Are medical doctors legally doctors wherever they are?

On an international Delta flight, I sat next to a couple that on their previous connecting flight, had seen a man experience some sort of stroke or heart attack.
Coincidentally, a steward from that flight who took care of the emergency was one of the crew of my flight, and he and the couple next to me started talking about it and shared the whole experience with me.

It turns out that for medical emergencies, crew members by law are trained in first-aid. Also I learned that they have access to a sort of “medical” phone on the back of the plane, which when used, immediately connects the crew with a doctor and he instructs the crew what to do in case of medical emergencies.

So it may not even matter (or airlines might not “care” whether there is a doctor on the plane or not), as the crew members are trained to at least be relays for the “on-call” doctor of the airline. I’m not sure where the doctor on the other end of the line has to be licensed from, nor if this is even a legal requirement for all airlines. But I learned this had occurred on a Delta international flight.

I’d imagine that if the “medical” phone is required my law, that the airlines would want to handle the issue using their protocols rather allowing than some random “doctor” that happened to be on the flight to intervene, due to legal liabilities. Of course the protocols and law become a bit fuzzy during an emergency at 5,000 feet, and I’m sure that the crew has a lot of discretion on deciding what’s the best thing to do as an emergency evolves.

A quick google search on the subject leads me to articles like this one that confirm what I learned from that conversation.

Please assume that you are.

I can only give you the answer for example Dutch law, but a lot of countries have similar regulations (apart from it being your ethical duty).

Dutch law Article 450 states (translated by me):

He who, witnessing immediate and life threatening danger to another, does not render aid to his ability, without reasonably endangering himself or others, will be, if the other dies, punished with up to 3 months in prison or a fine of the second order (as of 2014: €4,050).

So in general you are liable if you do not render aid to your ability (your ability might just be calling emergency services).

There are at least four aspects to this question:

• Legal obligation
• Legitimation
• Liability
• Moral

Obligation

Legal obligation is a common misconception. While generally there exists an obligation not only for medical professionals but for every person to help in most (all?) countries in the world, this obligation does not work the way laymen think.
You have the obligation to help another person if, and only if:

1. The other person’s life is in present and immediate danger or if there is a present and immediate danger which would lead to a very serious permanent damage (such as losing a hand)
2. The risk for you is “acceptable”. You have for example no obligation to enter a burning building or to unfasten your seatbelts in an airplane when turbulences are likely (or even during turbulences). You have no obligation to perform CPR without mask if the person has a rather obvious “infective” look or likely suffers from contact poisoning or such, etc, etc.

You have no obligations whatsoever if the patient is merely drunk (which makes up ca. 90% of all “emergencies” that I’ve seen aboard an airplane during 20 years) or airsick or has a bad tummy (which are 9.9% of the remaining 10%). In fact, I have personally never seen a real emergency (one that deserves the word “emergency”) aboard an airplane, but of course your mileage may vary.

Legitimation

Technically, aboard a foreign-company airplane, you are not legitimated to act as a medical professional most of the time. For example, the USA do not consider a German grade (although it is much better) valid, and Germany does not consider many (mostly eastern) grades valid, though the number has greatly decreased during the past few years due to EU memberships.

An airborne foreign airplane is “foreign ground”, so technically you may be breaking the law by acting as medical professional even if you are normally legitimated. In practice, nobody cares, at least as long as nobody dies. The flight personnel only wants someone to take over, passengers don’t know (and likely don’t care at that very moment either), and medical professionals usually don’t like thinking about legal stuff more than absolutely necessary (well, nurses do, but physicians usually don’t).

Liability

In countries with somewhat “sane” jurisdictions, damages from administering first aid are generally covered by a commonwealth indemnity insurance. This is to ensure that people do not abstain from helping in fear of liabilities. In some other countries, you can be dragged to court for $100 million if something goes wrong.

However, medical professionals are never covered by the public insurance and are expected to have an indemnity insurance of their own (which isn’t precisely free and which they must pay from their private money). Though I have never experienced this kind of problem, it is at least conceivable that the insurance company will try to perform a vanishing trick if you have “officially” operated outside your legitimation.

Reputable airlines used to give you a signed “cover everything, no matter what happens” waiver contract before you start, but some have begun to greed out based on “you need to have an insurance anyway”. Which of course means that since you get no payment for a presumably disturbing work and carry the complete risk, helping gets quite unattractive.

Moral (both ways)

There is nothing special about doctors or medical professionals in general as far as moral is concerned. The same moral applies to everybody else who likes to point a finger at someone else and say “their responsibility”.

Helping someone who is in danger is a moral obligation for everybody. On the other hand, getting vomited over by a stinking drunk isn’t anyone’s obligation.

It is, on the other hand, a serious question of morality of getting stinking only because drinks are free (not only because of the vomiting part, but also in a sense of general safety, also towards the roughly 200 other people in the cabin).

There is a statement on these questions by the World Medical Association here:

http://www.wma.net/en/30publications/10policies/a26/

Therefore the World Medical Association calls on its members to encourage national airlines providing medium and long range passenger flights to take the following actions:

Equip their airplanes with a sufficient and standardised set of medical emergency materials and drugs that:

• are packaged in a standardised and easy to identify manner;

• are accompanied by information and instructions in English as well the main languages of the countries of departure and arrival; and

• include Automated External Defibrillators, which are considered essential equipment in non-professional settings.

Provide stand-by medical assistance that can be contacted by radio or telephone to help either the flight attendants or to support a volunteering health professional, if one is on board and available to assist.

Develop medical emergency plans to guide personnel in responding to the medical needs of passengers.

Provide sufficient medical and organisational instruction to flight personnel, beyond basic first aid training, to enable them to better attend to passenger needs and to assist medical professionals who volunteer their services during emergencies.

Provide insurance for medical professionals and assisting lay personnel to protect them from damages and liabilities (material and non-material) resulting from in-flight diagnosis and treatment.

The World Medical Association calls on its members to encourage their national aviation authorities to provide yearly summarised reports of in-flight medical incidents based on mandatory standardised incident reports for every medical incident requiring the administration of first aid or other medical assistance and/or causing a change of the flight.

The World Medical Association calls on its members to encourage their legislators to enact legislation to provide immunity from legal action to physicians who provide emergency assistance in in-flight medical incidents.

In the absence of legal immunity, the airline must accept all legal and financial consequences of providing assistance by a physician.

The World Medical Association calls on its members to:

• educate physicians about the problems of in-flight medical emergencies;

• inform physicians of training opportunities or provide or promote the development of training programs where they do not exist; and

• encourage physicians to discuss potential problems with patients at high risk for requiring in-flight medical attention prior to their flight.

The World Medical Association calls on IATA to further develop precise standards in the following areas and, where appropriate, work with governments to implement these standards as legal requirements:

• medical equipment and drugs on board medium and long range flights;

• packaging and information materials standards, including multilingual descriptions and instructions in appropriate languages;

• medical emergency organisation procedures and training programs for medical personal.

Your question has both legal, but perhaps more important, also moral aspects.

Generally speaking, when airborne, an aircraft is subject to the legislation of the carrier’s home country. So far so good. I am not sure if medical doctors according to US law is both legally required to help in an emergency and liable to damages they inflict even if practicing in good faith, but if it is so, the doctor you are talking about is indeed relieved from these legal obligations when flying with a foreign carrier.

The legal regulations defining liabilities, but also the duty to help are however very different from country to country. E.g. German criminal code contains “non-assistance of a person in danger” (unterlassene Hilfeleistung) as an offense and obligates even lay-men to help in case of an accident or medical emergency. Failure to do so is punishable with a fine or even up to one year imprisonment.

I am also not aware of any country actually forbidding medical doctors or lay-men to provide assistance in case of emergencies. Members of “Médecins Sans Frontières” are regularly both assisting and practicing medicine in countries, in which they are in most cases probably not legally approved to work as doctors.

Even without any legal regulations, medical doctors at least ought (IMHO) to feel morally obligated to follow the Hippocratic oath and help wherever possible.