Should Airlines Exempt Physicians From Getting Bumped?

April 11, 2017

Disturbing videos of a 69-year-old physician getting dragged off an overbooked United Airlines flight, with blood on his face, because he refused to surrender his seat raises obvious questions. Can't airlines handle overbooking without resorting to brute force, or abandon overbooking in the first place?

And there's another question: As long as airlines persist in overbooking flights, should they automatically exempt physicians from getting bumped because of their profession?

Ethicists interviewed by Medscape Medical News tend to think not, even though they sympathize with the battered passenger, who said he was a physician with patients to see the next day.

"I do think that physicians have pulled rank and there has been a culture of pulling rank on a regular basis, just in the everyday routine of making patients wait, for example," said Linda Emanuel, MD, PhD, a medical ethicist and professor of medicine at Northwestern University in Evanston, Illinois. "None of that is really necessary and it is arrogant."

 A blanket exemption for physicians would be unfair to other healthcare professionals such as nurses, and even first-responders such as firefighters, added Nancy Berlinger, PhD, a research scholar at The Hastings Center, a bioethics think-tank in Garrison, New York.

"Maybe you're the only pharmacist in a rural town," said Dr Berlinger. "We all have good reasons, and we tend to think our reasons are really good ones."

Being a physician wasn't a good enough reason, though, for United Airlines when it removed a passenger identified by Reuters as David Dao, MD, from United Flight 3411 on April 9 before it took off from Chicago O'Hare International Airport for Louisville, Kentucky. Statements issued by United and the Chicago Department of Aviation (CDA) as well as passenger accounts and videos on social media lay out a startling narrative.

United personnel told seated passengers on the fully boarded flight that they needed four volunteers to turn over their seats to a United flight crew required in Louisville. Despite offers of $400 and later $800 in compensation, no one raised their hand. Then United told passengers that the airline would select four passengers for involuntary removal. Dr Dao was one of them. He protested that he needed to see patients the next day. CDA police said he became irate and started yelling to "voice his displeasure."

CDA police were summoned, and one officer pulled a screaming Dr Dao from his window seat. In the process, according to police, Dr Dao fell, his head striking an armrest. As captured on a smartphone camera, police then dragged him by his feet and on his back down the aisle and out of the plane while other passengers cried, "Oh my God!" Another video showed a dazed-looking and bloody-mouthed Dr Dao returning to the cabin, saying repeatedly "Just kill me," and "I want to go home." Police said he was taken to Lutheran General Hospital with injuries that were not life-threatening.

The response by United to the incident quickly evolved.

In an email to employees yesterday obtained by news outlets, United CEO Oscar Munoz expressed regret, but said airline personnel "were left with no choice but to call Chicago aviation security officers to assist in removing the customer," whom he described as "disruptive and belligerent." In a statement issued to the publication Business Insider, the airline explained that "one customer refused to leave the aircraft voluntarily."

"We apologize for the overbook situation," the airline said.

Munoz expanded on that sentiment in a news release yesterday. "This is an upsetting event to all of us here at United," he said. "I apologize for having to re-accommodate these customers."

A stronger mea culpa came from the CDA.

"The incident on United Flight 3411 was not in accordance with our standard operating procedure and the actions of the aviation security officer are obviously not condoned by the Department," said the CDA said in a statement issued to Medscape Medical News. The department said that one of the officers who removed Dr Dao from his seat had been placed on leave yesterday "pending a thorough review of the situation."

Today, United's Munoz turned up his company's apology.

"The truly horrific event that occurred on this flight has elicited many responses from all of us: outrage, anger, disappointment," Munoz said in a news release. "I want to apologize to the customer forcibly removed and to all the customers aboard. No one should ever be mistreated this way."

Days of Preferential Treatment for Physicians "Long Gone"

Overbooking, or selling more tickets to a flight than there are available seats, is designed to ensure full flights and maximum revenue. After all, not everyone who reserves a seat will claim it. Selling the seat twice, as it were, is likely to keep it occupied in that event.

But when every ticket purchaser on an overbooked flight shows up at the gate, the airline has to bump people. In 2016, the nation's 12 biggest airlines bumped roughly 475,000 passengers from overbooked flights, according to the US Department of Transportation. Of these, almost 41,000 were bumped involuntarily at a rate of 0.62 per 10,000 passengers on overbooked flights. United was on the low end of involuntary bumping rate — 0.43 per 10,000. ExpressJet Airlines led the airline industry with 1.51 per 10,000.

The so-called contract of carriage that governs an airline's relationship to a ticketholder gives the airline free rein in bumping passengers. United's contract states that the airline may prioritize passengers for involuntary bumping based on their fare class, itinerary, status in a frequent flier program, and time of check-in for a preassigned seat. The last to be involuntarily bumped — and therefore the most protected — are individuals with disabilities and unaccompanied minors aged under 18 years if losing their seat would create a hardship.

United and some other airlines, such as Southwest, do not mention passenger hardship in general as a factor in selecting someone to remove from an overbooked flight. One airline that does is American, which says in its contract of carriage that it will consider "extreme hardships."

United Airlines did not respond to a request to discuss its passenger bumping policies, or the Dr Dao incident.

Medical ethicists told Medscape Medical News that hardship would be a sound reason to exempt physicians from bumping. "There are occasions when physicians are the only ones who can take care of patients who are in great need," said Dr Emanuel, "and under those circumstances I would hope that people would be happy to stand back just as they should be happy to stand back to let an ambulance by in traffic."

A physician scheduled to operate on someone the next day is one example of a legitimate hardship, notes Dr Berlinger. However, ascertaining such facts on the spot before take-off isn't an easy task for airline crew members, she said. "And doctors themselves would disagree about who in their profession should be exempt." At the very least, she said, an airline ought to distinguish between physicians in patient care and physicians in administration.

An airline trip can be critical for someone regardless of their job, said Stuart Youngner, MD, a professor of bioethics and psychiatry at Case Western Reserve University in Cleveland, Ohio. "What about the woman who says, 'My mother is dying. She may not make it until noon. I need to get there,' "

Dr Youngner told Medscape Medical News that when he graduated from medical school in 1970, physicians might have received more deferential treatment on an overbooked flight.

"Doctors were treated like gods," he said. "We didn't get speeding tickets. We stepped to the front of the line. We double-parked with an 'MD on call' sign in the car.

"Those days are long gone."

Follow Robert Lowes on Twitter @LowesRobert


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