Nearly every state has some variation on a “Good Samaritan” law. In Illinois, the statute says that any licensed medical professional “who, in good faith, provides emergency care without fee to a person, shall not, as a result of his or her acts or omissions, except willful or wanton misconduct on the part of the person, in providing the care, be liable for civil damages.” 745 ILCS 49/25.

So what does “without fee” mean? The patient didn’t get a bill — or the doctor wasn’t paid at all?

The Illinois Supreme Court answered that interesting question on Thursday morning, unanimously holding in Home Star Bank and Financial Services v. Emergency Care and Health Organization, Ltd. that an emergency room physician who responded to a Code Blue emergency elsewhere in the hospital was not entitled to immunity under the Illinois Good Samaritan Act.

Home Star began nearly thirteen years ago, when a patient was admitted first to the hospital emergency room, and later transferred to the intensive care unit. Three days after he was admitted, the patient began having labored breathing and trouble swallowing. A “Code Blue” was called in the early morning hours, and the defendant physician, who was working in the emergency room at the time, responded and attempted to intubate the patient. The patient suffered severe and permanent brain injuries, and the plaintiffs sued the physician and his employer physicians group for malpractice.

The physician moved for summary judgment, arguing that the Good Samaritan law applied, since the patient was not billed for the physician’s services. The plaintiff opposed summary judgment, arguing that whether or not the patient was billed, the doctor didn’t respond to the Code Blue as a volunteer – he was doing his job.

The evidence was all over the place. According to the independent contractor agreement between the doctor and the physicians group, he “may render service to any patient” in “dire emergencies,” when no emergency room patient required immediate assistance. The hospital’s “Clinical Operations” policy stated that ER physicians “respond[ ] to all Code Blues in the hospital.” The nursing supervisor testified that in her experience, the emergency room physician typically responded to Code Blues at night. The defendant physician agreed that the ER physician on duty “would be expected to respond to a Code Blue.” The CEO of the physicians group, on the other hand, testified that responding to Code Blues was not “an inherent prescribed part of [the physician’s] work,” and that he would respond “in the matter a good samaritan would respond to that dire emergency.” The nurse anesthetist who assisted at the patient’s Code Blue testified that in her experience, the emergency room physician was “usually there first” at nighttime Code Blues. The patient’s laryngologist testified that his understanding was that an in-house ER physician would respond to Code Blues. The CEO of the hospital testified that it had been hospital policy for many years that the ER physician would respond to Code Blues, but that she didn’t believe there was anything specific about it in the hospital’s agreement with the defendant physicians group.

The trial court granted summary judgment on the grounds that the patient had never been billed for the physician’s services. The Appellate Court reversed, finding after a review of the legislative history and relevant cases that the statute was not intended to immunize doctors who responded to a scene because they were paid to do so.

In an opinion by Justice Robert R. Thomas, the Supreme Court unanimously affirmed the Appellate Court.

The Court began by reviewing the history of Illinois’ Good Samaritan law and its predecessors. The law had originally been enacted in 1965, and was quite narrow in scope, applying only to medical professionals providing emergency care without fee “at the scene of a motor vehicle accident or in case of nuclear attack.” In 1969, the legislature broadened the statute to include any accident by striking the words “motor vehicle.” Four years later, the legislature struck all reference to accidents and nuclear attacks and added a limitation that for immunity to apply, the medical professional couldn’t have had “prior notice of the illness or injury.” In 1998, the legislature struck the “prior notice” limitation.

The Supreme Court has never construed the statute, but the Appellate Court has addressed it several times. Early cases tended to hold that a physician could claim immunity as long as the patient wasn’t charged. In these early cases, the courts tended not to look into reasons why the patient wasn’t charged. In Estate of Heanue v. Edgcomb, for the first time the Appellate Court held that immunity applied only when a decision not to bill was made in good faith (the court believed that the phrase “good faith” in the statute modified both “provides emergency care” and “without fee”).

The same year as Heanue, the federal district court addressed the statute in Henslee v. Provena Hospitals. Henslee was a diversity case, so it required the district court to make an Erie prediction of how the Supreme Court would address the matter. The court concluded that the Illinois courts had strayed far from the legislature’s intent in enacting the statute. “Without fee” was sufficiently ambiguous, the court found, to encompass either situations where the patient didn’t get billed or the doctor didn’t get paid. The court ultimately opted for a broader definition of the term “without fee” for several reasons: denying paid physicians immunity was more consistent with the legislature’s intent of encouraging volunteerism, was more consistent with modern medical billing practices, and finally, that excluding paid physicians prevented defendants from engineering immunity by simply deciding not to send the patient a bill.

But four years later, another federal district court addressed the issue in Rodas v. SwedishAmerican Health System Corp. and squarely disagreed with Henslee. Then, just to make things even more confusing, the Seventh Circuit reversed the district court’s judgment in Rodas.

The Court sided with the district court in Henslee. “Without fee” was sufficiently ambiguous to encompass either meaning, the Court found — “didn’t bill” or “wasn’t paid.”

So the court turned to various aids to construction. Dictionary definitions of the term “good samaritan” suggested that a doctor had to be a volunteer, but weren’t conclusive.

But the legislative history seemed clear. The statute itself said that the law was intended to protect citizens “who volunteer their time and talents to help others.” The court quoted a state Senator’s comment that the Act was intended to protect medical professionals acting “on the spot, not in his doctor’s office or in the hospital on the operating table.” A state representative stated that the law was intended to encourage “good samaritans to do the right thing on the streets of Illinois.” Another stated that the law “only covers services that are rendered without compensation.” The court also cited with approval to a California decision, Colby v. Schwartz, where the court found that physicians responding to emergencies at a hospital because they served on the hospital’s emergency call surgical panel were not protected by California’s good samaritan law. Such physicians did not need the protection of the law, the court found, since they were acting within the scope of their jobs.

The closing pages of Home Star showed yet again that questions at oral argument often the Court’s reflect serious concerns — and may well be coming from the author of the opinion. During the oral argument, Justice Thomas asked whether the defendant’s construction of the statute, where immunity turned on whether or not the patient was billed, might result in the poor having less access to the tort system: the wealthy would always get billed, but the poor often would not – thus triggering immunity – because the hospital or physicians group had no hope of payment. Justice Thomas’ opinion raises the same point again as public policy grounds for rejecting the defendant’s narrow construction of “without fee.”

In the end, the Court concluded that a broad construction of “without fee” best effectuated the legislature’s intent of extending immunity to true volunteers, but no further. Accordingly, the Court affirmed the Appellate Court’s judgment denying statutory immunity to the defendants.

Image courtesy of Flickr by Ewan Munro (no changes).