HA 625 Unit 7 ethics committee memo example

Memorandum

To: Hospital Ethics Committee

From: Administrative Fellow, on behalf of the case manager and attending physician

Date: February 26, 2026

Re: Whether the hospital may transfer Mr. R. to an accepting hospital in Guatemala City on his sister's telephone consent

The Question and Who Is Asking

Question: May the hospital arrange Mr. R.'s transfer by air ambulance to an accepting private hospital in Guatemala City on the authority of his sister's consent, given by telephone from Guatemala? The case manager and the attending physician asked for this review on February 20, because the air ambulance company has offered a date in the second week of March and needs a signed consent by March 2. The committee advises; the decision belongs to the patient's lawful decision maker and, on the hospital side, to the chief medical officer.

Clinical and Social Facts

Mr. R. is a 38-year-old man who fell from scaffolding at a construction site on December 16, 2025, and sustained a severe traumatic brain injury. After surgery and 71 days in the hospital, he breathes through a tracheostomy without a ventilator, is fed through a gastrostomy tube, opens his eyes and tracks, but does not follow commands consistently or communicate. The neurology team expects slow improvement over months, with an uncertain ceiling; he is medically stable and no longer needs hospital-level care. He needs a long-term care setting with tracheostomy and tube-feeding care and rehabilitation.

Mr. R. came to the United States from Guatemala nine years ago and is not a citizen or lawful permanent resident. He has no health insurance and does not qualify for full Medicaid; no skilled nursing facility contacted will accept him without a source of payment. He has no spouse or children. His sister, who lives in Guatemala, speaks with the social worker weekly by telephone and says the family wants him home. Two coworkers who visit say he often talked about returning to his village once he had saved enough to build a house for his mother. There is no written advance directive and no health care power of attorney. The accepting hospital in Guatemala City has a neurological rehabilitation unit, and the family has said they will pay for his care there. The hospital would pay the air ambulance cost of about $38,000.

Legal Block: What Is Settled and What Is Not

Settled. Mr. R. lacks capacity to consent to or refuse the transfer. The Ohio statute listing family members who may decide for a patient, Ohio Rev. Code § 2133.08, applies to withholding or withdrawing life-sustaining treatment when the patient is terminally ill or permanently unconscious. It does not give a relative general authority to consent to other treatment decisions, and it does not reach a decision to move a patient to another country. Without a health care power of attorney, the person with legal authority to make a decision of this weight would be a guardian appointed by the probate court under Ohio Rev. Code § 2111.02. The sister has no such appointment.

Settled. The hospital's discharge planning duties apply. The Medicare conditions of participation require the hospital to have a discharge planning process, to involve the patient or the patient's representative in it, and to transfer or refer the patient with the necessary medical information to the appropriate post-hospital provider (42 C.F.R. § 482.43). A discharge to another country is not excluded by those rules, but it must be arranged with the same involvement of a lawful representative as any other discharge.

Unsettled. Federal and Ohio law do not specifically address international transfer of a patient who lacks capacity, and courts have not given hospitals clear rules. A widely reported Florida case, in which a hospital flew a brain-injured Guatemalan worker home by chartered plane while his court-appointed guardian was contesting the plan, led to years of litigation and remains a caution for hospitals considering the same course (Young & Lehmann, 2014).

Ethics Block

Respect for the patient's wishes. Mr. R. cannot speak for himself now, but there is credible evidence of his values: repeated statements to coworkers that he meant to return home and support his mother. The transfer his sister requests may be what he would choose. That evidence supports the transfer, but it was said by a healthy man about retirement, not about returning disabled to a hospital, and it should be weighed with care rather than treated as a directive.

Benefit and harm. The accepting hospital appears able to provide the care he needs, and being near family who will visit may help his recovery. The risks are the flight itself and the chance that the receiving care is less than promised; both can be reduced by physician-to-physician handoff and written confirmation of services. Keeping him in an acute hospital indefinitely is itself a harm, since it offers no rehabilitation and exposes him to infection.

Justice and the hospital's interest. The hospital is paying for a bed he does not need, at real cost, and the committee should say so openly rather than disguise it. Ethics commentators have argued that involuntary repatriation driven by cost violates the duties clinicians owe patients (Young & Lehmann, 2014). The hospital's financial interest is legitimate, but it must not be the reason for bypassing the consent a U.S. citizen in the same condition would receive.

Where Law and Ethics Part

The ethics analysis leans toward transfer, because it likely matches Mr. R.'s values and his family's wishes and could improve his care. The law does not allow it on the present authority. The legal constraint is binding: the hospital may not act on a consent the law does not recognize, however sincere. What ethics still requires is that the hospital not let the legal step become a reason for indefinite delay, and that it pursue the lawful route as promptly as it would for any patient.

Options and Recommended Process

Option 1: transfer on the sister's telephone consent by March 2. Not recommended. The consent is not legally valid, and the hospital would be exposed to claims that it removed a patient without lawful authority.

Option 2: seek a guardian and, if the guardian consents, transfer. Recommended. The hospital's counsel files a guardianship petition in probate court this week, proposing the sister, a local relative or a professional guardian, as the court finds appropriate. The guardian receives the full clinical picture, the receiving hospital's written description of services, and the evidence of Mr. R.'s wishes, and decides. The hospital offers the air ambulance and a physician-to-physician handoff.

Option 3: continued search for a U.S. placement alongside Option 2. Also recommended. Case management continues to seek a nursing facility or charity-care arrangement, so the guardian has a real alternative to weigh.

The committee should also recommend that the hospital adopt a policy for any future international transfer of a patient without capacity, requiring a lawful decision maker, written confirmation of receiving services, and ethics review before scheduling.

References

Discharge planning, 42 C.F.R. § 482.43 (2025).

Ohio Rev. Code § 2111.02 (2025).

Ohio Rev. Code § 2133.08 (2025).

Young, M. J., & Lehmann, L. S. (2014). Undocumented injustice? Medical repatriation and the ends of health care. New England Journal of Medicine, 370(7), 669-673. https://doi.org/10.1056/NEJMhle1311198