Health Affairs Source Article | Comments Courtesy of Matt Zavadsky
Interesting counsel from the authors, and, interesting reference to the transport policies in Philly…
When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply?
Sara F. Jacoby Elinore J. Kaufman Therese S. Richmond Daniel N. Holena
OCTOBER 1, 2018
At the University of Utah Hospital last October, a nurse was arrested when she refused to draw blood from an unconscious patient for a police officer who was lacking a legal warrant. Surveillance footage of her arrest and rough treatment drew national media attention. As a consequence, the police officer involved was fired from his job, and the hospital issued a policy that now bans law enforcement activities in patient care areas of its medical center. The Utah Legislature responded as well by passing a bill to outline conditions under which police can obtain blood samples from patients for investigative purposes.
This case may have been extreme, but conflicts between clinicians and police are not uncommon. Emergency departments are arguably an epicenter of opportunity for this kind of conflict. It is in these clinical settings that intersections between health care and law enforcement activities are most frequent, for example, when police respond to medical emergencies or seek information to inform emerging criminal investigations. The challenge of these interactions is that clinicians and police have distinct professional priorities, and there is notable ambiguity in how best to interpret guiding policy and ethics.
Clinicians And Police Have Intersecting But Potentially Conflicting Responsibilities
Traumatic injuries, such as gunshot wounds or motor vehicle crash injuries, are conditions that attract both health care and law enforcement responses. In these circumstances, clinicians and police share a mandate to protect injured people and public safety. However, the police mission to initiate an investigation and solve crimes may compete with the urgency of emergency health care, which is built on protocol-driven systems for rapid diagnosis, medical stabilization, and triage.
Injured people, themselves, are rarely in a position to advocate for their own medical and legal needs during emergency care. Traumatic injuries can cause physiologic and psychological alterations that limit the ability to fully consent to medical procedures and legal interrogation. Once a person is transported from the scene of an injury and into a health system, health care ethics and laws obligate clinicians to offer help and guardianship. This includes protection of privacy over health information and patients’ autonomy in decisions that affect health and well-being.
A Complex Policy Landscape With No Clear Oversight
To date, there are no universal cross-disciplinary policies from which to outline clear expectations for interactions among trauma patients, clinicians, and police in health care institutions. The American College of Emergency Physicians published a statement in 2010 that reinforces the primacy of patients’ rights, dignity, and interests when law enforcement activities take place in health care institutions. Members of the emergency medical community have subsequently advocated for the creation of explicit policy guidance for these activities and offer a sample policy for implementation. Enacting, operationalizing, and auditing compliance to these policies is/would become the responsibility of individual health care systems. This is not necessarily a simple pursuit. In doing so, health systems will need to consider and integrate their own institutional policies and practice norms with relevant but potentially inconsistent federal, state, and local policies.
The federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 prohibits clinicians from releasing information about patients to police without consent or a court-ordered warrant. Exceptions are made when: required by law (that is, state-mandated reporting), where criminal conduct is suspected (as a cause of a patient’s death or during medical care), or to avert a serious threat to public health or safety.
In addition, a 2003 US Supreme Court ruling affirmed the constitutionality of police seeking testimony for a criminal investigation during emergency medical care when an injured non-Mirandized patient was suspected of a crime.
State laws may actually necessitate interactions between clinicians and police after a traumatic injury, but the conditions for mandated interactions can vary from state to state. In most states, clinicians are required to report evidence of child and elder abuse. In several but not all states, clinicians are also required to report any suspicion of assault, domestic violence, or drunk driving associated with an injury.
At a local level, municipal policies can influence the ways that clinicians and police interact in response to injuries. In Philadelphia, Pennsylvania, for example, where the rate of violent injuries outpaces the resources available for emergency medical systems, the city permits police to provide direct transport to the nearest accredited trauma center. As a result, a substantial proportion (more than 50 percent in recent years) of patients with penetrating wounds such as gunshot injuries arrive at Philadelphia trauma centers in police vehicles. Across national trauma systems, police transport has been shown to be as effective as ambulance transport and is believed to be a lifesaving intervention for cities with high rates of injuries and proximity to the resources of trauma centers. At the same time, this practice creates opportunities for police to question patients en route to a hospital and offers a direct pathway for law enforcement activities within trauma center emergency departments.
Lack Of Clear Policies Can Put Patients And Clinicians In Vulnerable Positions
The danger of the current policy landscape is that any interpretive ambiguities can result in ad hoc negotiations for when, where, and how law enforcement activities take place in health care institutions. This may lead to unintended, informal, and even illegal access to patients and disclosures of their health information to police. It can also promote interprofessional conflict and negative clinical outcomes. If, for example, patients can’t differentiate between questioning in the service of law enforcement and questioning in the service of medical care, they may be reluctant to communicate essential information to their health care team. Our recent research describes how black patients in a Philadelphia trauma center express conflicted interpretations of their interaction with police during emergency injury care. Some perceived police to be acting in their best interest by offering security and expediting transport to the hospital. Others found police questioning as an added stressor and disruption to the medical interventions they felt were essential for their survival. Victims of gun violence in Chicago describe similar impressions of their interactions with police in the aftermath of their injuries.
The diversity of federal, state, and local polices make it difficult to imagine a singular rule of conduct for all law enforcement activities in health care settings. Professional trauma surgery and nursing societies, however, have the opportunity to articulate the need for boundaries and necessary considerations when law enforcement activities take place within US trauma centers. One pathway toward leadership in this area would be for entities such as the American College of Surgeons Committee on Trauma, which accredit US trauma systems, to mandate and audit compliance to individual institutional policies. Not only would this present the opportunity to better protect injured patients, clarify professional role expectations, and prevent conflict, it would also better prepare legal counsel and ethical consult teams to support clinicians in cases of difficulty in policy interpretation.
Balancing Patients’ Rights And Health With Clinicians’ Rights
As institutional policies are developed, the process should ideally integrate multiple stakeholders including community members, police, and a full range of health system actors. There may also be benefit to bringing multiple institutions and sectors together with the leadership of city or state health departments to consider policy interventions that guide intersections between emergency health care and law enforcement that can account for local needs, resources, and environments. Although institutional context may vary, we recommend three core policy goals:
- Policies that guide law enforcement activity in health care institutions should make patient health the first priority. Except in extreme cases of public safety risk (active shooter threats, terrorist events, and so forth), law enforcement officers should not interview patients until they are medically stabilized as determined by treating clinicians. Health care institutions and law enforcement agencies should also work together to clearly define how patients who are under arrest or incarcerated are managed in the emergency department to permit clinicians the opportunity to provide the same standard of medical treatment as would be offered to any patient in their care.
- Patients’ rights are the next priority. Therefore, except as above, law enforcement officers should not interview patients until they are mentally ready to understand and participate (stable, not overly sedated or narcotized). Patients should also have access to appropriate legal counsel at all times, even if this delays questioning. Hospitals and local law enforcement and legal communities should set up systems to facilitate representation.
- Although health care personnel are not legal experts, they have a responsibility to protect patients’ health and rights and should be educated about guiding policies and feel empowered to step in as needed. Following the example of University of Utah Hospital, health care institutions need to put into place structures and processes to accomplish these goals.
Programmatic crossroads between law enforcement and injury and emergency care will likely continue to increase in response to looming public health threats. The Stop the Bleed campaign to prevent death after trauma and Naloxone distribution to prevent the consequences of opioid overdoses are two prominent examples in which health care and law enforcement providers are interacting to promote public health priorities outside of the hospital. While challenging, developing policy to extend cross-disciplinary collaboration within emergency department settings in a way that protects the rights and well-being of patients, health care providers, and the public is an ethical imperative.
All authors are senior fellows of the Leonard Davis Institute (LDI) of Health Economics at the University of Pennsylvania. Support for this work was provided by the LDI Policy Accelerator Program.