Up in the air

Is there a doctor on board? Ethical and legal considerations for in-flight emergencies

Although rare, in-flight emergencies do happen. Having an awareness of the laws and guidelines pertaining to emergency medical care in the sky can help physicians better navigate these situations.

Darren Dillard, DO

Darren Dillard, DO, is a core faculty physician and the Director of Osteopathic Medical Education for the Northside Hospital Gwinnett-Family Medicine Residency Program in Lawrenceville, Georgia.

Contact Dr. Dillard

“Is there a doctor on board?”

It’s a call for help that a physician may encounter during air travel. Since the lifting of COVID travel restrictions, more and more people are taking to the skies to travel for business and leisure. With this increase in travel, there is a higher likelihood of encountering a medical emergency during a flight.

These events are rare, and the majority of in-flight medical issues are treated by the air crew, but data on in-flight emergencies is not readily available. This is due to the fact that there are no regulatory mandates for airlines to report in-flight emergencies. While most physicians would be willing to help in an emergent circumstance, there are ethical and legal ramifications that should also be considered before engaging in such activities.

Legal (and moral) obligations

The first concept to understand is that a physician has no legal obligation to respond to an in-flight emergency if the flight carrier is registered in the United States. There is no duty to treat in the air. If you do not want to be involved, you do not have to act.

From a moral standpoint, however, one could argue that physicians have an obligation to treat a sick passenger during a flight. At the same time, there is no clear-cut language in the Hippocratic Oath about the responsibility of physicians to help during an emergency.

Physician liability

Under the Aviation Medical Assistance Act of 1998 (AMAA), physicians who provide medical care during an in-flight medical emergency will not be held liable for damages in a federal or state court. However, patients still may sue if the physician conducts gross negligence or if the physician accepts any means of compensation for their actions (points, upgrades, etc.).

Importantly, a physician should only provide care that they feel comfortable providing. Preferably, the patient’s condition would be within their scope of practice. For example, a general surgeon may not feel comfortable evaluating a geriatric patient with acute chest pain. A physician should also not have ingested any substances (alcohol, sedatives) shortly prior to or during the flight that could alter their ability to make medical decisions.

International flights

International travel makes this an even more complicated matter. Many European countries do make it a legal requirement for any physician on board to treat in the event of an emergency. Based on international law, the country in which the aircraft is registered is where the legal jurisdiction is. For example, flying on an Air France flight from Paris to New York, the physician passenger may be responsible for responding to an in-flight emergency. However, literature on this type of “requirement to treat” litigation is difficult to find.

As for private malpractice insurance, most do cover in-flight medical emergencies. It is indeterminate if  an insurer will cover a lawsuit related to an in-flight emergency if the insurer restricts malpractice coverage to a physician’s employer’s sites. This is the case for many hospital-employed physicians. The airlines themselves do not provide any legal coverage for physicians responding to these emergencies. However, medical negligence litigation cases are very rare.

Final thoughts

In summary, while it may be a moral obligation to help during an in-flight emergency, a physician should weigh the legal consequences before rendering care. While the AMAA releases physicians from liability, be sure to provide care that is appropriate given the environment. If there is a concern that a medical condition is serious or life-threatening, inform the cabin crew and they will make the decision about diverting.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

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8 comments

  1. JWE

    The Hippocratic oath is, unfortunately, irrelevant today. There have been many iterations of it and the most recent sanitize the power of the classic 1943 translation that stated a physician would not prescribe an abortifacient. If one is recited at all, it as likely to be modified to the person’s personal desires of what they want it to say as not.

    Reply

  2. Thomas Moseley

    I would be curious to know the situation of a retired but licensed physician in this circumstance. As a pediatrician, many adult medicine situations might be considered out of my scope of confidence, but apart from that, what special considerations apply?

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  3. Robert Cutler

    I was on board a Delta flight with 2 other medical personnel when an individual arrested. With the onboard AED unusable for 7 minutes due to poor maintenance, and the need to recharge, we had to manually perform CPR until the AED worked. Bottom line, the individual responded to the defibrillator and was sitting up talking to the paramedics once we landed 20 minutes later after declaration of a medical emergency on-board. The individual made a complete recovery after recouping from viral myocardis which caused her to arrest. Bottom line, a life saved by the coordinated effort from all onboard medical personnel…otherwise the good outcome would not have been possible.

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  4. Thomas Horowitz

    As a bioethicist I might note that as physicians our primary duty is to minimize suffering. Should we have a skill set that could help a person in an emergent situation we should (as the law allows). On a personal note I have responded to aid inflight emergencies. The limited equipment available becomes a disability. But basic life support and reassurance become the most valuable actions. The airlines have a radio service to aviation medical consultants that may be available to plan the next step in care. As long as one sticks to essential care liability is minimal. Training in field care is most valuable.

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  5. Joseph Molnar ,DO ,FACOFPdist . - I need some more space

    I was on a flight to Barcelona and about 100 miles off the Portuguese coast there was a call for Medical assistance.
    One of the pilots had taken his mandatory break and when attempted to be aroused, he could not be. A neurologist was examining the patient when I came there and when he knew I worked the ED said, “You’re the man.”
    I had packed a small emergency kit and that unfortunately was all we had to use until the airlines basic medical kit could be found. The man was pulseless , cold and dilated pupils and had been probably dead for 30 to 45 minutes. One flight attendent knew CPR so the three of us continued CPR . A critical nurse ,our angel showed up and was a gift from heaven because it gave a little relief. The AED was finally found and showed no shockeable rhythm and we tried to call the code. We were then informed by the head flight attendent that we did not have the right to call the code because they and us by extension took our orders from the ground medical crew and that the protocol was CPR for 45 minutes no less.The medical kit was absolutely inadequate and I have seen it has not been upgraded .Finally the only flight attendent that seemed to have common sense waited for the head honcho to leave and said she had timed us at 46 minutes so stop.
    She was very kind. The rest were nauseated could not look at the body , informed us they had never seen a dead person , etc. I asked if they needed a report , the sensible attendent said she thought so because if it was

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  6. E Lowenthal

    On my very first international flight in 1995, an elderly woman collapsed in her seat 2 rows in front of me 2 hours into a flight from LAX. I had made the mistake of letting the lovely couple seated next to me know I was a doctor en route to a meeting in Australia (they had asked). I froze when the request for medical attention came from the flight attendant, but the couple pointed to me and practically shoved me into the aisle to go help. The only “medical kit” on board was a stethoscope and a blood pressure cuff; and of course a clip board on which we were to record our name, state of medical licensure, and liability carrier. We carefully laid the hypotensive, still breathing, lady to the galley, placed her in trendelberg, and discerned that she was in unstable 3rd degree heart block and had a pulse ranging from 20-40 bpm. Thankfully, a GP, a podiatrist, and a cardiologist also turned up as well.
    The four of us took turns monitoring her blood pressure and pulse but there were no meds and no AED . The decision was made for an emergency landing in Hawaii. An ambulance met us on the runway and the lady survived, only by the grace of God. The unionized air crew were compelled to have a 10 hour break in Hawaii, so the airline had to pay for lodging and food for all the passengers and rebook about 300 flights. The “good Samaritans” each got a bottle of champagne. I gave that to the couple next to me. I will never forget the helplessness of feeling so under equipped, yet liable.

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  7. James W. Ziccardi, DO

    I have given emergency care in-flight on several occaisions. In the early 80s on a flight to Hawaii, airline attendants called several times for medical assistance, I was on vacation and had imbibed several mini wines so I didn’t intially respond. After the third call, I introduced myself to the airline attendants, informed them I was a cardiologist but had several drinks, but would be willing to provide any help with that understanding. I was taken to the passenger who was having chest discomfort, he was about 60 yoa had hypertension and had not taken his meds for over a week. I explained to him that I was a cardiologist but had been drinking and that he could refuse any help from me, because of this. He said he would like me to help despite my admission of drinking. At the time there was no emergency equipment on the plane. I sat next to him, his pulse rate was about 120 and was bounding suggesting his blood pressure was high? In the next two hours of flight, he and I talked and every 15 minutes I took his pulse and each time his pulse rate decreased and his chest discomfort improved, and he was less anxious. On arrival in Hawaii the paramedics came on board and took him off the plane. He contacted me about 6mos later, had done well, thanked me and promised he always made sure he had his meds with him on vacation. It seems that just being a physician and caring person was helpful. I received a letter from United Airlines Medical thanking me for my “honesty and care”.

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  8. Dr DO

    On a recent flight to Jamaica, there was a medical emergency.
    I ended up performing CPR for 30 minutes. We had to use the AED, but there was no shockable rhythm.

    The flight attendant asked for my seat #.

    I did not receive any correspondence from American Airlines, which I thought odd, looking back at this situation.

    Reply

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