Lesley v. Chie, 250 F.3d 47 (1st Cir. 2001)

This opinion concerns a summary judgment motion on a Rehabilitation Act claim against a doctor who refused to treat an HIV-positive pregnant woman and instead referred her to a hospital with a special program for delivering children of HIV-positive women. The First Circuit held that the plaintiff’s HIV status was a disability under the Rehabilitation Act and that the doctor’s receipt of Medicaid funds made him a federally funded entity under the Act. The court then reasoned that, when considering doctors’ referrals of patients with disabilities, courts must balance the need to defer to doctors’ medical decisions with the need to ensure that such deference does not allow discrimination. The court interpreted Section 504 of the Rehabilitation Act to require that patients demonstrate that treatment was denied solely by reason of the disability. The court then concluded that a patient may challenge her doctor’s decision to refer her elsewhere by showing the decision to be devoid of any reasonable medical support and was unreasonable in a way that reveals it to be discriminatory. The First Circuit stated that a plaintiff may meet this standard, for example, by demonstrating that: (1) a physician’s decision was so unreasonable that the implication is that it was pretext for a discriminatory motive; or (2) the doctor’s medical reason for the referral is unreasonable because it is based on “stereotypes of the disabled rather than an individualized inquiry into the patient’s condition.” Using this standard, the First Circuit held that the physician’s decision was not unreasonable because he had performed an individualized inquiry into his ability to treat the plaintiff and that his decision was supported by other doctors and nurses involved in the plaintiff’s care.

The First Circuit’s holding, unfortunately, did not give appropriate weight to the fact that all that would be required in delivery was an intravenous treatment of antiretroviral drugs, which, according to testimony of a doctor who served on the U.S. Public Health Service task force, was “straightforward” and did not require specialized knowledge beyond that possessed by a licensed practitioner of obstetrics. Advocates pursuing similar cases, however, should consider facts that might distinguish Lesley from their case. For example, the physician in Lesley routinely treated HIV-positive women, which the court used to determine that the physician was not refusing to treat out of animus or fear. Moreover, the physician did not merely refuse to treat; he referred her to another hospital, and only after researching and consulting with other doctors and experts. The court also relied on the fact that the plaintiff was due to deliver in 1995—increased knowledge and availability of antiretroviral drugs since this time might cast a new light on a case today.

It is also important to note that Lesley is limited to Section 504 of the Rehabilitation Act, which the First Circuit interpreted to require that a plaintiff show his or her disability was the sole cause of the refusal to treat. It is widely accepted that plaintiffs bringing a cause of action under the ADA need only demonstrate that discrimination was a motivating factor, and not the sole cause of discrimination.