Abstract

Excerpted From: Christina Dalton, Delayed & Denied: How One Court's Interpretation of EMTALA Obstructs Emergency Abortion Care & Threatens Women's Health, 35 University of Florida Journal of Law and Public Policy 233 (Spring, 2025) (267 Footnotes) (Full Document)

At what point does a medical emergency become life-threatening? In late August of 2022, Amanda Zurawski learned the answer to that question the hard way. A resident of Austin, Texas, Amanda was eighteen weeks pregnant when her water broke prematurely, putting her at high risk for a life-threatening infection: sepsis. Even though the fetus would not survive, emergency room doctors told Amanda they were unable to terminate the pregnancy due to the language of Texas abortion laws. In Texas, abortion is illegal unless the pregnant individual's life is in danger, and a physician who violates Texas' abortion statute can face a life sentence in prison. Because her doctors did not think Amanda was sick enough to put her life in danger, she was sent home and told to watch for signs of infection.

Three days later, only after Amanda developed a temperature of 103 degrees and became too weak to walk, did her doctors finally feel that she was “sick enough” to conclude that her life was in danger. After her pregnancy was terminated, Amanda developed sepsis and nearly died. Amanda continues to face long-term complications from the bacterial infection. Amanda's life-threatening illness and subsequent complications all happened because she had to wait three days to receive necessary healthcare.

Why were Amanda's physicians not permitted to perform the medically necessary abortion as required under the Emergency Medical Treatment and Active Labor Act (EMTALA)? While Amanda was waiting to become “sick enough” to allow her doctors to legally terminate her pregnancy under Texas law, two U.S. district courts issued conflicting decisions about whether EMTALA preempted state abortion laws. Unfortunately for Amanda, the Texas district court concluded that EMTALA did not preempt Texas abortion laws.

Amanda is just one of many women impacted by the Supreme Court's decision in Dobbs v. Jackson Women's Health Organization to overturn Roe v. Wade. But her story is critical for several reasons. First, it demonstrates how the consequences of the decision to overturn Roe will extend beyond the immediate right to terminate a pregnancy. Second, it illustrates how Dobbs has created a legal landscape filled with uncertainty, creating compliance dilemmas for healthcare providers. Lastly, Amanda's story portrays the clear tension that exists between EMTALA and several state abortion bans.

This Note addresses whether EMTALA preempts state abortion bans in the context of a medical emergency. Part I provides background information on the Dobbs decision and how states responded, discusses the Department of Health and Human Services' interpretation of EMTALA's preemptive effect, and introduces the competing district court cases. Notably, the analysis of these district court cases focuses on the relevant state abortion bans as they existed at the time of each decision. Part II discusses EMTALA, specifically Congress' intent in enacting the statute and the obligations it imposes on hospitals and physicians. Part III then provides an overview of preemption and an analysis of EMTALA's preemption provision. Part IV analyzes why the district court's decision in Texas is “egregiously wrong,” arguing that EMTALA preempts state abortion bans to the extent they conflict. Part V provides an overview of the legal challenges that followed these district court decisions and then highlights the continued confusion, chaos, and uncertainty that persists for emergency abortion care. Lastly, Part VI discusses the implications of these competing decisions on the legal landscape, healthcare providers, and women's health.

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In conclusion, EMTALA is a federal law that requires Medicare participating hospitals to provide stabilizing care to any individual who presents to the hospital's emergency department with an emergency medical condition. Nothing in the statute's language suggests that any type of condition or category of medical treatment is excluded from the requirements under EMTALA. The medical community has long recognized that in certain circumstances, termination of pregnancy may be considered the standard of care and the medical intervention necessary to stabilize a pregnant woman experiencing an emergency medical condition, such as previable preterm premature rupture of membranes (PPROM). Therefore, EMTALA should preempt state abortion bans to the extent the law draws its exceptions more narrowly than the requirements under EMTALA.

In August of 2022, two federal district courts addressed this issue, however, the court in Texas v. Becerra got it “egregiously wrong.” The future of access to necessary emergency medical care for pregnant women in restrictive states still hangs in the balance. However, what remains clear is that the decision in Dobbs has created confusion, chaos, and a fractured legal landscape. These two competing district court cases and the subsequent litigation that followed illustrate how overturning Roe will have vast, far-reaching, and devastating impacts on women's rights and health, physician autonomy, and the practice of medicine generally. Unfortunately, these conflicting EMTALA cases are just the beginning.

EMTALA plays a critical role in ensuring that all individuals have access to emergency medical care. However, restrictive state abortion bans, and the confusion and uncertainty created by their narrow and vague exceptions, effectively weaken and, in some circumstances, even strip women of their right to emergency medical care under EMTALA. A woman's right to access and receive time sensitive, evidence-based emergency medical treatment should not depend on her zip code.

Editor's Note: This note was primarily drafted during the 2022-2023 academic year and discusses two district court decisions addressing the interplay between state abortion restrictions and EMTALA after the Supreme Court overturned Roe v. Wade. Since these two district court decisions were issued in August of 2022, there have been several appeals. Additionally, in early 2025, the current administration dropped the lawsuit against Idaho that led to one of these district court opinions. While I have edited the original draft to reflect and briefly discuss the long and complex subsequent history of these two cases, the main purpose of this Note was to compare these similar yet competing district court decisions and examine the public policy implications. Although it is important to recognize the subsequent history of these two district court decisions, the analysis provided in this Note remains relevant, in particular, the discussion of the consequences that these legal challenges and restrictive state abortion bans have on the practice of emergency medicine and women's health.