Circuit Split: Should a Plaintiff Suing a Hospital under EMTALA for a Screening-Based Violation Have to Prove the Hospital had an Improper Motive?
Emily Westerfield, Associate Member, University of Cincinnati Law Review
Earlier this year, the Sixth Circuit upheld its 1990 ruling in Cleland v. Bronson Health Care Group, Inc. that a plaintiff alleging a screening-based violation of the Emergency Medical Treatment and Labor Act (EMTALA) must prove that the hospital had an improper motive for failing to appropriately screen the plaintiff. By upholding Cleland in Elmhirst v. McLaren, the Sixth Circuit perpetuated its split from the First, Fourth, Eighth, Tenth, and D.C. circuits on the issue of whether a former patient who alleges that a hospital failed to provide an “appropriate screening” in violation of 42 U.S.C.A. § 1395dd(a) has the burden of proving that the hospital had an improper motive for committing the violation. Subsection (a) of EMTALA requires hospitals to provide an “appropriate medical screening examination within the capability of the hospital’s emergency department . . . to determine whether or not an emergency medical condition . . . exists” to any person who goes to the emergency department requesting treatment for a medical condition. The statute makes no explicit reference to the hospital’s motive, let alone any requirement that a plaintiff bringing a lawsuit against a hospital under subsection (a) of EMTALA prove that the hospital had an improper motive for failing to provide the plaintiff with an “appropriate medical screening” pursuant to the statute. At issue is if the plaintiff alleging inappropriate care must prove the hospital had an “improper motive” (e.g. desire to avoid non-paying patients) in the inappropriate care. Only the Sixth Circuit imposes this additional burden on the plaintiff.
In Power v. Arlington Hospital Ass’n, the Fourth Circuit referred to the lack of an explicit “improper motive” requirement as a reason for why plaintiffs suing under subsection (a) of EMTALA should not be required to prove the hospital had an improper motive. Ultimately, the arguments for not requiring the plaintiff suing under subsection (a) of EMTALA are far more persuasive than the Sixth Circuit’s basis for interpreting the statute as implying an “improper motive” requirement. The fact that every other circuit that has ruled on the issue offers further credence to the argument that there ought to be no improper motive requirement.
In Cleland, the Sixth Circuit determined that the term “appropriate” in subsection (a) of EMTALA must refer to the motives behind a hospital’s actions pertaining to medical screening provided by its emergency department. The court went on to explain that liability under subsection (a) of EMTALA may arise whenever a hospital’s emergency department fails to provide a medical screening that rises to the standard typically exhibited during medical screenings, for any reason other than the informed medical judgment of the physician or other hospital employee who administered the screening. The court listed a number of improper motivations that may cause someone on the staff of a hospital’s emergency department to administer care that falls below the hospital’s standard of care while providing a medical screening, including race, gender, inability to pay, and drunkenness. However, the court expressly noted that the improper motivations comprising that list were meant to be illustrative, not exhaustive.
The primary rationale behind the Sixth Circuit’s interpretation of subsection (a) of EMTALA was that the additional pleading requirement would distinguish a cause of action under EMTALA, a federal law, from medical malpractice causes of action under state law. This argument simply does not stand up to the Fourth Circuit’s reasoning behind the First, Fourth, Eighth, Tenth, and D.C. circuits’ stance that proof of an “improper motive” for failing to provide the plaintiff with appropriate screening is not necessary to bring a cause of action against a hospital for a violation of subsection (a) of EMTALA.
First, the Fourth Circuit asserted that an express reference to an “improper motive” pleading requirement is absent from subsection (a) of EMTALA. Instead, the court noted that the statute explicitly indicates that the issue of whether a medical screening was “appropriate” or not depends on the standard of care of the particular hospital facing liability in the case at hand. The court indicated that according to subsection (a) of EMTALA, that standard is determined by the capabilities of the hospital staff and the services that are typically made available in the emergency department of that particular hospital.
Second, the Fourth Circuit pointed out that the ability of a plaintiff to bring suit against a hospital under subsection (a) of EMTALA for providing substandard care during a medical screening in its emergency department as a result of any motivation that does not involve reasonable medical judgment essentially eliminates the need for a requirement that the plaintiff prove what exactly that improper motive was.
Third, and perhaps most importantly, the Fourth Circuit contended that requiring plaintiffs to prove the inner motivations of a hospital employee or physician is far too great a burden to impose. According to the court, the virtual impossibility of meeting that high of a pleading standard would effectively preclude legal recovery in most cases.
Looking forward, it seems that the Sixth Circuit may be open to revising its position on the issue of whether a plaintiff suing a hospital under subsection (a) of EMTALA for a screening-based violation should be required to prove that the hospital had an improper motive for failing to provide an appropriate medical screening in the hospital’s emergency department. In its opinion in Elmhirst, the Sixth Circuit, in recognizing its divergence from the other circuits, suggested en banc review may be appropriate. Hopefully, the Sixth Circuit will be persuaded that, as the Fourth Circuit articulated in Power, that an “improper motive” pleading requirement for plaintiffs bringing suit under subsection (a) of EMTALA is unrealistic, unduly stringent on plaintiffs, and ultimately unfounded. This conclusion is based not only on the plain wording of the statute itself, but also on the negative implications of such a requirement on plaintiffs.
 Elmhirst v. McLaren N. Mich., 726 Fed. Appx. 439, 442 (6th Cir. 2018).
 42 U.S.C.A. § 1395dd(a) (1986). This statute was passed after alleged incidents of hospitals refusing to treat indigent patients. The statute requires screening in an emergency room to determine if an emergency conditions exists. Cleland v. Bronson Health Care Grp., 917 F.2d 266, 268 (6th Cir. 1990).
 Power v. Arlington Hospital Ass’n, 42 F.3d 851, 857 (4th Cir. 1994).
 Elmhirst, 726 Fed. Appx. at 443.
 Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 272 (6th Cir. 1990).
 Id. at 272.
 Power, 42 F.3d at 857.
 Id. at 858.
 Id. at 857-58.
 Id. at 858.
 Elmhirst, 726 Fed. Appx. at 444.