Case Title: Shannon Preston v. Meriter Hospital, Inc.

Citation: 2005 WI 122

Docket Number: 2003AP001376

State: wisconsin

Court: Wisconsin Supreme Court

Date: 2005-07-13T00:00:00Z

Document:
2005 WI 122 
 
 
SUPREME COURT OF WISCONSIN 
 
 
 
 
 
CASE NO.: 
2003AP1376 
COMPLETE TITLE: 
 
 
Shannon Preston,  
          Plaintiff-Appellant-Petitioner, 
Charles Johnson and Estate of Bridon M. Johnson,  
          Plaintiffs, 
     v. 
Meriter Hospital, Inc. and Wisconsin  
Patients Compensation Fund,  
          Defendants-Respondents. 
 
 
 
 
REVIEW OF A DECISION OF THE COURT OF APPEALS 
2004 WI App 61 
Reported at:  271 Wis. 2d 721, 678 N.W.2d 347 
(Ct. App. 2004-Published) 
 
 
OPINION FILED: 
July 13, 2005   
SUBMITTED ON BRIEFS: 
        
ORAL ARGUMENT: 
April 28, 2005   
 
 
SOURCE OF APPEAL: 
 
 
COURT: 
Circuit   
 
COUNTY: 
Dane   
 
JUDGE: 
Stuart A. Schwartz   
 
 
 
JUSTICES: 
 
 
CONCURRED: 
CROOKS, J., concurs (opinion filed). 
ABRAHAMSON, C.J., and BRADLEY and BUTLER, JR., 
J.J., join the concurrence.   
 
DISSENTED: 
ROGGENSACK, J., dissents (opinion filed). 
WILCOX, J., joins the dissent.   
 
NOT PARTICIPATING:         
 
 
 
ATTORNEYS: 
 
For the plaintiff-appellant-petitioner there were briefs by 
Scott 
D. 
Obernberger 
and 
Obernberger 
& 
Associates, 
LLC, 
Milwaukee, James M. Bopp, Jr. and Thomas J. Marzen and National 
Legal Center for the Medically Dependent & Disabled, Inc., Terre 
Haute, IN, and oral argument by Thomas J. Marzen. 
 
For the defendant-respondent, Meriter Hospital, Inc,. there 
was a brief by Curtis S. Swanson, David J. Pliner and Corneille 
Law Group,L.L.C., Madison, and oral argument by David J. Pliner. 
 
 
2005 WI 122
NOTICE 
This opinion is subject to further 
editing and modification.  The final 
version will appear in the bound 
volume of the official reports.   
No.  2003AP1376   
(L.C. No. 
00 CV 886) 
STATE OF WISCONSIN  
 
 
   : 
IN SUPREME COURT 
 
 
Shannon Preston, 
 
          Plaintiff-Appellant-Petitioner, 
 
Charles Johnson and Estate of Bridon M. 
Johnson, 
 
          Plaintiffs, 
 
     v. 
 
Meriter Hospital, Inc. and Wisconsin Patients 
Compensation Fund, 
 
          Defendants-Respondents. 
 
 
FILED 
 
JUL 13, 2005 
 
Cornelia G. Clark 
Clerk of Supreme Court 
 
 
 
 
 
REVIEW of a decision of the Court of Appeals.  Reversed and 
cause remanded.   
 
¶1 
DAVID T. PROSSER, J.   This is a review of a published 
decision of the court of appeals, Preston v. Meriter Hospital, 
Inc., 2004 WI App 61, 271 Wis. 2d 721, 678 N.W.2d 347.  Shannon 
Preston and Charles Johnson, in their personal capacity and as 
personal representatives of their son Bridon's estate, filed a 
complaint asserting four claims against Meriter Hospital and the 
No. 2003AP1376  
 
2 
 
Wisconsin Patients Compensation Fund.1  The court of appeals 
affirmed the circuit court's grant of summary judgment to 
Meriter on all four claims, but it determined that the 
plaintiff's claim under the Emergency Medical Treatment and 
Active Labor Act (EMTALA), 42 U.S.C. § 1395dd (1994),2 really 
amounted to two claims, one of which was not addressed and thus 
dismissed by the circuit court.  Preston petitioned this court 
to review the dismissal of this second EMTALA claim, that 
Meriter Hospital failed to give Bridon an appropriate medical 
screening examination in violation of 42 U.S.C. § 1395dd(a). 
¶2 
EMTALA 
requires 
a 
hospital 
with 
an 
emergency 
department 
to 
provide 
"an 
appropriate 
medical 
screening 
examination" to any individual who "comes to the emergency 
department" with a request to be examined or treated for a 
medical condition.  42 U.S.C. § 1395dd(a).  The court of appeals 
                                                 
1 We will refer to Shannon Preston, Charles Johnson, and the 
Estate of Bridon Michael Johnson collectively as Preston. 
2 In the case of a hospital that has a hospital 
emergency department, if any individual (whether or 
not eligible for benefits under this subchapter) comes 
to the emergency department and a request is made on 
the individual's behalf for examination or treatment 
for a medical condition, the hospital must provide for 
an appropriate medical screening examination within 
the capability of the hospital's emergency department, 
including ancillary services routinely available to 
the emergency department, to determine whether or not 
an emergency medical condition (within the meaning of 
subsection (e)(1) of this section) exists. 
42 U.S.C. § 1395dd(a) (1994).  All references to the United 
States Code are to the 1994 edition, unless otherwise stated. 
No. 2003AP1376  
 
3 
 
concluded that this EMTALA requirement did not apply to Bridon 
because he arrived at Meriter through the birthing center, not 
the emergency room.  Preston, 271 Wis. 2d 721, ¶¶37, 39.  We 
must resolve whether the EMTALA screening requirement applies to 
an infant born in a hospital birthing center.  Specifically, we 
must interpret whether the statutory phrase "comes to the 
emergency department" requires a baby to be born in a hospital 
emergency room for the EMTALA screening requirement to apply.   
¶3 
Preston argues that the court of appeals' narrow 
interpretation of § 1395dd(a) is not consistent with the intent 
of 
EMTALA, 
and 
that 
a 
hospital's 
emergency 
department 
encompasses its birthing center.  Thus, Meriter had a duty to 
screen Bridon.  Conversely, Meriter argues that EMTALA does not 
impose a duty to screen a newborn presented in the birthing 
center, because the birthing center is not "the emergency 
department" 
and 
because, 
in 
Bridon's 
case, 
he 
was 
an 
"inpatient," to whom the EMTALA screening requirement does not 
apply.   
¶4 
We agree with Preston with respect to the hospital's 
duty to screen.3  Based on the allegations in the complaint, 
Meriter had a duty to give Bridon an appropriate screening 
examination to determine whether he had an emergency medical 
condition.  When a baby is born in a hospital birthing center, 
the newborn has come to the emergency department for purposes of 
                                                 
3 On the question of Bridon's alleged status as an 
"inpatient," see infra n.12. 
No. 2003AP1376  
 
4 
 
the EMTALA duty to provide a medical screening examination.  
Because the court of appeals interpreted EMTALA differently, we 
reverse. 
¶5 
This case involves a grant of summary judgment by the 
circuit court.  However, the court of appeals reviewed Meriter's 
motion on Preston's EMTALA screening claim as if it were a 
motion to dismiss rather than a summary judgment motion.  Here, 
our review is de novo, whether we apply the methodology 
appropriate for review where summary judgment has been granted 
or the methodology for review where a motion to dismiss has been 
granted, benefiting as usual from the analyses of the circuit 
court and the court of appeals.  Under these circumstances, we 
will review the Meriter motion on the EMTALA screening claim in 
a manner similar to that of the court of appeals.  Consequently, 
we decide merely whether the requirement of EMTALA, that any 
individual who "comes to the emergency department" of a hospital 
must be provided appropriate medical screening, applies to an 
infant born in an emergency medical condition at a hospital's 
birthing facility.  We do not decide whether Meriter's response 
to 
Bridon's 
presence 
satisfied 
its 
duty 
to 
provide 
an 
appropriate medical screening examination. 
I. FACTS AND PROCEDURAL HISTORY 
¶6 
Preston arrived at Meriter Hospital in Madison on 
November 9, 1999, at 5:33 p.m.  She was 23-and-2/7ths weeks 
pregnant and had leaked amniotic fluid for a number of days.  At 
the time of her hospitalization, Preston was unemployed and on 
Medical Assistance. 
No. 2003AP1376  
 
5 
 
¶7 
Preston was admitted to the hospital and taken to the 
birthing center.  There, physicians performed an ultrasound to 
evaluate the unborn child's condition.  At 3:55 a.m. the 
following morning, Preston gave birth to a son whom she named 
Bridon Michael Johnson.  The child weighed 700 grams.  The 
hospital staff made no attempt to prolong the baby's life, and 
Bridon died two-and-a-half hours later. 
¶8 
Preston's complaint alleged the following:  
 
. . . .  
 
4. 
On November 10, 1999 Plaintiff, Shannon 
Preston, 
gave 
birth 
on 
an 
emergency 
basis 
to 
Plaintiffs' decedent, Bridon Michael Johnson while an 
inpatient at Defendant Meriter Hospital, Inc. 
 
5. 
Following the birth of the minor child, 
Defendant 
Meriter 
Hospital, 
Inc.'s 
employees 
and 
agents were aware of the birth of the child and aware 
of his emergent need of medical care, but failed, 
refused, and neglected to provide any care whatsoever 
to the newborn infant, who was at a gestational age of 
23 and 2/7th weeks, weighed one and one half pounds, 
and was 13 inches in length. 
 
6. 
Defendant Meriter Hospital, Inc. and its 
employees 
knew, 
that 
without 
at 
a 
minimum 
resuscitation and the administration of oxygen and 
fluids, that the infant child had virtually no medical 
chance to survive, but nevertheless intentionally 
withheld all treatment for the infant child who 
therefore died after two and one half hours of life. 
 
. . . .  
 
14. The 
conduct 
of 
the 
Defendant 
Meriter 
Hospital, Inc. and its employees was in violation of 
42 U.S.C. § 1395dd. 
 
15. Plaintiffs 
Bridon 
Michael 
Johnson 
and 
Shannon Preston were discriminated against and refused 
No. 2003AP1376  
 
6 
 
treatment 
because 
they 
lacked 
private 
health 
insurance, contrary to 42 U.S.C. § 1395dd. . . .  
Paragraphs 14 and 15 were printed under the heading "EMTALA 
CLAIM." 
¶9 
Preston sued Meriter for (1) medical negligence; (2) 
failure to obtain informed consent; and (3) neglect of a 
patient, contrary to Wis. Stat. § 940.295(1)(j)1. (1997-98),4 in 
addition to (4) violation of EMTALA.  The Dane County Circuit 
Court, Stuart A. Schwartz, Judge, granted Meriter summary 
judgment on all four of Preston's claims.  The circuit court 
dismissed Preston's medical malpractice claim for failure to 
identify an expert witness.  It dismissed her claim for patient 
neglect because Wis. Stat. § 940.295(1)(j)1. is part of the 
criminal code and does not create a private cause of action.  It 
dismissed her informed consent claim because such claims cannot 
be brought against a hospital.  It also dismissed her EMTALA 
claim. 
¶10 Following Meriter's motion for summary judgment, the 
court received additional evidence.  The court was told that 
Meriter physicians had determined, based on the prebirth 
ultrasound, that Bridon's lungs were so underdeveloped that he 
would likely die shortly after being born.  The court was told 
health care personnel made observations of Bridon shortly after 
                                                 
4 All references to the Wisconsin Statutes are to the 1997-
98 edition, unless otherwise stated. 
No. 2003AP1376  
 
7 
 
his birth and assigned Bridon an Apgar score of one.5  Based on 
this information and because Preston did not particularize her 
EMTALA claim, the court interpreted the claim as one of failing 
to stabilize the medical condition of an individual who comes to 
the hospital, in violation of 42 U.S.C. § 1395dd(b).  The court 
stated: "Preston's complaint focuses on the hospital's failure 
to treat/resuscitate Bridon immediately after his birth.  This 
allegation appears to implicate the EMTALA's stabilization 
requirement and not the screening requirement."  The court 
reached this conclusion at least in part because Preston stated 
in a brief to the court that: 
There are many obligations under the EMTALA 
statute including an obligation to stabilize severely 
ill people before transferring them or discharging 
them, 
as 
well 
as 
mandated 
uniform 
methods 
for 
screening patients in emergency rooms et. al.  None of 
those requirements is a consideration in the Preston 
case, since we are only claiming that Meriter Hospital 
failed to stabilize an acutely ill newborn, Bridon 
Johnson. 
(Emphasis added.)  This statement to the court supplies the 
basis for Meriter's argument that Preston waived any claim that 
Meriter failed to provide an appropriate medical screening 
examination.  
                                                 
5 The Apgar score is an "evaluation of a newborn infant's 
physical status by assigning numerical values (0 to 2) to each 
of five criteria: heart rate, respiratory effort, muscle tone, 
response to stimulation, and skin color.  A score of 10 
indicates the best possible condition."  Stedman's Medical 
Dictionary 1264 (4th Unabridged Lawyers' ed. 1976). 
No. 2003AP1376  
 
8 
 
¶11 Although the circuit court granted summary judgment to 
Meriter on the hospital's motion, it focused on EMTALA's 
stabilization requirement and did not rule directly on a claim 
that Meriter violated EMTALA's screening requirement.  The court 
of appeals reviewed Preston's screening claim pursuant to the 
motion-to-dismiss methodology.  Preston, 271 Wis. 2d 721, ¶30 
("We consider the facts pled true and construe inferences from 
the pleadings in favor of the party against whom the motion is 
brought.").   
¶12 As noted previously, because our review is de novo, 
whether we apply the methodology appropriate for review where 
summary judgment has been granted or the methodology for review 
where a motion to dismiss has been granted, we will review the 
circuit court’s grant of summary judgment on Preston's screening 
claim as if it were decided on a motion to dismiss.  See Johnson 
v. Rogers Mem'l Hosp., Inc., 2001 WI 68, ¶10 n.3, 244 Wis.2d 
364, 627 N.W.2d 890 (noting that although the defendant moved 
for summary judgment, because the circuit court decided the case 
as a motion to dismiss, we review the motion in a similar 
manner). 
II. STANDARD OF REVIEW 
¶13 This case requires us to review the dismissal of part 
of a complaint for failure to state a claim upon which relief 
can be granted.  Whether a complaint states a claim is a 
question of law that we review de novo.  Beloit Liquidating 
Trust v. Grade, 2004 WI 39, ¶17, 270 Wis. 2d 356, 369, 677 
N.W.2d 298.  For purposes of determining whether a complaint is 
No. 2003AP1376  
 
9 
 
legally sufficient, we: (1) accept all facts pleaded as true; 
(2) derive all reasonable inferences from those facts; and (3) 
construe those facts and inferences in the light most favorable 
to the plaintiff.  Thus, a court properly grants a motion to 
dismiss only if it is clear that "a plaintiff cannot recover 
under any circumstances."  Id.; see Johnson, 244 Wis. 2d 364, 
¶15. 
¶14 To decide whether Preston's complaint states an EMTALA 
claim for which relief can be granted, we must interpret a 
federal statute.  Statutory interpretation is a question of law 
that we review de novo.  Seider v. O'Connell, 2000 WI 76, ¶26, 
236 Wis. 2d 211, 612 N.W.2d 659. 
III. ANALYSIS 
¶15 Before considering the substance of Preston’s EMTALA 
claim, we digress briefly into the realm of waiver. 
A. 
Waiver 
¶16 Waiver 
is 
the 
"voluntary 
and 
intentional 
relinquishment of a known right."  Milas v. Labor Ass’n of Wis., 
Inc., 214 Wis. 2d 1, 9, 571 N.W.2d 656 (1997).  The general rule 
is that a party waives a claim that is "neither pleaded nor 
argued to the trial court," and such a claim will not be 
considered on appeal.  Stern v. Credit Bureau of Milwaukee, 105 
Wis. 2d 647, 654-55, 315 N.W.2d 511, 515-16 (Ct. App. 1981).  
There are exceptions to this rule.  Thus, when an issue involves 
a question of law, has been briefed by the opposing parties, and 
is of sufficient public interest to merit a decision, this court 
has discretion to address the issue.  Apex Elecs. Corp. v. Gee, 
No. 2003AP1376  
 
10 
 
217 Wis. 2d 378, 384, 577 N.W.2d 23 (1998).  Waiver is merely a 
rule of "administration and does not involve the court’s power 
to address the issues raised."  Wirth v. Ehly, 93 Wis. 2d 433, 
444, 287 N.W.2d 140 (1980). 
¶17 Although Preston's statements to the court arguably 
support the conclusion that Preston waived her EMTALA claim for 
failure to screen, we will exercise our discretion to consider 
the merits of this dispute.  This case fits squarely within the 
exception to waiver: (1) the interpretation of the statutory 
phrase "comes to the emergency department" is a question of law; 
(2) both parties have fully briefed this issue before the court 
of appeals and this court; and (3) the determination of a 
hospital's duty to screen newborn infants is of sufficient 
public interest to warrant review.  In addition, the court of 
appeals has addressed the issue in a published opinion.  
Preston, 271 Wis. 2d 721. 
B. 
Interpretation of EMTALA 
¶18 The parties dispute the meaning of the phrase "comes 
to the emergency department" in 42 U.S.C. § 1395dd(a).  In its 
entirety, this subsection states: 
(a) Medical screening requirement 
In the case of a hospital that has a hospital 
emergency department, if any individual (whether or 
not eligible for benefits under this subchapter) comes 
to the emergency department and a request is made on 
the individual's behalf for examination or treatment 
for a medical condition, the hospital must provide for 
an appropriate medical screening examination within 
the capability of the hospital's emergency department, 
including ancillary services routinely available to 
No. 2003AP1376  
 
11 
 
the emergency department, to determine whether or not 
an emergency medical condition (within the meaning of 
subsection (e)(1) of this section) exists. 
42 U.S.C. § 1395dd(a) (emphasis added).   
¶19 Preston argues that the phrase "comes to the emergency 
department" implies a duty to screen any time an individual 
arrives at a place in a hospital with the capacity to respond to 
a request for emergency medical care.  Meriter takes the 
position that the phrase "comes to the emergency department" 
means that it has a duty to screen only when an individual 
arrives at an identified location.  It points to the distinction 
between the phrase "comes to the emergency department" in 
§ 1395dd(a) 
and 
the 
phrase 
"comes 
to 
the 
hospital" 
in 
§ 1395dd(b), and asks how the two phrases can mean the same 
thing.  Preston's interpretation of "emergency department" is 
functional.  Meriter's definition of "emergency department" is 
spatial. 
¶20 A statute is not ambiguous simply because the parties 
disagree as to its meaning.  State ex rel. Kalal v. Circuit 
Court for Dane County, 2004 WI 58, ¶47, 271 Wis. 2d 633, 681 
N.W.2d 110; Seider, 236 Wis. 2d at 227.  Rather, a statute is 
ambiguous if reasonable people can understand it in more than 
one way.  Kalal, 271 Wis. 2d 633, ¶47.  Analysis of statutory 
ambiguity begins with the statutory language itself.  Id., ¶45; 
Keup v. DHFS, 2004 WI 16, ¶17, 269 Wis. 2d 59, 75, 675 N.W.2d 
755.  When the statutory language is clear and unambiguous, we 
do not look beyond the plain words, although legislative history 
may 
be 
consulted 
to 
confirm 
or 
verify 
a 
plain-meaning 
No. 2003AP1376  
 
12 
 
interpretation.  Kalal, 271 Wis. 2d 633, ¶¶45, 51.  If statutory 
language is ambiguous after considering the statute's plain 
words as well as its intrinsic scope, context, and purpose, then 
we may use relevant extrinsic sources, including administrative 
regulations 
and 
legislative 
history 
to 
ascertain 
the 
legislatively intended meaning.  Keup, 269 Wis. 2d 59, ¶¶13-17; 
see Kalal, 271 Wis. 2d 633, ¶¶50-51. 
¶21 The text of § 1395dd(a) does not lead us inexorably to 
either a spatial or functional interpretation of "emergency 
department."  Both interpretations are reasonable.  On one hand, 
emergency department may be synonymous with emergency room, 
suggesting a spatial definition.  If we were to apply Meriter's 
proposed 
definition 
of 
emergency 
department, 
the 
Meriter 
birthing center would not be encompassed by the term, and 
Meriter would have no EMTALA duty to Bridon under § 1395dd(a).  
On the other hand, a department may also denote a division that 
specializes in a particular product, service, or field of 
knowledge.  See American Heritage Dictionary of the English 
Language 501 (3d ed. 1992).  This latter interpretation 
implicates any area of the hospital——not just the emergency 
room——that routinely supplies care for an emergency medical 
condition.6  If we were to apply Preston's definition of 
                                                 
6 The EMTALA defines an emergency medical condition as: 
(A) a medical condition manifesting itself by acute 
symptoms of sufficient severity (including severe 
pain) such that the absence of immediate medical 
attention could reasonably be expected to result in—— 
No. 2003AP1376  
 
13 
 
emergency department, a birthing center would be encompassed by 
the term, since it specializes in treating the emergency medical 
conditions common to premature infants. 
¶22 We do not agree with Meriter that comparing the 
differing phrases in 1395dd(a) and (b) makes the phrase "comes 
to the emergency department" in subsection (a) clear and 
unambiguous.  Even Meriter's counsel was unable to delineate the 
boundaries of Meriter's "emergency department," especially when 
pressed on "ancillary services."  Acknowledging a distinction 
between "the emergency department" and "the hospital" does not 
lead to the conclusion that "emergency department" means "the 
emergency room." 
¶23 Because conflicting interpretations of "comes to the 
emergency department" are reasonable, we must look to extrinsic 
sources for guidance in determining the legislative intent of 
                                                                                                                                                             
(i) placing the health of the individual (or, 
with respect to a pregnant woman, the health of the 
woman or her unborn child) in serious jeopardy, 
(ii) serious impairment to bodily functions, or 
(iii) 
serious dysfunction of any bodily organ 
or part; or 
(B) with respect to a pregnant wom[a]n who is having 
contractions— 
(i) that there is inadequate time to effect a 
safe transfer to another hospital before delivery, or 
(ii) that transfer may pose a threat to the 
health or safety of the woman or the unborn child. 
42 U.S.C. § 1395dd(e)(1). 
No. 2003AP1376  
 
14 
 
the statute.  See Kalal, 271 Wis. 2d 633, ¶50 ("Wisconsin courts 
ordinarily do not consult extrinsic sources of statutory 
interpretation 
unless 
the 
language 
of 
the 
statute 
is 
ambiguous."). 
1. 
Legislative History 
¶24 Congress enacted EMTALA in 1986 in response to reports 
that hospitals were refusing to treat patients who did not have 
medical insurance.  100 Stat. 82 (1986); H.R. Rep. No. 241, 99th 
Cong., 1st Sess., pt. 1, at 27 (1985).  Courts and commentators 
commonly refer to EMTALA as the Anti-Patient Dumping Act.  See 
e.g., Baber v. Hosp. Corp. of Am., 977 F.2d 872, 873 n.1 (4th 
Cir. 1992).  Patient dumping refers to a hospital's refusal to 
treat indigent and uninsured patients, thereby necessitating 
either formal or informal transfers of individuals from private 
to public hospitals.  Burks v. St. Joseph's Hosp., 227 Wis. 2d 
811, 817, 596 N.W.2d 391 (1999).  An underlying purpose of 
EMTALA, therefore, is to "provide an 'adequate first response to 
a medical crisis' for all patients."  Baber, 977 F.2d at 880 
(quoting 131 Cong. Rec. S13904 (Oct. 23, 1985) (statement of 
Sen. Durenberger)). 
¶25 The emphasis in the legislative history on ensuring 
emergency medical treatment for all individuals favors Preston's 
interpretation of "comes to the emergency department."  A United 
States District Court in Virginia, though addressing EMTALA's 
stabilization requirement, captured the essence of Preston's 
position when it said: 
No. 2003AP1376  
 
15 
 
[T]he rationale behind the COBRA patient anti-dumping 
statute is not based upon the door of the hospital 
through which a patient enters, but rather upon the 
notion of proper medical care for those persons 
suffering 
medical 
emergencies, 
whenever 
such 
emergencies 
occur 
at 
a 
participating 
hospital.  
Indeed, it is a ridiculous distinction, one which 
places form over substance, to state that the care a 
patient receives depends on the door through which the 
patient walks. 
McIntyre v. Schick, 795 F. Supp. 777, 781 (E.D. Va. 1992). 
2. 
Implementing Regulations 
¶26 Regulations interpreting EMTALA further support our 
conclusion 
that 
the 
proper 
interpretation 
of 
§ 1395dd(a) 
requires a hospital to provide an emergency medical screening 
examination 
to 
an 
individual 
requesting 
emergency 
care, 
regardless of where he or she presents in the hospital. 
¶27 Congress expressly charged the Department of Health 
and Human Services (DHHS) with enforcing EMTALA.  See 42 U.S.C. 
§ 1395dd(d).7  DHHS promulgated regulations in 1994 that were in 
effect in 1999 at the time of Bridon's birth.  These regulations 
define the phrase "comes to the emergency department" to mean: 
"with respect to an individual requesting examination or 
treatment, that the individual is on the hospital property 
(property 
includes 
ambulances 
owned 
and 
operated 
by 
the 
                                                 
7 The Secretary of DHHS may impose civil money penalties of 
up to $50,000 upon a hospital for each EMTALA violation.  42 
U.S.C. § 1395dd(d)(1)(A) (directing enforcement pursuant to 42 
U.S.C. 
§ 1320a-7a; 
see 
42 
U.S.C. 
§ 1320a-7a(c)(1) 
("The 
Secretary may initiate a proceeding to determine whether to 
impose a civil money penalty, assessment, or exclusion under 
subsection (a) or (b) of this section only as authorized by the 
Attorney General pursuant to procedures agreed upon by them."). 
 
No. 2003AP1376  
 
16 
 
hospital, even if the ambulance is not on hospital grounds)."  
42 C.F.R. § 489.24(b) (1999) (emphasis added).8 
¶28 We review 
DHHS's 
construction of 
§ 1395dd(a) in 
accordance with Chevron U.S.A., Inc. v.  Natural Resources 
Defense Council, Inc., 467 U.S. 837 (1984).  See St. Anthony 
Hosp. v. United States Dep't of Health & Human Servs., 309 F.3d 
680, 691-92 (10th Cir. 2002) (applying Chevron deference to DHHS 
enforcement of EMTALA); Arrington v. Wong, 237 F.3d 1066, 1070-
72 
(9th 
Cir. 
2001) 
(applying 
Chevron 
deference 
to 
DHHS 
interpretation of EMTALA).   
¶29 Under 
Chevron, 
the 
determination 
of 
the 
proper 
deference to afford an agency interpretation is a two-step 
process.  467 U.S. at 842-43.  First, a court must determine 
whether the statute is ambiguous.  Id. at 842.  If the statute 
is unambiguous and "Congress has directly spoken to the precise 
question at issue," both the court and the agency must give 
effect to the clearly expressed intent of Congress.  Id. at 842-
43.  Only if a statute is ambiguous or silent on the precise 
question does a court reach the second step.  Id.  In the second 
step, the inquiry shifts to whether the agency interpretation is 
"a permissible construction of the statute."  Id. at 843. 
¶30 Courts employ one of two tests to determine whether an 
agency interpretation is permissible.  If Congress expressly 
                                                 
8 DHHS has the authority to make and publish regulations to 
interpret and enforce the EMTALA pursuant to 42 U.S.C. § 1302. 
All references to the Code of Federal Regulations are to 
the 1999 edition, unless otherwise stated. 
No. 2003AP1376  
 
17 
 
delegated rule-making authority to an agency, the agency's 
interpretation 
is 
permissible 
unless 
it 
is 
"procedurally 
defective, arbitrary or capricious in substance, or manifestly 
contrary to the statute."  United States v. Mead Corp., 533 U.S. 
218, 227 (2001); see also Chevron, 467 U.S. at 843-44.  
Alternatively, if Congress impliedly delegated authority to an 
agency, the agency's interpretation is permissible unless it is 
unreasonable.  Id. at 844; Mead Corp., 533 U.S. at 229.   
¶31 Since 
Congress 
expressly 
delegated 
to 
DHHS 
the 
authority to make and publish rules concerning EMTALA, and 
because EMTALA provides no definition for the phrase "comes to 
the emergency department," we must give DHHS's definition of 
"comes to the emergency department" controlling weight unless it 
is arbitrary or capricious.  See Chevron, 467 U.S. at 844. 
¶32 Under the "arbitrary and capricious" standard, the 
scope of review "is narrow and a court is not to substitute its 
judgment for that of the agency."  Motor Vehicle Mfrs. Ass'n of 
U.S., Inc. v. State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43 
(1983).  A regulation may be arbitrary or capricious if: 
[T]he agency [1] has relied on factors which Congress 
has not intended it to consider, [2] entirely failed 
to consider an important aspect of the problem, [3] 
offered an explanation for its decision that runs 
counter to the evidence before the agency, or [4] is 
so implausible that it could not be ascribed to a 
difference in view or the product of agency expertise. 
Id.; Prometheus Radio Project v. Fed. Communications Comm'n, 373 
F.3d 372, 390 (3d Cir. 2004); Arent v. Shalala, 70 F.3d 610, 616 
(D.C. Cir. 1995).  However, if the agency can satisfactorily 
No. 2003AP1376  
 
18 
 
explain its regulatory decision and if there is "a rational 
connection between the facts found and the choice made," a court 
should defer to the agency.  See Motor Vehicle Mfrs., 463 U.S. 
at 43. 
¶33 We conclude that the regulation defining "comes to the 
emergency department" is not arbitrary and capricious for 
several reasons.   
¶34 First, DHHS drafted proposed regulations and solicited 
public comments, allowing it to take into consideration any 
objections from interested parties.9  In the course of this 
notice-and-comment history, DHHS satisfactorily explained why it 
defined "emergency department to be coextensive with hospital 
property."  Two explanations stand out: (1) DHHS deemed a 
functional definition of "emergency department" necessary to 
impose EMTALA duties upon hospitals that may not have a formally 
labeled emergency department or emergency room, see 59 Fed. Reg. 
                                                 
9 DHHS solicited comments after publishing its proposed 
definition of "comes to the emergency department" in 1994, and 
has periodically reviewed this definition.  See 59 Fed. Reg. 
32,098, 32,101 (June 22, 1994) (setting forth the comments 
received in response to the first regulations interpreting 
EMTALA and DHHS's responses to those comments); 65 Fed. Reg. 
18,522-23 (April 7, 2000) (reconsidering and rejecting a comment 
that the screening requirement of § 1395dd(a) be restricted to 
individuals who present to an emergency room); 67 Fed. Reg. 
31,472-76 (May 9, 2002) (explaining a proposed rule to clarify 
the definition of "comes to the emergency department"); 68 Fed. 
Reg. 53,227-44 (Sept. 9, 2003) (setting forth the comments 
received in response to the proposed clarifications to the 
definition of "comes to the emergency department" and DHHS's 
responses to those comments). 
No. 2003AP1376  
 
19 
 
32,101;10 and (2) DHHS concluded that a narrowly drawn definition 
would thwart the primary objective of EMTALA: to ensure that 
those in need of emergency care receive it.  See id. at 32,098. 
¶35 Second, although DHHS has refined its definition of 
"comes to the emergency department," the agency has consistently 
defined the phrase to include all hospital property.  Compare 42 
C.F.R. § 489.24(b) (1999) with 42 C.F.R. § 489.24(b) (2004).11  
                                                 
10 During oral argument, Meriter's attorney had difficulty 
pinning down exactly what constituted the Meriter emergency 
department.  This imprecision underscores the wisdom of this 
regulation. 
11 The relevant portion of the 1999 regulations defines 
"comes to the emergency department" as: 
[W]ith respect to an individual requesting examination 
or treatment that the individual is on the hospital 
property 
(property 
includes 
ambulances 
owned 
and 
operated by the hospital, even if the ambulance is not 
on hospital grounds). . . . 
42 C.F.R. § 489.24(b) (1999) (emphasis added). 
The relevant portion of the 2004 regulations defines "comes 
to the emergency department" as: 
[W]ith respect to an individual who is not a patient 
(as defined in this section), the individual—— 
(1) Has presented at a hospital's dedicated 
emergency department, as defined in this section, and 
requests 
examination 
or 
treatment 
for 
a 
medical 
condition, or has such a request made on his or her 
behalf.  In the absence of such a request by or on 
behalf of the individual, a request on behalf of the 
individual will be considered to exist if a prudent 
layperson 
observer 
would 
believe, 
based 
on 
the 
individual's 
appearance 
or 
behavior, 
that 
the 
individual 
needs examination or 
treatment 
for 
a 
medical condition; 
No. 2003AP1376  
 
20 
 
DHHS's 
adherence 
to 
the 
core 
concept 
that 
an 
emergency 
department extends to all hospital property, despite periodic 
reconsideration of the definition, demonstrates a carefully 
considered policy choice. 
¶36 Third, DHHS's interpretation advances the purpose of 
EMTALA. 
 
By 
broadly 
defining 
"comes 
to 
the 
emergency 
department," the regulation better ensures that all individuals 
in need of emergency care actually receive it.  See 59 Fed. Reg. 
32,098 (June 22, 1994) (noting that if the screening duty 
imposed by § 1395dd(a) depended upon where an individual entered 
a 
hospital, 
such 
an 
interpretation 
would 
"frustrate 
the 
objectives of the statute in many cases and lead to arbitrary 
results").  We conclude that there is a rational connection 
between defining "comes to the emergency department" to include 
the entire hospital property and the primary EMTALA objective of 
ensuring access to emergency medical treatment.  See e.g., 
Individual Reference Svcs. Group, Inc. v. Fed. Trade Comm'n, 145 
F. Supp. 2d 6, 31 (D.D.C. 2001) (noting that the regulation at 
                                                                                                                                                             
 
(2) Has 
presented 
on 
hospital 
property, 
as 
defined in this section, other than the dedicated 
emergency department, and requests examination or 
treatment for what may be an emergency medical 
condition, or has such a request made on his or her 
behalf.  In the absence of such a request by or on 
behalf of the individual, a request on behalf of the 
individual will be considered to exist if a prudent 
layperson 
observer 
would 
believe, 
based 
on 
the 
individual's 
appearance 
or 
behavior, 
that 
the 
individual needs emergency examination or treatment. 
42 C.F.R. § 489.24(b) (2004) (emphasis added). 
No. 2003AP1376  
 
21 
 
issue was not arbitrary and capricious since it was consistent 
with and promoted the policy of the underlying statute). 
¶37 Finally, 
the DHHS 
regulation is 
not 
"manifestly 
contrary to the statute."  When a statute is ambiguous, "an 
agency's interpretation cannot, by definition, be found to 
directly contravene it."  Hagen v. LIRC, 210 Wis.2d 12, 21, 563 
N.W.2d 454 (1997) (quoting Harnischfeger Corp. v. LIRC, 196 Wis. 
2d 650, 662, 539 N.W.2d 98 (1995)). 
¶38 For these reasons, we conclude that the proper 
interpretation of "comes to the emergency department" in this 
case imposes a duty upon a hospital to provide a medical 
screening examination to a newborn who (1) presents to the 
emergency room of the hospital or (2) is born in the birthing 
center of the hospital and otherwise meets the conditions set 
forth in 42 C.F.R. § 489.24(b) (1999). 
C. 
Whether Preston's 
§ 1395dd(a) 
Claim Should 
Have 
Been 
Dismissed 
¶39 Taking the facts pleaded as true, we conclude that 
Preston's complaint states a claim upon which relief can be 
granted, namely, a violation of the screening requirement in 42 
U.S.C. § 1395dd(a).  The complaint alleged that Bridon was born 
[in the birthing center] at Meriter Hospital and that hospital 
employees and agents allegedly failed and "refused . . . to 
provide any care whatsoever to the newborn infant."  These 
employees must have been asked to provide care if they allegedly 
"refused" to provide care.  The alleged failure to provide care 
implicitly included the failure to provide an appropriate 
No. 2003AP1376  
 
22 
 
medical screening examination.  All this occurred in a major 
hospital in a place with the capacity to respond to a request 
for emergency care, a place well within the then-existing 
definition of "emergency department" in 42 C.F.R. § 489.24(b) 
(1999).  The complaint alleges that Meriter not only failed to 
provide an appropriate medical screening examination but also 
did so because Shannon Preston and Bridon Johnson lacked private 
health insurance.12 
¶40 The circuit court's dismissal of Preston's failure to 
screen claim requires us to reverse.  The circuit court's action 
is understandable but unsustainable in the wake of the court of 
appeals' discussion of the issue.   
¶41 We wish to emphasize that we do not decide whether 
Meriter's response to Bridon's presence in the birthing facility 
satisfied its duty to provide an appropriate medical screening 
examination.  The circuit court will have to resolve the scope 
of the EMTALA duty to screen and whether Meriter discriminated 
against 
Bridon 
in 
the 
way 
it 
conducted 
any 
screening 
examination. 
 
                                                 
12 Meriter raises the argument that EMTALA does not apply to 
Bridon because he was admitted to Meriter as an inpatient.  
Since we are reviewing this matter as if a motion to dismiss had 
been granted, we have considered only whether the facts and 
inferences in the complaint state a claim under EMTALA's 
screening requirement.  Therefore, we disregard subsequent 
factual revelations and the legal conclusions that follow from 
those facts for purposes of this decision.  Accordingly, based 
solely on the complaint, we hold that Preston has pleaded an 
EMTALA screening claim. 
No. 2003AP1376  
 
23 
 
IV. CONCLUSION 
¶42 We conclude that the court of appeals misinterpreted 
the phrase "comes to the emergency department" in 42 U.S.C. 
§ 1395dd(a).  Because of this misinterpretation, the court of 
appeals erroneously concluded that Meriter owed Bridon no EMTALA 
screening duty because he presented to the birthing center 
rather than the emergency room of the hospital.  The duty to 
provide a medical screening examination should not depend upon 
the hospital room——be it the emergency room, the birthing 
center, or an operating room——into which a baby is born.  The 
court of appeals decision affirming the decision of the circuit 
court is reversed, and this case is remanded to the circuit 
court for action consistent with this opinion. 
 
By the Court.—The decision of the court of appeals is 
reversed and the cause is remanded to the circuit court. 
 
 
 
 
 
No.  2003AP1376.npc 
 
1 
 
¶43 N. PATRICK CROOKS, J.   (concurring).  While I join 
the majority opinion, I write to address that portion of the 
dissent that addresses the issue of whether or not Bridon was an 
inpatient for purposes of EMTALA.   
¶44 The majority did not address that issue.  See majority 
op., ¶39 n.12.  While the dissent suggests a roadmap for such a 
determination, it is merely the opinion of one justice.  The 
issue of whether a newborn infant is considered an inpatient 
upon his or her mother's admission to a hospital has yet to be 
determined by this, or to our knowledge any other, court.  The 
question is complicated further by the circumstances of this 
case, in which the hospital never intended to, nor did it, 
provide any treatment to Bridon.  As the court of appeals' 
decision is reversed, and this case is remanded to the circuit 
court for further proceedings, the parties should fully brief 
this issue for the circuit court's consideration. 
¶45 For the above stated reason, I respectfully concur. 
¶46 I am authorized to state that Chief Justice SHIRLEY S. 
ABRAHAMSON and Justices ANN WALSH BRADLEY and LOUIS B. BUTLER, 
JR. join this concurrence. 
No.  2003AP1376.pdr 
 
1 
 
¶47 PATIENCE 
DRAKE 
ROGGENSACK, 
J. 
(dissenting).   The 
majority errs in its review of the Emergency Medical Treatment 
and Active Labor Act (EMTALA) screening claim by concluding that 
Preston's complaint13 states a claim upon which relief can be 
granted, as did the court of appeals, because its analysis of 
EMTALA overlooks Bridon's status as an inpatient.14  I conclude 
that the screening provision of EMTALA, 42 U.S.C. § 1395dd(a) 
(1994),15 does not apply to hospital inpatients.  Because Bridon 
became an inpatient when his mother was admitted before his 
birth, the screening provision of EMTALA does not apply to him.  
Therefore, because I would affirm the court of appeals decision 
dismissing Preston's claim, albeit on different grounds, I 
respectfully dissent. 
                                                 
13 I refer to Shannon Preston, Charles Johnson and the 
estate of Bridon Michael Johnson collectively as "Preston," 
unless otherwise noted. 
14 The dismissal of "all claims" at the circuit court was 
upon a motion for summary judgment.  As a determination of 
whether the complaint states a claim, the first step in a 
summary judgment analysis, Brownelli v. McCaughtry, 182 Wis. 2d 
367, 372, 514 N.W.2d 48 (Ct. App. 1994), I begin by examining 
the complaint.  This is where the court of appeals stopped in 
its analysis, as does the majority opinion.  See majority op., 
¶¶5, 12, 39 n.12.  However, we are not confined to the four 
corners of the complaint, as we review the summary judgment the 
circuit court granted. 
15 All subsequent citations to the United States Code are to 
the 1994 version unless otherwise noted. 
No.  2003AP1376.pdr 
 
2 
 
I.  DISCUSSION 
A. 
Standard of Review 
¶48 We review a circuit court's decision granting summary 
judgment independently, but we apply the same methodology as the 
circuit court.  Mrozek v. Intra Fin. Corp., 2005 WI 73, ¶14, ___ 
Wis. 2d ___, ___ N.W.2d ___ (citing Smaxwell v. Bayard, 2004 WI 
101, ¶12, 274 Wis. 2d 278, 682 N.W.2d 923).  Pursuant to 
Wis. Stat. § 802.08(2), summary judgment "shall be rendered if 
the pleadings, depositions, answers to interrogatories, and 
admissions on file, together with the affidavits, if any, show 
that there is no genuine issue as to any material fact and that 
the moving party is entitled to a judgment as a matter of law."   
¶49 As our first step in a summary judgment analysis, we 
determine whether Preston's complaint states an EMTALA claim for 
which relief can be granted.  See Brownelli v. McCaughtry, 182 
Wis. 2d 367, 372, 514 N.W.2d 48 (Ct. App. 1994).  We then 
examine the answer to determine whether an issue of material 
fact or law is disputed.  Id.  If issue has been joined, we then 
look to the moving party's affidavits to determine whether that 
party has made a prima facie case for summary judgment.  Id.  If 
it has, we look to the opposing party's affidavits to determine 
whether there are any material facts in dispute that entitle the 
opposing party to a trial.  Id. at 372-73.   
¶50 As part of this summary judgment analysis, we must 
interpret the EMTALA statute, 42 U.S.C. 1395dd.  Statutory 
interpretation is a question of law that we review de novo.  
Columbus Park Hous. Corp. v. City of Kenosha, 2003 WI 143, ¶9, 
No.  2003AP1376.pdr 
 
3 
 
267 Wis. 2d 59, 671 N.W.2d 633.  When we interpret or apply a 
statute, we attempt to ascertain its meaning in order to give 
the statute its full intended effect.  State ex rel. Kalal v. 
Circuit Court for Dane County, 2004 WI 58, ¶44, 271 Wis. 2d 633, 
681 N.W.2d 110.  We begin with the words chosen by the 
legislature, giving them their plain and ordinary meanings.  
Id., ¶45.  This is our initial focus, because as we have 
explained, "[w]e assume that the legislature's intent is 
expressed in the statutory language."  Id., ¶44.  We are aided 
in ascertaining the meaning of a statute by the context in which 
words are placed.  Id., ¶46.  If the statute's meaning is clear 
on its face, we need go no further; we simply apply it.  Id., 
¶45.  However, if the statutory language is capable of being 
understood by reasonably well-informed persons in two or more 
ways, then it is ambiguous.  Bruno v. Milwaukee County, 2003 WI 
28, ¶19, 260 Wis. 2d 633, 660 N.W.2d 656.  A statute may also be 
ambiguous due to its interactions with other statutes.  State v. 
White, 97 Wis. 2d 193, 198, 295 N.W.2d 346 (1980).  If the 
statutory language is ambiguous, we may consult extrinsic 
sources to ascertain legislative intent.  Stockbridge Sch. Dist. 
v. Department of Pub. Instruction Sch. Dist. Boundary Appeal 
Bd., 202 Wis. 2d 214, 223, 550 N.W.2d 96 (1996). 
B. 
Preston's Claim 
¶51 The claim at issue here is Preston's claim against 
Meriter under the screening requirement of EMTALA, 42 U.S.C. 
1395dd(a).  That provision states: 
Medical screening requirement. In the case of a 
hospital that has a hospital emergency department, if 
No.  2003AP1376.pdr 
 
4 
 
any individual (whether or not eligible for benefits 
under this subchapter [42 USCS §§ 1395 et seq.]) comes 
to the emergency department and a request is made on 
the individual's behalf for examination or treatment 
for a medical condition, the hospital must provide for 
an appropriate medical screening examination within 
the capability of the hospital's emergency department, 
including ancillary services routinely available to 
the emergency department, to determine whether or not 
an emergency medical condition (within the meaning of 
subsection (e)(1)) exists. 
¶52 The majority's discussion of the screening requirement 
is focused on the meaning of the language "comes to the 
emergency department" found in 42 U.S.C. 1395dd(a).  The 
majority concludes that: 
the proper interpretation of "comes to the emergency 
department" in this case imposes a duty upon a 
hospital to provide a medical screening examination to 
a newborn who (1) presents to the emergency room of 
the hospital or (2) is born in the birthing center of 
the hospital and meets the conditions set forth in 42 
C.F.R. § 489.24(b) (1999). 
Majority op., ¶38.  The majority further explains that in 42 
C.F.R. § 489.24(b), the Department of Health and Human Services 
(DHHS) has consistently defined the phrase "comes to the 
emergency 
department" 
to 
include 
all 
hospital 
property.  
Majority op., ¶35.  While I agree with the majority's conclusion 
about the meaning of "emergency department," the majority 
overlooks the dispositive issue in the present case, which is 
whether EMTALA applies to inpatients.  Because, as I explain 
below, Bridon was an inpatient rather than someone who "comes 
to" the hospital, I conclude Preston's claim regarding Bridon 
falls outside the scope of EMTALA and instead sounds in 
Wisconsin's medical malpractice law. 
No.  2003AP1376.pdr 
 
5 
 
¶53 There have been no prior decisions directly addressing 
whether EMTALA's screening requirement applies to inpatients.  
However, it is only EMTALA's screening requirement that is 
before us on this review.  The dearth of cases is not surprising 
considering that most EMTALA claims do not implicate the unique 
attributes present in pregnancies, where essentially a "patient 
with a patient" arrives at the hospital, the expectant mother 
carrying the unborn child.  However, court decisions and federal 
regulation16 
regarding 
EMTALA's 
stabilization 
and 
transfer 
requirements, 42 U.S.C. 1395dd(b)-(c),17 shed light on the 
relation of EMTALA to inpatients. 
                                                 
16 See 42 C.F.R. § 489.24 (2005), discussed below.  All 
subsequent references to the Federal Register are to the 2005 
version unless otherwise noted. 
17 In addition to the screening requirement at issue in the 
present case, EMTALA requires hospitals to stabilize the medical 
condition of patients arriving with an emergency medical 
condition or in active labor, 42 U.S.C. 1395dd(b), and restricts 
the transfer of unstabilized patients, 42 U.S.C. 1395dd(c).  
These provisions state: 
(b) Necessary stabilizing treatment for emergency 
medical conditions and labor. 
(1) In general. If any individual (whether or not 
eligible for benefits under this subchapter [42 USCS 
§§ 1395 et seq.]) comes to a hospital and the hospital 
determines 
that the 
individual has an 
emergency 
medical condition, the hospital must provide either—— 
(A) within the staff and facilities available at 
the hospital, for such further medical examination and 
such treatment as may be required to stabilize the 
medical condition, or 
(B) for transfer of the individual to another 
medical facility in accordance with subsection (c) of 
this section. 
No.  2003AP1376.pdr 
 
6 
 
¶54 Before the implementation of the DHHS regulation, 
jurisdictions were split as to whether the stabilization and 
transfer provisions of EMTALA applied to a patient once he or 
she was admitted to a hospital.  In Thornton v. Southwest 
Detroit Hospital, 895 F.2d 1131, 1132 (6th Cir. 1990), a patient 
suffered a stroke, arrived at the hospital's emergency room and 
spent 10 days in the hospital's intensive care unit and 11 more 
days in regular inpatient care before being discharged to her 
sister's home for basic nursing care.  The patient brought an 
action under the stabilization requirement of EMTALA, alleging 
that the hospital failed to stabilize her before discharging 
her. 
 Id.  
The 
hospital 
argued 
that the 
stabilization 
requirement did not apply once a patient was admitted to the 
hospital.  Id. at 1135.  The Sixth Circuit Court of Appeals 
disagreed, stating: 
Although emergency care often occurs, and almost 
invariably begins, in an emergency room, emergency 
care does not always stop when a patient is wheeled 
from the emergency room into the main hospital.  
Hospitals may not circumvent the requirements of the 
Act merely by admitting an emergency room patient to 
the 
hospital, 
then 
immediately 
discharging 
that 
patient.  Emergency care must be given until the 
patient's emergency medical condition is stabilized.  
Id.  
                                                                                                                                                             
. . . . 
(c) 
Restricting 
transfers 
until 
individual 
stabilized. 
(1) Rule. If an individual at a hospital has an 
emergency 
medical 
condition 
which 
has 
not 
been 
stabilized  . . . the hospital may not transfer the 
individual unless [certain conditions are met]. 
No.  2003AP1376.pdr 
 
7 
 
¶55 In Lopez-Soto v. Hawayek, 175 F.3d 170, 171 (1st Cir. 
1999), the patient arrived at the hospital with normal labor 
pains.  The patient was examined and admitted to the maternity 
ward, where the doctor ordered a cesarean section.  Id.  The 
patient gave birth to a baby boy who emerged with severe 
respiratory and pulmonary problems.  Id.  The infant was 
transferred to a hospital with a functioning neonatal intensive 
care unit without first being stabilized, and he later died.  
Id.  The patient brought an action under the stabilization and 
transfer provisions of EMTALA, arguing that the hospital did not 
stabilize the infant before transferring him, but the district 
court dismissed the claim on the ground that the newborn had 
come to the hospital via the operating room, and EMTALA applied 
only to entries via the emergency room.  Id. at 172.  The First 
Circuit 
Court 
of 
Appeals 
reversed, 
concluding 
that 
the 
stabilization and transfer requirements were not limited to 
entries via the emergency room: 
Congress obviously had a horizon broader than the 
emergency room in mind when it enacted EMTALA.  The 
statute explicitly embraces women in labor, see 42 
U.S.C. § 1395dd(e)(1)(B) (defining emergency medical 
condition)——yet most gravid women go to maternity 
wards, not emergency rooms, when they are ready to 
give birth. 
. . . Congress's preoccupation with patient dumping is 
served, not undermined, by forbidding the dumping of 
any hospital patient with a known, unstabilized, 
emergency condition.  After all, patient dumping is 
not a practice that is limited to emergency rooms.  If 
a hospital determines that a patient on a ward has 
developed an emergency medical condition, it may fear 
that 
the 
costs 
of 
treatment 
will 
outstrip 
the 
patient's resources, and seek to move the patient 
elsewhere.  That strain of patient dumping is equally 
No.  2003AP1376.pdr 
 
8 
 
as pernicious as what occurs in emergency departments, 
and we are unprepared to say that Congress did not 
seek to curb it. 
Id. at 176-77.   
¶56 However, other jurisdictions concluded that EMTALA's 
stabilization requirement did not apply to inpatients.  In 
Bryant v. Adventist Health System/West, 289 F.3d 1162, 1164 (9th 
Cir. 2002), a patient sought care at a hospital's emergency room 
after coughing up blood, and the doctor failed to detect a large 
lung abscess.  The patient was discharged after being diagnosed 
with pneumonia and asthma, and the doctor requested he return 
the next day for further treatment.  Id.  The patient returned 
the following day, the lung abscess was detected and he was 
admitted to the hospital.  Id.  Within three days, the patient's 
condition declined rapidly, and he was transferred to another 
hospital, where he had surgery.  Id.  He later returned home and 
appeared to be improving, but died suddenly within 10 days of 
being discharged.  Id.  The patient's heirs filed an action 
alleging EMTALA violations concerning both the initial emergency 
room visit and the subsequent inpatient care.  Id.  Regarding 
the inpatient care, the Ninth Circuit Court of Appeals held that 
"the stabilization requirement normally ends when a patient is 
admitted for inpatient care."  Id. at 1167.  The court stated: 
The stabilization requirement is . . . defined 
entirely in connection with a possible transfer and 
without any reference to the patient's long-term care 
within the system.  It seems manifest to us that the 
stabilization requirement was intended to regulate the 
hospital's care of the patient only in the immediate 
aftermath of the act of admitting her for emergency 
treatment and while it considered whether it would 
undertake 
longer-term 
full 
treatment 
or 
instead 
No.  2003AP1376.pdr 
 
9 
 
transfer the patient to a hospital that could and 
would undertake that treatment.  It cannot plausibly 
be 
interpreted 
to 
regulate 
medical 
and 
ethical 
decisions outside that narrow context. 
Id. (quoting Bryan v. Rectors & Visitors of the Univ. of Va., 95 
F.3d 349, 352 (4th Cir. 1996).  The court discussed the Thornton 
and Lopez-Soto cases, but noted that because "Congress enacted 
EMTALA 'to create a new cause of action, generally unavailable 
under state tort law, for what amounts to failure to treat' and 
not to 'duplicate preexisting legal protections'" and that state 
tort law provided for negligent medical care for inpatients, 
EMTALA should not apply.  Id. at 1168-69 (quoting Gatewood v. 
Washington Healthcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 
1991).  The court concluded, "If EMTALA liability extended to 
inpatient care, EMTALA would be 'converted . . . into a federal 
malpractice statute, something it was never intended to be.'"  
Id. at 1169 (quoting Hussain v. Kaiser Found. Health Plan, 914 
F. Supp. 1331, 1335 (E.D. Va. 1996). 
¶57 The Bryant court also addressed the concern in 
Thornton that hospitals might be able to avoid liability under 
EMTALA by admitting and then refusing to treat patients.  See 
Thornton, 895 F.2d at 1135.  The court stated: 
We agree with the [Thornton court] that a 
hospital cannot escape liability under EMTALA by 
ostensibly "admitting" a patient, with no intention of 
treating 
the 
patient, 
and 
then 
discharging 
or 
transferring the patient 
without 
having 
met the 
stabilization requirement.  In general, however, a 
hospital admits a patient to provide inpatient care.  
We will not assume that hospitals use the admission 
process 
as 
a 
subterfuge 
to 
circumvent 
the 
stabilization requirement of EMTALA.  If a patient 
demonstrates in a particular case that inpatient 
No.  2003AP1376.pdr 
 
10 
 
admission was a ruse to avoid EMTALA's requirements, 
then liability under EMTALA may attach. 
Bryant, 289 F.3d at 1169. 
¶58 Similarly, the court in Dollard v. Allen, 260 F. Supp. 
2d 1127, 1135 (D. Wyo. 2003), ruled that the stabilization and 
transfer provisions of EMTALA do not apply to individuals 
admitted for inpatient care.  In that case, the patient 
periodically visited her doctor for lower back pain and numbness 
in her buttocks.  Id. at 1129.  The problems continued and the 
patient was admitted to the hospital for pain management and 
rest.  Id.  After reporting that the back pain was not as 
severe, but the numbness had increased, the doctor discharged 
the patient.  Id. at 1130.  The next morning the patient began 
experiencing excruciating pain in her stomach and was unable to 
urinate.  Id.  She called the hospital and was readmitted under 
the care of a new doctor, who determined that the patient had a 
large ruptured disc in her back, as well as a rare neurological 
disorder affecting the lower end of the spinal cord.  Id.  The 
patient underwent lower-back surgery the day after she was 
admitted for the second time.  Id.  The patient filed suit 
alleging 
that 
the 
hospital 
violated 
the 
screening 
and 
stabilization before transfer requirements of EMTALA upon her 
first admission to the hospital.  Id. at 1134.  The court 
granted summary judgment to the hospital on the stabilization 
and transfer claim on two grounds, one being that the hospital 
"did 
not 
violate 
EMTALA's 
stabilization 
before 
transfer 
requirement because that provision does not apply to individuals 
that have been admitted to the hospital for in-patient care."  
No.  2003AP1376.pdr 
 
11 
 
Id. at 1135.  The court stated that allowing EMTALA claims in 
inpatient situations, where state tort law applied, would 
"render[] the Act's preemption subsection superfluous."  Id.  
The preemption provision, 42 U.S.C. 1395dd(f), states, "The 
provisions of this section do not preempt any State or local law 
requirement, except to the extent that the requirement directly 
conflicts with a requirement of this section."  The court 
reasoned 
that 
because 
EMTALA's 
purpose 
is 
to 
eliminate 
"'patient-dumping'" 
and 
not 
to 
"'federalize 
medical 
malpractice,'" EMTALA does not apply in inpatient situations, 
where state tort law applies.  Dollard, 260 F. Supp. 2d at 1135 
(quoting Ingram v. Muskogee Reg'l Med. Ctr., 235 F.3d 550, 552 
(10th Cir. 2000). 
¶59 In 2003, as a response to the questions raised by 
cases such as these, DHHS promulgated a rule "interpreting 
hospital obligations under EMTALA as ending once the individuals 
are admitted to the hospital inpatient care."  Medicare Program; 
Clarifying Policies Related to the Responsibilities of Medicare-
Participating Hospitals in Treating Individuals With Emergency 
Medical Conditions, 68 Fed. Reg. 53222, 53244-45 (September 9, 
2003) [hereinafter "Clarifying Medicare Policies"].  The rule 
set out in 42 C.F.R. § 489.24 now states: 
Exception: Application to inpatients. (i) If a 
hospital has screened an individual under paragraph 
(a) of this section and found the individual to have 
an emergency 
medical 
condition, 
and admits 
that 
individual as an inpatient in good faith in order to 
stabilize 
the 
emergency 
medical 
condition, 
the 
hospital has satisfied its special responsibilities 
under this section with respect to that individual. 
No.  2003AP1376.pdr 
 
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C. 
42 C.F.R. § 489.24   
¶60 Under Chevron U.S.A. Inc. v. Natural Resources Defense 
Council, Inc., 467 U.S. 837, 842-44 (1984), 42 C.F.R. § 489.24 
controls regarding the issue of whether EMTALA's stabilization 
requirement applies to inpatients.  Chevron explains how courts 
are to review an agency's interpretation of a statute.  Chevron, 
467 U.S. at 842-44.  First, we must determine whether the 
statute at issue is ambiguous regarding the question presented, 
here, whether EMTALA's requirements apply to inpatients.  Id. at 
842-43.  If we conclude the statute is ambiguous or silent on 
the issue, our inquiry shifts to determine whether the agency's 
interpretation is "based on a permissible construction of the 
statute."  Id.  We employ one of two tests to make this 
determination.  If Congress explicitly delegated rule-making 
authority to the agency, then the agency's interpretation is 
"given controlling weight unless [it is] arbitrary, capricious, 
or manifestly contrary to the statute."  Id. at 843-44; see also 
United States v. Mead Corp., 533 U.S. 218, 227 (2001).  If 
Congress implicitly delegated authority to the agency, the 
agency's interpretation controls so long as it is reasonable.  
Chevron, 467 U.S. at 844. 
¶61 Applying this analysis to the issue of whether EMTALA 
covers inpatients, I first note that EMTALA is silent as to this 
question.18  Therefore, the inquiry shifts to a determination of 
whether the agency's interpretation in 42 C.F.R. § 489.24 is 
                                                 
18 As I discuss above, the consequences of this silence can 
be 
seen 
in 
courts' 
inconsistent 
application 
of 
EMTALA's 
stabilization requirement to inpatients. 
No.  2003AP1376.pdr 
 
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based on a permissible construction of EMTALA.  I agree with the 
majority 
that 
Congress 
explicitly 
charged 
DHHS 
with 
the 
authority to make and publish regulations interpreting EMTALA.19  
42 U.S.C. § 1302.  Therefore, the interpretation in 42 C.F.R. 
§ 489.24 controls, unless it is arbitrary, capricious or 
manifestly contrary to the statute. 
¶62 I conclude the 
regulation 
stating 
that EMTALA's 
stabilization requirement does not cover inpatients is not 
arbitrary, capricious, or manifestly contrary to the statute.  
DHHS drafted proposed regulations and solicited public comments 
to ensure discussion among interested parties regarding the 
inpatient issue.  In the supplementary information included with 
the final rule, DHHS includes a lengthy discussion of the issue, 
including comments made by various parties and DHHS's responses.  
Clarifying Medicare Policies, supra ¶59, at 53243-48.  DHSS 
thoroughly considered these comments, and in response to 
comments opposed to this proposed rule, as well as cases such as 
Bryant, DHHS ultimately decided to exclude coverage under EMTALA 
once a person was admitted to the hospital.  Id. at 53244-48.  
Accordingly, DHHS's 
interpretation 
cannot be 
described as 
arbitrary or capricious.  
¶63 Because the final regulation advances the purpose of 
EMTALA, it cannot be described as "manifestly contrary to the 
statute" either.  As discussed in the Bryant and Dollard cases 
above, EMTALA was designed to "fill the gap" in legal liability 
for hospitals regarding the failure to treat emergency medical 
                                                 
19 See majority op., ¶27 n.8. 
No.  2003AP1376.pdr 
 
14 
 
conditions.  Given that medical malpractice liability deals with 
the quality of inpatient treatment, the regulation clarifying 
that inpatients are not covered by EMTALA merely eliminates 
possible overlap and retains the protection against "dumping" 
that EMTALA was created to implement.  Therefore, because I 
conclude that the interpretation of EMTALA in 42 C.F.R. § 489.24 
is permissible, it controls regarding whether the stabilization 
requirement of EMTALA applies to inpatients. 
¶64 The reasoning that underlies DHHS's regulation in 42 
C.F.R. § 489.24 applies equally to the screening provision of 
EMTALA.  There is no principled basis to distinguish EMTALA 
coverage between screening and stabilization procedures for 
inpatients given that substandard care regarding screening would 
be subject to a medical malpractice claim just as a substandard 
effort to stabilize would be.  Additionally, the screening 
requirement is the procedure used to assess whether one who 
comes to the emergency department should be admitted to the 
hospital.  If the person is already admitted, the purpose that 
drives 
the 
screening 
requirement 
has 
already 
been 
met.  
Therefore, I conclude that the screening provision of EMTALA 
does not apply once an individual becomes an inpatient. 
¶65 I further note that the DHHS regulation controls the 
present case even though the regulation was not passed until 
2003.  In Smiley v. Citibank (South Dakota), N.A., 517 U.S. 735, 
744 n.3 (1996), the United States Supreme Court responded to the 
argument that "deferring to the regulation in this case 
No.  2003AP1376.pdr 
 
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involving antecedent transactions would make the regulation 
retroactive."  The Court stated: 
There might be substance to this point if the 
regulation replaced a prior agency interpretation——
which, as we have discussed, it did not.  Where, 
however, a court is addressing transactions that 
occurred at a time when there was no clear agency 
guidance, it would be absurd to ignore the agency's 
current 
authoritative 
pronouncement 
of 
what 
the 
statute means. 
Id.; see also Barnhart v. Walton, 535 U.S. 212, 221 (2002) 
("[Defendant] 
also 
asks 
us 
to 
disregard 
the 
Agency's 
interpretation of its formal regulations on the ground that the 
Agency only recently enacted those regulations, perhaps in 
response to this litigation.  We have previously rejected 
similar arguments.").  As was the case in Smiley, DHHS 
promulgated the regulation clarifying the status of inpatients 
under EMTALA to provide guidance where there had been none, as 
can be seen in the splits among the various jurisdictions 
regarding the inpatient issue that existed before the advent of 
the regulation. 
¶66 The final issue raised by this case is whether Bridon 
was an inpatient and therefore, is subject to the previous 
analysis.  It is not disputed that Shannon Preston was admitted 
shortly after arriving at Meriter, and that she gave birth to 
No.  2003AP1376.pdr 
 
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Bridon while she was an inpatient.20  Preston's unborn child 
"came to the hospital" at the same time she did.   
¶67 Care for an unborn child is often required prior to 
birth, and in providing that care, the unborn child becomes a 
second inpatient.  We have recently held that a pregnant woman 
and her unborn child are two inpatients during the course of 
delivery.  See Pierce v. Physicians Ins. Co. of Wis., Inc., 2005 
WI 14, ¶12, 278 Wis. 2d 82, 692 N.W.2d 558 ("we have the unique 
situation where the patient, Bonnie Pierce, was also the parent 
of the patient, Brianna Lynn Marcks," who was stillborn).  
Further support for the contention that a child in utero is an 
inpatient is shown by the surgery that is performed on unborn 
children to treat such maladies as spina bifida and lung 
malformations.  See, e.g., Claudia Kalb & Mary Carmichael, 
Treating the Tiniest Patients, Newsweek, June 9, 2003, at 48; 
Maggie Jones, A Miracle, and Yet, N.Y. Times, July 15, 2001, § 6 
                                                 
20 Paragraph 4 of the complaint alleges that Shannon Preston 
gave birth "on an emergency basis" to Bridon "while an 
inpatient" at Meriter.  Although Meriter's answer denies 
"knowledge or information sufficient to form a belief as to the 
truthfulness of the allegations contained in Paragraphs 1 and 4 
of plaintiff's Complaint," this appears to be a denial to the 
"emergency basis" contention and not the claim that Shannon was 
an inpatient.  Meriter's brief in support of its motion for 
summary judgment cites the complaint for the contention that 
Preston was an inpatient, and the affidavit of Peter J. Ouimet, 
the risk manager for Meriter, in support of motions for judicial 
determination and to stay discovery, states that Preston was 
"admitted to the hospital" at about 7:00 p.m. on November 9, 
1999.  Preston's medical records filed with the affidavit 
contain a "Nursing Admission Assessment" listing the time of 
admission as 7:00 p.m. 
No.  2003AP1376.pdr 
 
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(Magazine), at 39.  An unborn child capable of being operated on 
is an inpatient just as is the mother who carries that child.     
¶68 In this case, Bridon received care before and after 
his birth.  His medical records show that an ultrasound was 
performed to evaluate the condition of his lungs before he was 
born.  In addition, Bridon's hospital records show he was 
resuscitated shortly after birth, his heart rate was monitored 
and he was scored twice, using APGAR.21  Based on these 
undisputed facts of record, I conclude that Bridon became an 
inpatient when his mother did, and accordingly, the EMTALA 
screening requirement does not apply to him.  Therefore, I would 
affirm the court of appeals dismissal of Preston's claim under 
42 U.S.C. § 1395dd(a). 
II.  CONCLUSION 
¶69 I conclude that the screening provision of EMTALA, 42 
U.S.C. § 1395dd(a), does not apply to hospital inpatients.  
Because Bridon became an inpatient when his mother was admitted 
                                                 
21 APGAR is a scoring mechanism that evaluates a newborn's 
vital signs.  The acronym stands for:  Activity (muscle tone), 
Pulse, Grimace (reflex irritability), Appearance (skin color) 
and Respiration.  Two points are possible for each criterion.  A 
score of 7-10 is considered normal.  See "APGAR Scoring for 
Newborns," 
available 
at 
http:// 
www.  
childbirth.org/articles/apgar.html.  Bridon scored 1 out of a 
possible 10 points. 
No.  2003AP1376.pdr 
 
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before his birth, the screening provision of EMTALA does not 
apply to him.  Therefore, because I would affirm the court of 
appeals decision dismissing Preston's claim, albeit on different 
grounds, I respectfully dissent.  
¶70 I am authorized to state that Justice JON P. WILCOX 
joins this dissent. 
 
No.  2003AP1376.pdr 
 
 
 
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