Abstract

New medical graduates and pre-clinical doctors face a dilemma when confronted with in-flight medical emergencies. Intervening could raise ethical, legal, and practical concerns, while staying quiet may violate the moral obligation to provide care. This reflective essay discusses the challenges, including lack of standard protocols, racism, and sexism experienced by doctors in-flight. It also highlights the importance of reciprocity and proposes solutions like standardising medical kits. In conclusion, pre-clinical doctors can play a crucial role in in-flight emergencies, and should respond confidently to an emergency call. A nuanced discussion is necessary to determine their role.

Keywords: in-flight emergency, pre-clinical, ethics, moral obligation

As the plane hit turbulence, a passenger suddenly slumped forward, unconscious. The captain’s voice came over the intercom, “Is there a doctor on board?”

I looked up from my book, feeling a sense of duty to respond. As an MBBS doctor with an MS degree, I felt it was my duty to help the patient. I composed myself and started to get up from my seat. Just then, my inner voice raised concerns:

You don’t know the patient’s medical history, what if you give a drug that causes harm? And don’t forget that it’s been ten long years since you attended to a patient; you are out of practice and not trained to attend to an emergency. You are a pre-clinical doctor, a teacher, how can you be of any help?

These harsh thoughts shattered me; I hesitated, feeling uncertain and unprepared. I closed my eyes and tried to disappear into my seat.

Is it acceptable for a doctor to stay aloof in such situations?

There is no clear-cut answer, but doctors are not legally obliged to respond to medical emergencies on flights. They may choose to prioritise their own safety and well-being, particularly if they are fatigued or unwell themselves. They may be worried about providing care without adequate equipment and facilities, and about facing liability by providing care in a non-traditional setting. Doctors of various specialities, like dermatology, or ophthalmology, may face an ethical dilemma, not being trained or equipped to handle emergency medical situations outside their area of expertise. I knew laws differed across the globe regarding a doctor’s duty to care during medical emergencies. The US Aviation Medical Assistance Act of 1998 provides liability protection for doctors who provide care in good faith during medical emergencies on flight. The European Union has implemented regulations requiring airlines to provide medical assistance and equipment on board, and to have procedures for handling medical emergencies.

But moral obligation and professionalism also have to be considered. We take the Hippocratic oath, at the start of medical school, to provide care to those in need, regardless of the circumstances. By staying quiet, we may be violating this oath. A doctor has a moral and professional duty to provide care in the event of a medical emergency. Some argue that doctors have a moral duty to rescue those in distress, even if it’s not legally required. Staying quiet may be seen as a breach of professional ethics, damaging public trust in the medical profession. By not responding, doctors may be perceived as abandoning their responsibility to care for patients. Doctors who stay away may experience guilt and self-doubt, potentially affecting their mental health and well-being. Their decision may damage their professional reputation, affecting their relationships with colleagues and patients.

In flight emergencies are very common as people are stuffed into an enclosed space, thousands of feet above ground with little leg room. An estimated 44,000 in-flight medical emergencies occur worldwide each year [1]. The most common emergencies are abdominal pain, chest pain, shortness of breath, syncope and seizures [2]. Chest pain and heart problems are commonly associated with flight diversion [3]. However, cabin crews are trained to manage such situations and provide the necessary drugs. A doctor’s intervention is required when a serious event occurs. There have been instances of medical emergencies on board with happy endings in the past, like childbirth on a plane. A news item in The Hindu, titled “When a ‘passenger’ joined mid-air”, reported that a premature baby was born mid-air on a Delhi-Bengaluru flight [4]. Luckily, a gynaecologist was present on board and the process was hassle-free. But what if a doctor with no experience in childbirth had been present? Emergencies can arise after birth, like a postpartum haemorrhage ― what then?

Then again, incidents of disrespect shown to doctors by the patient’s relatives and crew members have been reported [5]. How does one ignore the racism and sexism experienced by doctors in-flight? This pressing concern has been covered in Time Magazine under the “Health and Medicine” section titled “7 Female Doctors Speak Out About Racism and Sexism during Airplane Emergencies” [5]. Dr Tamika Cross made headlines when she posted a troubling airplane encounter on Facebook: that she, a young black doctor, was turned away when she tried to provide medical care to a sick passenger. “Oh no, sweetie put [your] hand down, we are looking for actual physicians or nurses or some type of medical personnel,” Cross recalled a flight attendant telling her, before asking for credentials and accepting help from a white physician. “Whether this was race, age, gender discrimination, it’s not right”, said Cross [5].

International aviation companies do not have universal rules on how to deal with in-flight emergencies. Indian commercial flights do carry first aid kits for cabin crew to administer, and physician’s kits meant for doctors, with basic medical supplies [6]. Each kit is certified by the company doctor and includes a comprehensive medical incident reporting form. These too, need to be standardised and regularly reviewed and updated. Additionally, enabling real-time telemedicine consultation with ground-based medical professionals, would enhance the quality of in-flight care. In regular settings, doctors and patients have the right to choose each other. However, in emergencies, doctors must treat patients if they have the means to save their lives. Without basic facilities, doctors can’t effectively treat emergencies like heart attacks.

If doctors prioritise their personal interests over those of others, it may erode their own sense of social responsibility which is crucial for their profession. Staying quiet could contribute to a culture of indifference.

No matter how scary it sounds, a doctor is still a doctor. “I did it”, sounds way better than I could’ve done it. A doctor with no specialisation in a particular branch and with little or no hands-on experience, can still play a crucial role in an in-flight or any emergency by maintaining a clear mind and positive approach. Panicking can lead to poor decision-making, hence staying calm is the first step. I could ask the flight attendants about the passenger’s condition, which could help in gathering important information. Most importantly, being honest about one’s abilities and limitations of one’s skill set could be a good move. The cabin crew are already trained to provide CPR, use of the Automated External Defibrillator (AED) and basic first aid. The doctor is required more for authorisation. The crew may need assistance in using the equipment such as oxygen tanks or blood pressure cuffs. Reassuring the sick passenger and their companions and helping to calm them down would be the most effective way to keep the situation under control.

Of course, the responsibilities of a doctor do not end here. Post-emergency protocols must not be ignored. Any actions taken and any medical equipment used must be noted down with proper feedback. In case the patient is hospitalised after landing, documentation of the whole case is vital. Thinking about what was learned and what can be improved in future emergencies can be a valuable take-home message.

Ultimately, the ethical implications of doctors staying away from in-flight emergencies depend on individual circumstances and personal values. Pre-clinical doctors, out of touch with regular practice, face a dilemma when confronted with in-flight medical emergencies. Intervening in such situations raises ethical, legal, and practical concerns. A nuanced discussion is necessary to determine the role of pre-clinical doctors in emergency situations. While there’s no one-size-fits-all, it is essential to consider the social and ethical aspects of one’s actions.

Perhaps, this whole issue could be resolved with the appointment of an in-flight doctor with all the necessary training and tools to work on-board. It may seem simple, but the reality is much more complex. Including a doctor on every flight would significantly increase operational costs for airlines. Including recruiting, training, and compensating medical professionals may not be feasible for all airlines.

Until a comprehensive solution to all these challenges is found, a doctor travelling as a passenger will inevitably be relied upon to take charge and provide medical assistance. Thousands of feet above the ground, amidst the clouds, if someone extends a helping hand, then he/she can surely be called a good Samaritan. Comparing a doctor to God is over-hyped and unrealistic as a doctor cannot alter fate. All these thoughts kept jostling for space in my brain.

“Is there a doctor on-board?”, the pilots’s voice again shook me. I remembered the time when I was a fresh graduate, still in my internship, while booking my train tickets I would proudly tick the box of a doctor. This time, I stilled all the conflicting thoughts in my brain, smiled and got up to help. My every step was now filled with confidence, as I moved towards the ailing passenger.

Authors: Fariha Sabeen ([email protected], https://orcid.org/0000-0001-8415-5728), Tutor of Anatomy, Mahatma Gandhi Memorial Medical College, Jamshedpur, Jharkhand, INDIA.

Conflict of Interest: None declared                                                                                                                                                                                         Funding: None

Acknowledgements: Meta AI was used for writing and editing assistance. It was used for grammatical corrections and to structure sentences.

To cite: Sabeen F. To act or not to act in an in-flight emergency. Indian J Med Ethics. Published online first on June 13, 2025. DOI: 10.20529/IJME.2025.049

Submission received: February 8, 2025

Submission accepted: April 5, 2025

Manuscript Editor: Vijayaprasad Gopichandran

Copyright and license

©Indian Journal of Medical Ethics 2025: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only noncommercial and non-modified sharing in any medium, provided the original author(s) and source are credited.