## Facts

- Rosa Rivera arrived at DeTar Hospital’s emergency department in Victoria, Texas, in active labor at or near term, with ruptured membranes and severe hypertension, and she lacked prenatal care and ability to pay.
- DeTar contacted Dr. Michael L. Burditt, the on-call obstetrician for unassigned patients.
- Before examining Rivera, Burditt stated he did not want to treat her and instructed staff to prepare a transfer to a hospital about 170 miles away.
- After hospital staff insisted on an examination and compliance with federal requirements, Burditt came to the hospital, examined Rivera, and observed extremely high blood pressure.
- Burditt nonetheless ordered transfer; limited medication was started only after discussion with nursing staff.
- Burditt signed a transfer certification but did not document a medically grounded risk-benefit basis for transfer.
- The transfer proceeded with inadequate arrangements for a high-risk obstetric emergency; Rivera delivered in the ambulance, and the ambulance diverted for emergent care.
- At Rivera’s request the ambulance returned to DeTar; Burditt initially refused to treat her and directed discharge if “stable,” and another physician assumed care.
- HHS assessed a $20,000 civil money penalty against Burditt personally; the Departmental Appeals Board affirmed.

## Issues

1. Whether EMTALA permits HHS to impose civil money penalties on an individual on-call physician as a “responsible physician” for screening, stabilization, and transfer violations.
2. Whether substantial evidence supported the agency’s findings that Burditt failed to stabilize an emergency medical condition and authorized an improper transfer.
3. Whether EMTALA’s obligations and penalties constitute an uncompensated taking of physicians’ services in violation of the Fifth Amendment.

## Decision

- The Fifth Circuit affirmed and enforced the HHS order imposing a $20,000 civil money penalty.
- The court held that EMTALA applies to “responsible physicians,” and Burditt’s role in examining Rivera, ordering transfer, and signing the certification supported personal liability.
- The court found substantial evidence that Rivera had an emergency medical condition, was not stabilized before transfer, and that the transfer was not “appropriate” under EMTALA.
- The court rejected the takings claim, reasoning EMTALA operates as a condition of voluntary participation in Medicare-related arrangements rather than a compelled appropriation of services.

## Legal Principles

- EMTALA requires an appropriate medical screening and, if an emergency medical condition exists (including active labor with serious complications), stabilizing treatment before transfer or discharge unless statutory transfer conditions are satisfied.
- Transfer of an unstabilized patient is permissible only if the patient requests transfer or a physician certifies, based on medical judgment, that expected benefits at another facility outweigh the increased risks; the certification must reflect an actual medical risk-benefit assessment.
- An “appropriate transfer” requires medically suitable arrangements, including adequate personnel and equipment and compliance with EMTALA’s procedural safeguards.
- EMTALA authorizes civil money penalties against individual “responsible physicians” who knowingly participate in violations.
- Conditioning Medicare participation on EMTALA compliance does not constitute a Fifth Amendment taking where participation in the regulated program is voluntary.

## Conclusion

The Fifth Circuit sustained HHS’s penalty against an on-call obstetrician for ordering transfer of an unstabilized labor patient without a medically grounded risk-benefit justification and without an appropriate transfer plan, and it held that EMTALA’s enforcement against physicians does not amount to an unconstitutional taking.


Burditt v. U.S. Dep’t of Health & Hum. Servs., 934 F.2d 1362 (5th Cir. 1991)