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  • Taking Chances2:24

          Physicians can transfer the care of a disabled patient without being held liable for discrimination under federal law as long as the decision to do so is medically reasonable.  In the case of Lesley v. Chie, the United States Court of Appeals for the First Circuit considered whether an obstetrician’s decision to transfer the care of an HIV positive patient to a facility that had more experience providing pre-natal care to HIV patients was discriminatory and a violation of federal law.    

            The Rehabilitation Act is a federal statute which prohibits physicians who receive Medicare and Medicaid benefits from refusing to care for a disabled patient because of the patient’s disability.  Vickie Lesley claimed that her treating obstetrician, Dr. Chie, violated this Act when he transferred her prenatal care to another physician after he discovered she was HIV positive. 

            Dr. Chie was a board certified obstetrician who received Medicaid program funding.  Dr. Chie had been treating Lesley since 1992.  When Lesley became pregnant in December of 1994, she went to Dr. Chie for prenatal care.  During her first prenatal visit, Dr. Chie classified Lesley’s pregnancy as complicated based upon the risk of birth defects from the medication she was taking for manic depression, her history of diabetes, and her risk for cervical incompetence due to a late term abortion in 1994. 

            On March 2, 1995, Dr. Chie drew a blood sample for routine testing which included HIV and ordered a fetal echocardiogram to check for fetal heart abnormalities from the medication she was taking.  Dr. Chie learned that Lesley was HIV positive and informed Lesley and her husband about the risk of transmission of the disease to the fetus.  A second blood test performed a week later confirmed that Lesley had HIV. 

            In March of 1994, the Department of Public Health in Massachusetts distributed a clinical advisory to obstetricians regarding the administration of a drug called AZT to pregnant women with HIV.  AZT had been shown to reduce the transmission of HIV to the fetus in a clinical trial group study which had been completed in February of 1994.  The DPH advisory also recommended that ostetricians consult with an internist, infectious disease specialist or perinatologist knowledgeable about HIV disease in pregnancy.  Although Dr. Chie had treated HIV positive patients in his practice, he had never prescribed AZT to a patient or monitored a patient receiving AZT for side effects. 

            After learning Lesley was HIV positive, Dr. Chie contacted the pharmacy at the hospital at which he practiced to inquire whether they had AZT available to be given intravenously during labor.  Dr. Chie discovered that the drug was not available and that he would need approval from the hospital’s Pharmaceutics and Therapy Committee to administer the drug.  Dr. Chie contacted the Chairman of the Committee about this issue to see if the Committee would approve the use of AZT.  Dr. Chie also contacted the Nurse Noone, the coordinator of the HIV Program at Worcester Memorial Hospital to see if they had any treatment options to offer Lesley.  The HIV Program at Memorial was one of eight medical centers to participate in the clinical trials of using AZT.  Dr. Chie advised Nurse Noone that he was searching for a primary care physician or local obstetrician who had experience with AZT to consult with.  Dr. Noone offered to act as a consultant to assist Dr. Chie. 

            Dr. Chie consulted Lesley’s primary care physician to advise him that there was no AZT program at his hospital.  Dr. Chie advised him that he would probably need to refer Lesley to Worcester Memorial.  Lesley’s primary care physician confirmed that he had not heard anything about the hospital approving the use of AZT intravenously. 

            At Lesley’s next appointment on March 20, 1995, Dr. Chie informed her that he had never prescribed AZT and did not know how to manage its side effects.  He suggested transferring her care to Worcester Memorial.  Lesley’s psychiatrist also suggested that she receive treatment at a university hospital given the complicating factors of her pregnancy. 

            On March 30, 1995, Dr. Chie told Lesley that the hospital did not have an AZT program in place and that he did not have confidence using AZT.  Dr. Chie told Lesley that it was in her best interest to transfer her care to Memorial Hospital.  In response, Lesley urged Dr. Chie to get AZT approved at the local hospital and consult with Worcester Memorial about her care.  Dr. Chie refused to continue treating Lesley.  Three weeks later, on April 26, 1995, AZT was administered for the first time at Dr. Chie’s hospital in preparation for the delivery of an HIV positive woman. 

            Lesley continued her prenatal care at Worcester Memorial and delivered her baby on July 10, 1995.  Lesley was satisfied with the care she received at Worcester Memorial and her baby tested negative for HIV at birth and at follow up tests. 

            In March of 1997, Lesley filed a lawsuit against Dr. Chie stating that his decistion to transfer her care was discriminatory and violated federal law.  Lesley argued that the administration of AZT was straightforward and did not require specialized knowledge, and argued that transfer of her care was not appropriate based upon her HIV status alone.  Lesley relied upon the DPH advisory to support her contention that Dr. Chie wrongfully transferred her case.  Dr. Chie argued that Lesley’s pregnancy was complicated by a combination of psychiatric and medical problems, that knowledge about managing HIV positive pregnancies in the general medical community was limited at the time he transferred her care, and that implementation of the DPH advisory guidelines took several months for most hospitals.  Dr. Chie claimed that was appropriate for Dr. Chie to transfer Lesley’s care because of the lack of assurance that the hospital would have AZT protocols in place in time for Lesley’s delivery. 

            The lower court held that there was no evidence to support Lesley’s claim that Dr. Chie’s decision to transfer her care was discriminatory and dismissed her case before the time of trial.  In upholding the lower court’s decision, the First Circuit held that disability laws were not enacted to prevent a physician from referring a disabled patient if the patient’s disability creates a specialized complication.  A decision to transfer a disabled patient will be considered discriminatory only if the decision so unreasonable it can be considered arbitrary or capricious.  The Court found that Dr. Chie’s reason for transferring Lesley’s care was medically reasonable, and believed that this was the true reason for the decision to transfer in light of the fact that Dr. Chie knowingly treated other HIV patients and the fact that Dr. Chie did not jump to his conclusion. 

            The Court explained that its decision in Lesley was necessary to protect the professional autonomy of physicians.  The Court concluded that this was a case of reasoned medical judgment in which the patient disagreed with the treatment, and that the remedy for such cases is state medical malpractice law and not a disability claim. 

            In light of the Lesley decision, physicians who treat disabled patients can refer the care of such patients to other providers as long as the decision to transfer is medically reasonable.  A physician who is contemplating such a transfer should take steps to fully document the medical reasoning behind their decision.  Reasonable steps include investigating the resources available at the physician’s local hospital and conferring with a physician who is more knowledgeable in treating the disability at issue.  Physicians should make efforts to show the final decision was logically reached after careful consideration.  Before any decision is reached, a physician must ensure that the patient’s condition is medically stable for transfer, and that the other physician is accepting of the transfer and medically capable to treat the patient.

Care of a Disabled Patient

by Attorney Frank E. Reardon

January 2001