. Bursztajn ("Dr. Bursztajn"), a professor
of psychiatry at Harvard Medical School, who concluded that Howard did
have an emergency medical condition upon arriving at the hospital, and
had not stabilized by the time he was discharged. Dr. Bursztajn based
his conclusion on Dr. Lessem's own notes from December 17, 2002, in which
Dr. Lessem had diagnosed Howard as having an atypical psychosis and possibly
suicidal behavior. Dr. Bursztajn concluded that "the symptoms and mental
state described by Dr. Lessem could not be resolved in one to two days,
yet the decision to discharge Mr. Howard was made one day later." (J.A.
at 68-69.) Dr. Bursztajn's> expert report was served and filed on October
25, 2006, as part of Plaintiff's reply materials in connection with an
earlier motion to compel a mental examination of Howard. Plaintiff includes
this expert report in the record on appeal.
DISCUSSION
I. Standard of Review
This Court reviews a district court's grant of summary judgment de
novo. Monette v. Electronic Data Sys. Corp., 90 F.3d 1173,
1176 (6th Cir.1996). Summary judgment is appropriate if the pleadings,
depositions, answers to interrogatories, and admissions on file,
together with the affidavits, if any, "show that there is no genuine
issue as to any material fact and that the movant is entitled to
a judgment as a matter of law." Fed.R.Civ.P. 56(c). As the moving
party, Defendants bear the burden of showing the absence of a genuine
issue of material fact as to at least one essential element of Plaintiff's
claim. See Celotex Corp. v. Catrett, 477 U.S. 317, 324,
106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). Plaintiff, as the non-moving
party, must then present sufficient evidence from which a jury could
reasonably find for her. See Anderson v. Liberty Lobby, Inc.,
U.S. 242, 252, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). This Court
must then determine "whether the evidence presents sufficient disagreement
to require submission to a jury or whether it is so one-sided that
one party must prevail as a matter of law." Id. at 251-52,
106 S.Ct. 2505. In making this determination, this Court must draw
all reasonable inferences in favor of Plaintiff. See Nat'l
Enters., Inc. v. Smith, 114 F.3d 561, 563 (6th Cir.1997).
II. Overview of EMTALA
For all hospitals that participate in Medicare and have an "emergency
department," EMTALA sets forth two requirements. First, for any individual
who "comes to the emergency department" and requests treatment, the hospital
must "provide for an appropriate medical screening examination ... to
determine whether or not an emergency medical condition... exists." 42
U.S.C. § 1395dd(a). Second, if "the hospital determines that the individual
has an emergency medical condition, the hospital must provide either
(A) within the staff and facilities available at the hospital, for such
further medical examination and such treatment as may be required to
stabilize the medical condition, or (B) for transfer of the individual
to another medical facility[.]" § 1395dd(b). Thus, for any individual
who seeks treatment in a hospital, the hospital must determine whether
an "emergency medical condition" exists, and if the hospital believes
such a condition exists, it must provide treatment to "stabilize" the
patient. Thornton v. Sw. Detroit Hosp., 895 F.2d 1131, 1134
(6th Cir.1990).
The statute defines "emergency medical condition" as "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 ... [inter alia] placing
the health of the individual ... in serious jeopardy[.]" § 1395dd(e)(1)(A)(i). "To
stabilize" a patient with such a condition means "to assure, within reasonable
medical probability, that no material deterioration of the condition
is likely to result from or occur during the transfer of the individual
from a facility[.]" § 1395dd(e)(3)(A). "Transfer" is defined in the statute
to include moving the patient to an outside facility or discharging him.
§ 1395dd(e)(4).
Including the argument made for the first time during oral argument before
the district court, Defendants appear to have moved for summary judgment
on three grounds: (1) Plaintiff lacks standing to sue under EMTALA; (2)
EMTALA's requirements were satisfied when the hospital admitted Howard
on December 13, 2002; and (3) because Howard was indisputably screened
and diagnosed as not having an emergency medical condition, EMTALA did
not apply. Because any one of these grounds would have been sufficient
for the district court to grant summary judgment to the Defendants, we
address each of them in turn.
III. Standing
In deciding Defendants' motion for summary judgment, the district court
did not reach the issue of whether, as a non-patient, Plaintiff has standing
under EMTALA to bring a claim, although it did deny Defendants' previous
motion to dismiss on that ground. Because Defendants prevailed below,
this Court may consider affirming summary judgment based on Plaintiff's
lack of standing. See Dandridge v. Williams, 397 U.S. 471,
475 n. 6, 90 S.Ct. 1153, 25 L.Ed.2d 491 (1970) ("The prevailing party
may, of course, assert in a reviewing court any ground in support of
his judgment, whether or not that ground was relied upon or even considered
by the trial court.").
Pursuant to EMTALA's civil enforcement provision, "[a]ny individual who
suffers personal harm as a direct result of a participating hospital's
violation of a requirement of this section 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." 42 U.S.C. § 1395dd(d)(2)(A).
Neither this subsection, nor any other part of EMTALA, includes any mention
of non-patients. Moreover, this Court is not aware of any federal appellate
court that has addressed whether non-patients who allege harm as a result
of a hospital's violation of EMTALA have standing to sue. Defendants
cite two district court decisions from other circuits, which hold that
the relatives of a patient who suffers harm cannot sue a hospital in
their individual capacities for harm suffered by the patient. See Zeigler
v. Elmore County Health Care Auth., 56 F.Supp.2d 1324 (M.D.Ala.1999); Sastre
v. Hosp. Doctor's Center, Inc., 93 F.Supp.2d 105 (D.Puerto Rico
2000). However, because the estate of the individual who suffered an
actual personal injury brings the suit in this case, claiming personal
harm as a direct result of the hospital's decision, those decisions are
inapposite and of limited persuasive value.
"In the absence of an indication to the contrary, words in a statute are
assumed to bear their `ordinary, contemporary, common meaning.'" Walters
v. Metro. Educ. Enters., Inc., 519 U.S. 202, 207, 117 S.Ct. 660,
136 L.Ed.2d 644 (1997) (quoting Pioneer Inv. Servs. Co. v. Brunswick
Ass'ns Ltd. P'ship, 507 U.S. 380, 388, 113 S.Ct. 1489, 123 L.Ed.2d
74 (1993)). The plain language of the civil enforcement provision of
EMTALA contains very broad language regarding who may bring a claim: "any
individual who suffers personal harm as a direct result" of a hospital's
EMTALA violation may sue. § 1395dd(d)(2)(A) (emphasis added). This language
would seem to include Plaintiff, whose suit alleges that Moses-Irons'
death was the direct result of the hospital's decision to release her
husband before his psychiatric emergency medical condition had stabilized.
In arguing that only harmed patients may sue, Defendants contend
that the phrase "any individual" in § 1395dd(d)(2)(A) must be read in
the context of other parts of the statute. Because the medical screening
requirement in § 1395dd(a) refers to an "individual" who "comes to the
emergency department" and the stabilization requirement in § 1395dd(b)
refers to an "individual" who "comes to a hospital," the term "any individual" in
the civil enforcement provision should also be so limited. There are
two problems with reading the statute this way. First, the medical screening
requirement and the stabilization requirement do not refer to the same "individual"—the
medical screening requirement of § 1395dd(a) only applies to individuals
who come to an "emergency department," presumably a smaller subset of
individuals than those "who come[] to a hospital" and are the subject
of § 1395dd(b). This differing language indicates that Congress did not
intend EMTALA's entire statutory scheme to apply to the same "individual" in
every part of the statute. Second, the fact that the statute expressly
limits the individual to whom the hospital owes its EMTALA obligations
in §§ 1395dd(a) and (b) further indicates that the breadth of the civil
enforcement provision was no accident. "[W]here Congress includes particular
language in one section of a statute but omits it in another section
of the same Act, it is generally presumed that Congress acts intentionally
and purposely in the disparate inclusion or exclusion." Russello
v. United States, 464 U.S. 16, 23, 104 S.Ct. 296, 78 L.Ed.2d 17
(1983); see also Gozlon-Peretz v. United States, 498
U.S. 395, 404-05, 111 S.Ct. 840, 112 L.Ed.2d 919 (1991). If Congress
had intended to limit the right of action to any individual who "comes
to a hospital" as a patient, it could have done so, just as it did in
other parts of the statute. See United States v. Parrett,
530 F.3d 422 (6th Cir. 2008) ("Plain meaning is examined by looking at
the language and design of the statute as a whole.").
Defendants also argue that EMTALA's legislative history supports their
narrower construct of the civil enforcement provision. The original bill,
reported out of the House Ways and Means Committee, extended the private
right of action to "any person or entity that is adversely affected directly
by a participating hospital's violation[.]" H.R.Rep. No. 99-241, pt.
1, at 132, reprinted in 1986 U.S.C.C.A.N. 579, 605. The bill
was referred to the House Judiciary Committee, which amended the civil
enforcement provision to a version essentially the same as its current
form, changing "adversely affected" to "suffers harm as a direct result," and
changing "person or entity" to "individual." H.R.Rep. No. 99-241, pt.
3 at 6, ireprinted in 1986 U.S.C.C.A.N. 726, 728. The report from the
House Judiciary Committee states that as a result of its amendment to
the bill, the only individual who can sue is the "individual patient
who suffers harm as a direct result of hospital's failure to appropriately
screen, stabilize, or properly transfer that patient." Id.
However, where a House committee's explanation of the meaning of a statute
seems to differ from the statute's actual wording, this Court should
not rely on that committee's statement as the exclusive explanation for
the meaning of the statute. See Exxon Mobil Corp. v. Allapattah
Servs., Inc., 545 U.S. 546, 568, 125 S.Ct. 2611, 162 L.Ed.2d 502
(2005) ("[J]udicial reliance on legislative materials like committee
reports, which are not themselves subject to the requirements of Article
I, may give unrepresentative committee members—or, worse yet, unelected
staffers and lobbyists—both the power and the incentive to attempt strategic
manipulations of legislative history to secure results they were unable
to achieve through the statutory text."). In this case, the parties have
not pointed to any further legislative history, other than the one statement
from the report of the House Judiciary Committee, as proof of Congress'
intent with respect to the scope of the civil enforcement provision.
We have also failed to uncover any substantive debate over the provision
on either the House or Senate floors. As this Court has previously noted
in examining EMTALA's legislative history, "[t]he only clear guidance
from the legislative history is that Congress intended to prevent hospitals
from dumping patients who suffered from an emergency medical condition
because they lacked insurance to pay the medical bills." Thornton,
895 F.2d at 1134.
Regardless of the paucity of the legislative record on the standing issue,
we believe that the civil enforcement provision, read in the context
of the statute as a whole, plainly does not limit its reach to the patients
treated at the hospital. We therefore need not—and ought not—consult
an isolated statement in a committee report. See United States
v. Choice, 201 F.3d 837, 840 (6th Cir.2000) ("The language of
the statute is the starting point for interpretation, and it should also
be the ending point if the plain meaning of that language is clear.").
We recognize that our interpretation of the civil enforcement provision
may have consequences for hospitals that Congress may or may not have
considered or intended. However, our duty is only to read the statute
as it is written, as we have in our past analysis of EMTALA. In Cleland
v. Bronson Health Care Group, Inc., 917 F.2d 266, 269 (6th Cir.1990),
the defendants argued that because Congress sought to protect the rights
of the indigent and uninsured in enacting EMTALA, only the indigent or
uninsured should be allowed to sue under the act. This Court expressly
rejected this narrow reading of the civil enforcement provision, stating
that "[u]nfortunately for this theory, Congress wrote a statute that
plainly has no such limitation on its coverage." Id. Similarly
here, EMTALA's plain language belies Defendants' argument that Congress
intended to deny non-patients the right to sue in every circumstance.
Thus, for the foregoing reasons, we conclude that Plaintiff has standing
to sue pursuant to EMTALA.
IV. The Hospital's Obligations Upon Finding an Emergency Medical Condition
Defendants argue that, if Howard did have an emergency medical condition
when he came to the hospital, the hospital's decision to admit him for
six days and perform further testing satisfied its obligations under
EMTALA to treat so as to stabilize the patient. We disagree.
Contrary to Defendants' interpretation, EMTALA imposes an obligation on
a hospital beyond simply admitting a patient with an emergency medical
condition to an inpatient care unit. The statute requires "such treatment
as may be required to stabilize the medical condition," § 1395dd(b),
and forbids the patient's release unless his condition has "been stabilized," §
1395dd(c)(1). A patient with an emergency medical condition is "stabilized" when "no
material deterioration of the condition is likely, within reasonable
medical probability, to result from or occur during" the patient's release
from the hospital. § 1395dd(e)(3)(B). Thus, EMTALA requires a hospital
to treat a patient with an emergency condition in such a way that, upon
the patient's release, no further deterioration of the condition is likely.
In the case of most emergency conditions, it is unreasonable to believe
that such treatment could be provided by admitting the patient and then
discharging him.
In Thornton, this Court examined whether EMTALA requires
hospitals to do more for patients with emergency medical conditions than
just admit them. 895 F.2d at 1134. In that case, it was undisputed that
the patient initially had an emergency medical condition when the defendant
hospital admitted her to the emergency room for a stroke; the issue was
whether the hospital violated EMTALA by releasing her twenty-one days
later from the hospital's regular inpatient care unit. Id. Although
ultimately affirming summary judgment because the patient's condition
had stabilized prior to her release, this Court first rejected the hospital's
argument that once it transferred the patient from the emergency room
to inpatient care, its obligations under EMTALA were fulfilled:
Congress sought to insure that patients with medical emergencies
would receive emergency care. Although emergency care often occurs, and
almost invariably begins, in an emergency room, emergency care does not
always stop when a patient is wheeled from the emergency room into the
main hospital. Hospitals may not circumvent the requirements of the Act
merely by admitting an emergency room patient to the hospital, then immediately
discharging that patient. Emergency care must be given until the
patient's emergency medical condition is stabilized.
Id. at 1135 (emphasis added). Thus, the statute requires
more than the admission and further testing of a patient; it requires
that actual care, or treatment, be provided as well. Accordingly, Defendants
could not satisfy their EMTALA obligations merely by screening Howard
and admitting him to conduct further testing.
To support their narrower reading of EMTALA's requirements, Defendants
point to a rule promulgated by the Centers for Medicare and Medicaid
Services ("CMS"), the agency responsible for implementing EMTALA, that
effectively ends a hospital's EMTALA obligations upon admitting an individual
as an inpatient. 42 C.F.R. § 489.24(d)(2)(i). According to the CMS regulation, "[i]f
a hospital has screened an individual under paragraph (a) of this section
and found the individual to have an emergency medical condition, and
admits that individual as an inpatient in good faith in order to stabilize
the emergency medical condition, the hospital has satisfied its special
responsibilities under this section with respect to that individual." Id.
Although "[a]n agency's construction of a statutory scheme that it is
entrusted to administer is entitled to a degree of deference .... we
must ... `reject administrative constructions which are contrary to clear
congressional intent.'" Gallagher v. Croghan Colonial Bank,
89 F.3d 275, 277-78 (6th Cir.1996) (quoting Chevron, U.S.A., Inc.
v. Natural Res. Def. Council, Inc., 467 U.S. 837, 843, 104 S.Ct.
2778, 81 L.Ed.2d 694 (1984)). The CMS rule appears contrary to EMTALA's
plain language, which requires a hospital to "provide ... for such further
medical examination and such treatment as may be required to
stabilize the medical condition[.]" § 1395dd(b)(1)(A) (emphasis added).
Although "treatment" is undefined in the statute, it is nevertheless
unambiguous, because it is unreasonable to believe that "treatment as
may be required to stabilize" could mean simply admitting the patient
and nothing further. Moreover, the statute requires the patient to be "stabilized" upon
release; "[i]f an individual at a hospital has an emergency medical condition
which has not been stabilized ... the hospital may not transfer the individual
unless" the patient requests a transfer in writing or a physician or
qualified medical person certifies that the risks of further treatment
outweigh the benefits. § 1395dd(c)(1)(A). Therefore, a hospital may not
release a patient with an emergency medical condition without first
determining that the patient has actually stabilized, even if the
hospital properly admitted the patient. Such a requirement would be unnecessary
if a hospital only needed to admit the patient in order to satisfy EMTALA.
Because the CMS rule is contrary to the plain language of the statute,
this Court does not afford it Chevron deference. See Gallagher,
89 F.3d at 278.
Even if the CMS regulation could somehow be deemed consistent with the
statute, its promulgation in 2003, after Howard's stay in the hospital
ended, would preclude this Court from applying it to this case. "As a
general rule, a court `must apply the law in effect at the time it renders
its decision. Because `[r]etroactivity is not favored in the law,' however,
courts should not construe `congressional enactments and administrative
rules ... to have retroactive effect unless their language requires this
result.'" BellSouth Telecomms., Inc. v. Se. Tel., Inc.,
462 F.3d 650, 657 (6th Cir.2006) (quoting Landgraf v. USI Film
Prods., 511 U.S. 244, 263-64, 114 S.Ct. 1483, 128 L.Ed.2d 229
(1994)). To determine whether a regulation should be applied to events
arising prior to the regulation's enactment, courts first inquire whether
the regulation expressly reaches retroactively; if the regulation is
silent on the issue, then the court asks "`whether applying the statute
to the person objecting would have a retroactive consequence in the disfavored
sense of affecting substantive rights, liabilities, or duties on the
basis of conduct arising before its enactment.'" Id. at
658 (quoting Fernandez-Vargas v. Gonzales, 548 U.S. 30,
37, 126 S.Ct. 2422, 165 L.Ed.2d 323 (2006)). If such rights are affected,
then courts must apply a presumption against retroactivity. Id. Here,
the CMS regulation is silent on retroactivity, and because the regulation
would affect the extent of the care that Howard could have expected upon
admission as an inpatient, the regulation "attaches legal consequences
to events completed before its enactment," Landgraf, 511
U.S. at 270, 114 S.Ct. 1483. The CMS regulation therefore does not apply
to this case, regardless of whether its interpretation of the statute
is reasonable.
In short, the hospital was required under EMTALA not just to admit Howard
into the inpatient care unit, but to treat him in order to stabilize
him. Accordingly, Defendants are not entitled to summary judgment simply
on the ground that the hospital admitted Howard as an inpatient and subjected
him to several days of testing.
V. Existence of an Emergency Medical Condition
The district court's reasoning in granting summary judgment was partially
predicated on its finding that the hospital conducted an appropriate
screening, and that "no emergency medical condition was recognized on
the screening." (J.A. at 216.) We believe that whether Howard had an
emergency medical condition that the hospital recognized upon screening
him is an issue of fact that the court should have left for a jury to
decide.
As an initial matter, "before summary judgment may be granted against
a party, Fed.R.Civ.P. 56(c) mandates that the party opposing summary
judgment be afforded notice and a reasonable opportunity to respond to
all issues to be considered by the court." Routman v. Automatic
Data Processing, Inc., 873 F.2d 970, 971 (6th Cir.1989). "Rule
56(c) requires at a minimum that an adverse party be extended at least
ten days notice before summary judgment may be entered." Id. "Noncompliance
with the time provision of the rule deprives the court of authority to
grant summary judgment, unless ... [iinter alia] there has been no prejudice
to the opposing party by the court's failure to comply with this provision
of the rule." Kistner v. Califano, 579 F.2d 1004, 1006 (6th
Cir.1978) (citations omitted).
In this case, the district court granted summary judgment from the bench
at the end of oral argument, and based its decision in part on the fact
that the hospital never detected an emergency medical condition—a ground
that Defendants had not raised prior to oral argument. Moreover, Defendants'
briefs in support of their summary judgment motion did not include any supporting
evidence whatsoever, as their written arguments were based purely on
statutory interpretation; to the extent that the district court relied
on any evidence at all with respect to this ground, such evidence came
from exhibits Defendants attached to previous filings. Although there
is no rule prohibiting the district court from considering previously
submitted evidence—see Fed.R.Civ.P. 56(c) (allowing court to
consider "the pleadings, the discovery and disclosure materials on
file" in resolving a motion for summary judgment) (emphasis added)—it
is still difficult to discern how Plaintiff could have received sufficient
notice of this argument, or a reasonable opportunity to oppose it with
evidence, without being advised that this issue would determine the district
court's ruling on the motion.
With respect to prejudice, Plaintiff argues that had she known Defendants
would raise the absence of an emergency medical condition at oral argument,
she would have included Dr. Bursztajn's expert report in her opposition
to Defendants' motion. Defendants had notice of Dr. Bursztajn's report,
because it was filed in connection with a previous motion to compel during
discovery. We therefore will consider Dr. Bursztajn's report on appeal.
In reviewing this report as well as the remainder of the evidence in
the record, we find that issues of fact exist with respect to whether
the hospital physicians actually believed Howard lacked an emergency
medical condition.
An "emergency medical condition" is "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 ... [inter alia] placing the health of the individual...
in serious jeopardy[.]" § 1395dd(e)(1)(A)(i). The language in the statute
does not appear to preclude classifying a psychiatric condition as an
emergency medical condition, and "the health of the individual" could
certainly include the individual's mental health. Moreover, we are not
aware of any discussion of this issue in the legislative history. Without
such guidance, we hold that a mental health emergency could qualify as
an "emergency medical condition" under the plain language of the statute.
A. Howard's Condition Upon Arrival at the Hospital
At the time he came to the hospital, Howard was experiencing slurred speech,
disorientation, hallucinations and delusions, and was making threatening
statements, including telling his wife that he had "bought caskets." (J.A.
at 150.) Howard's condition included physical symptoms such as severe
headaches, muscle soreness, high blood pressure and vomiting. Moreover,
Dr. Bursztajn's report, based on a review of Howard's hospital records,
concluded that Howard had an emergency medical condition upon arriving
at the hospital. Thus, there is plenty of evidence in the record to create
an issue of fact with respect to whether Howard's condition was a mental
health emergency.
However, in order to trigger further EMTALA obligations, the hospital
physicians must actually recognize that the patient has an emergency
medical condition; if they do not believe an emergency medical condition
exists because they wrongly diagnose the patient, EMTALA does not apply. Roberts
ex rel. Johnson v. Galen of Virginia, Inc., 325 F.3d 776, 786
(6th Cir. 2003).[2] Yet while actual knowledge is required, "any
hospital employee or agent that has knowledge of a patient's emergency
medical condition might potentially subject the hospital to liability
under EMTALA." Id. at 788.
Howard was admitted to the hospital so that the hospital physicians could
conduct further tests, including an MRI, a lumbar puncture and a psychiatric
evaluation. On the first day of testing, Dr. Silverman's note that "an
acute psychotic episode [must] be ruled out" indicated both the possible
seriousness of Howard's condition and the need for further testing before
a complete diagnosis could be made. (J.A. at 153, 158.) Dr. Lessem diagnosed
Howard on December 17, 2002 as having "atypical psychosis," determined
that Howard should be transferred to 4 East, and instructed 4 East doctors
to take "suicide precautions." (J.A. at 173.) A legitimate possibility
that the patient might commit suicide would appear to "place the health
of the individual ... in serious jeopardy," and could thus fall under
the category of "emergency medical condition." See § 1395dd(e)(1)(A)(i).
It is noteworthy that Dr. Lessem recommended Howard be transferred to
4 East, the unit for patients "who are acutely mentally ill." (J.A. at
160.) This evidence supports Plaintiff's claim that the hospital physicians
believed Howard had an emergency medical condition upon his admission.
B. Howard's Condition Upon Discharge
Defendants argue further that, to the extent that Howard had an emergency
medical condition at the time of his admission, the hospital physicians
no longer believed that he had such a condition when they released him—i.e.,
that he was stable upon discharge. In Cleland, this Court,
in affirming summary judgment for the defendant, explained why it was
clear that the responsible doctors reasonably believed the patient had
been stable upon discharge:
To all appearances, the plaintiff's condition was stable. He
was not in acute distress, neither the doctors nor the patient or his
parents made the slightest indication that the condition was worsening
in any way, or that it presented any risk that might become life-threatening,
or that it would worsen markedly by the next day.
917 F.2d at 271.
Plaintiff has introduced evidence that challenges whether any of these
signs of stability noted in Cleland existed with respect to
Howard. First, the "final diagnosis" of Howard upon discharge of an "atypical
psychosis [with] delusional disorder" was substantially the same as Dr.
Lessem's diagnosis on December 17, 2002, which included "atypical psychosis." (J.A.
at 169, 178.) Moreover, Dr. Bursztajn's report concludes that "the symptoms
and mental state described by Dr. Lessem could not be resolved in one
to two days, yet the decision to discharge Mr. Howard was made one day
later." (J.A. at 68-69.) The doctors were aware on the day they released
Howard that Howard's wife did not think he had improved, and in fact
still "fear[ed] him." (J.A. at 219.) Finally, Dr. Lessem's note dated
December 17, 2002, in which he writes "will accept [Howard] to 4 east
if [Howard]'s insurance will accept criteria" (J.A. at 172), creates
at the very least a credibility issue with respect to whether the hospital
physicians actually believed that no emergency condition existed upon
Howard's release.
To support their argument, Defendants cite Dr. Mitchell's progress note
dated December 18, 2002, which states, "[Howard's] affect is brighter.
No physical symptoms now. [He] wishes to go home, wife fears him. Denies
any suicidality." (J.A. at 219.) Defendants also cite Dr. Mitchell's
progress report dated December 19, 2002 stating that Howard "cannot stay
as he is medically stable and now does not need 4 [East]." (J.A. at 89.)
First, these notes do not refute Plaintiff's evidence that Dr. Lessem believed
Howard was still unstable at the time of his release. But more importantly,
while these notes may arguably provide a basis for a jury to find for
Defendants, for the reasons discussed, Plaintiff's evidence still raises
a dispute of fact with respect to whether Howard had an emergency condition
on the day of his release, and what the hospital's doctors believed when
they released him.
Because issues of fact exist relating to Howard's medical condition—upon
his initial screening as well as prior to his release—the district court
erred in granting summary judgment on this ground.
VI. Plaintiff's EMTALA Claim Against Dr. Lessem
Plaintiff has brought suit against both the hospital and Dr. Lessem. EMTALA's
provision authorizing private suits expressly allows claims "against
the participating hospital," but does not refer to claims against individuals.
42 U.S.C. § 1395dd(d)(2)(A). Although the question of whether EMTALA
allows a private right of action against an individual physician is one
of first impression for this Court, other circuits to have considered
the issue have held or opined that EMTALA does not authorize an action
against an individual physician. See Baber v. Hosp. Corp. of Am.,
977 F.2d 872, 877-78 (4th Cir.1992); King v. Ahrens, 16
F.3d 265, 271 (8th Cir.1994); Eberhardt v. City of L.A.,
62 F.3d 1253, 1256-57 (9th Cir.1995); Delaney v. Cade, 986
F.2d 387, 393-94 (10th Cir.1993); Gatewood v. Wash. Healthcare
Corp., 933 F.2d 1037, 1040 n. 1 (D.C.Cir.1991) (dicta).
We agree with our sister circuits that EMTALA does not authorize a private
right of action against individuals. "The question of the existence of
a statutory cause of action is, of course, one of statutory construction." Touche
Ross & Co. v. Redington, 442 U.S. 560, 568, 99 S.Ct. 2479, 61
L.Ed.2d 82 (1979). It is possible that Congress meant to include
individual physicians in the civil enforcement provision and simply neglected
to do so; however, in comparing the civil enforcement provision with
the government enforcement provision that precedes it, the omission of
any reference to physicians in the civil enforcement provision appears
intentional. The government enforcement provision authorizes the Department
of Health and Human Services to commence its own actions against violators
of EMTALA. 42 U.S.C. § 1395dd(d)(1). Unlike the civil enforcement provision,
the provision authorizing government enforcement expressly states that "any
physician who is responsible for the examination, treatment, or transfer
of an individual in a participating hospital, including a physician on-call
for the care of such an individual, and who negligently violates a requirement
of this section ... is subject to a civil penalty" and exclusion from
further participation in government programs. § 1395dd(d)(1)(B). As previously
discussed, "where Congress includes particular language in one section
of a statute but omits it in another section of the same Act, it is generally
presumed that Congress acts intentionally and purposely in the disparate
inclusion or exclusion." Russello, 464 U.S. at 23,104 S.Ct.
296. Congress clearly knew how to make individuals responsible under
the statute, because it did so in the provision subjecting violators
to federal enforcement. Given the contrast in these two consecutive subsections
of the statute, Congress' omission of any reference to individuals in
the civil enforcement provision must have been intentional.
Moreover, to the extent that the absence of such a reference arguably
causes ambiguity with respect to this issue, the legislative history
reveals an intent to preclude private suits against individuals. According
to the report of the House Judiciary Committee, the committee recommended
amendments changing the civil enforcement provision to its current form
in order to "clarif[y] that actions for damages may be brought only against
the hospital which has violated the requirements of [the statute]." H.R.Rep.
No. 99-241, pt. 1, at 132, reprinted in 1986 U.S.C.C.A.N. 579, 728. No
other statement from Congress suggests any alternative reading of the
provision. Because the statute contains no language plainly at odds with
this stated purpose, we view the Judiciary Committee's report as further
support for our conclusion that private plaintiffs may not sue individuals
under EMTALA.
Thus, the district court's grant of summary judgment dismissing Plaintiff's
claim against Dr. Lessem pursuant to EMTALA is affirmed.
CONCLUSION
For the reasons set forth above, with respect to Plaintiff's claims against
the hospital, the judgment of the district court is REVERSED and REMANDED
for further proceedings consistent with this opinion. With respect to
Plaintiff's claim against Dr. Lessem pursuant to EMTALA, the district
court's order granting summary judgment is AFFIRMED.
-
The Honorable Frederick P. Stamp, Jr., Senior
United States District Judge for the Northern District of West Virginia,
sitting by designation.
-
To the extent Plaintiff argues that the hospital's
physicians were negligent in failing to recognize that Howard had
an emergency medical condition, such an allegation is reserved for
state malpractice law. See, e.g., Bryant v. Adventist Health
Sys., 289 F.3d 1162, 1166 (9th Cir.2002).