Physicians fly every day for business and/or pleasure. Occasionally, they may hear the flight crew ask, “Is there a physician on board?” Although uncommon, in-flight medical emergencies do occur, and it would be prudent for physicians to have an understanding of the medical guidelines, moral/ethical principles (Hippocratic Oath), and state, federal, and international laws that apply to rendering emergency medical care while in flight. This knowledge will help physicians decide if and how to respond to these medical emergencies in the air.
A dramatic increase in business and leisure air travel post-COVID has resulted in a greater probability that a physician may encounter a medical emergency during a flight. Because the airlines are not subject to regulatory mandates to report in-flight emergencies in the United States, no data are available.
When the flight crew asks, “Is there a physician on board?” what should a physician do? Instinct would prompt the physician to immediately render medical care, but ethical/moral and legal ramifications might give them pause to consider the wisdom of providing that care. This topic has had minimal discussion in the field of medicine, and case law is hard to find.
Do Moral/Ethical and Legal Obligations Exist?
First and foremost, physicians must understand that they have no legal obligation to respond to an in-flight emergency if the airline is registered in the United States. There is no doctor-patient relationship, so there is no fiduciary duty. A physician who does not want to be involved in the in-flight medical emergency does not have to act.
From a moral/ethical perspective, however, inaction would appear to be morally and ethically bankrupt. Morally and ethically, one could argue, a physician does have an obligation to respond to an in-flight medical emergency, but the Hippocratic Oath makes no such demand. Does this imply there is no ethical/moral duty? Physicians are left with much uncertainty.
What Is a Physician’s Potential for Legal Liability?
Legal liability is a concern for every physician. Under the Aviation Medical Assistance Act of 1998 (AMAA), physicians who participate in emergent medical care during an in-flight medical emergency will not be held liable for damages in a federal or state court. However, patients may allege negligence if it is legally determined that the physician is grossly negligent, or if the physician accepts compensation for their medical actions.
It is important to note that physicians should only provide in-flight medical emergency care to a patient who has a medical condition that falls within the physician’s scope of practice expertise. Clearly a physician who has ingested alcohol or other substances that could impair cognition and medical judgment should not provide medical care in an in-fight medical emergency.
A more difficult but pertinent question is whether, given the potential call for their medical expertise during an in-flight medical emergency, should physicians ingest food, drink, or use substances that could impair judgment during a flight. Are physicians on-call when they are in the air?
International Flights May Have Different Legal Responsibilities
On international flights, physicians may find themselves under different legal obligations. Many European countries legally require physicians to respond to a medical in-flight emergency.
Based on international law, the country in which the airline is registered determines legal jurisdiction. A physician flying to Chicago aboard an airline registered in a European country may be required to respond to an in-flight emergency. This inconsistency between the United States and international law puts physicians in a Catch–22.
Although we believe the moral obligation trumps the lack of a legal obligation, given this new understanding of moral and legal obligations when a medical in-flight emergency occurs, physicians must decide for themselves how to respond to in-flight emergencies.
Medical Insurance
Most private medical insurance policies do cover in-flight medical emergencies. It is unknown whether an insurer will cover alleged negligence related to an in-flight medical emergency if the medical insurance policy restricts malpractice coverage to a physician’s employer’s sites of medical practice, such as hospital-employed physicians. The airlines do not provide medical practice coverage for physicians responding to in-flight medical emergencies.
The Physician's Dilemma
Balancing moral and legal responsibilities is challenging for physicians; there is no right or wrong answer. If it is a physician’s propensity to act, then we believe it would be prudent for the physician to obtain malpractice insurance that covers in-flight emergencies.
Additionally, it is imperative to recognize whether the medical emergency that occurs in-flight is within that physician’s scope of expertise; physicians should not act if it is not within their field. If the medical emergency is a life-or-death situation, the physician should advise the pilot to divert the flight to a landing with a tertiary care medical center.
Medical Malpractice Coverage Policies for In-Flight Medical Emergencies
Medical malpractice insurance policies should cover physicians responding to in-flight medical emergencies. This allows physicians to meet their inherent moral and ethical responsibility to provide medical care within their scope of practice during an in-flight medical emergency. Employed and independent physicians should demand this additional coverage when negotiating their coverage package with their medical malpractice insurer.
The Need for Additional Medical Malpractice Coverage for Physicians Responding to In-Flight Medical Emergencies
Airlines do not provide insurance coverage for physicians responding to in-flight medical emergencies — a flaw that should be rectified by federal legislation mandating airlines to provide medical malpractice coverage for physicians responding to in-flight medical emergencies. This would spread the risk of providing support to physicians meeting their ethical and moral duty to respond to a passenger in duress during an in-flight medical emergency.
Proposal to the Legislative Body of the Federal Government
Physicians who provide in-flight medical care should be held to the same standard as a Good Samaritan responding to a medical emergency. Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are, or whom they believe to be, injured, ill, in peril, or otherwise incapacitated. The protection is intended to reduce bystanders’ hesitation to assist for fear of being sued or prosecuted for unintentional injury or wrongful death.
The Good Samaritan doctrine is a legal principle that prevents a rescuer who has voluntarily helped a victim in distress from being successfully sued for wrongdoing. This type of protection should be provided to physicians who act in good faith to provide medical care in an in-flight medical emergency.
Conclusion
In our opinion, physicians should respond to in-flight medical emergencies. To resolve the physician conflicts associated with responding to in-flight medical emergencies, medical malpractice insurers must provide medical malpractice coverage for in-flight emergencies; the airline industry should provide medical malpractice for physicians responding in good faith to in-flight medical emergencies; and federal legislation should provide protection for physicians responding to in-flight medical emergencies in a manner similar to the protection offered by Good Samaritan laws.
The opinions rendered in this article are solely those of the authors.