This section contains the nature of the case and procedural background.

Rivera arrived in the emergency room of DeTar Hospital in Victoria, Texas at 4:00 p.m. on December 5, 1986. At or near term with her sixth child, she was experiencing one-minute, moderate contractions every three minutes and her membranes had ruptured. Two obstetrical nurses, Tammy Kotsur and Donna Keining, examined her and found indicia of labor and dangerously high blood pressure. Rivera had received no prenatal care and had neither a regular doctor nor a means of payment. Kotsur telephoned D, who was next on the call-list of physicians responsible for such 'unaligned' obstetrics patients. D told Kotsur that he 'didn't want to take care of this lady' and asked her to prepare Rivera for transfer to John Sealy Hospital 170 miles away. Kotsur and Keining told the nursing supervisor, Herman, and DeTar's Administrator, Sexton, that it would be unsafe to transfer Rivera. D was told that under hospital regulations and federal law, he would have to examine Rivera and personally arrange for the other Hospital to receive her before he could legally transfer her. Keining asked D for permission to start an intravenous push of magnesium sulfate as a precaution against convulsive seizures. Dt told Keining to begin administering this medication only if Rivera could be transported by ambulance. He said that otherwise, Keining was not to administer intravenous treatment because Rivera would have to go to the other Hospital by private car. D examined Rivera and confirmed her blood pressure to be the highest he had ever seen 210/130, and he assumed that she had been hypertensive throughout her pregnancy. D knew that there was a strong possibility that Rivera's hypertension would precipitate complications that might kill both Rivera and her baby. D also knew that the infants of hypertensive mothers are at higher-than-normal risk of intrauterine growth retardation. D arranged her transfer to the other Hospital, a perinatal facility better equipped than D's to care for underweight infants. D obtained telephonic acceptance. Dr. Downing at the transfer hospital, instructed Keining to administer magnesium sulfate intravenously and have Rivera transported by ambulance. D also knew that the infants of hypertensive mothers are at higher-than-normal risk of intrauterine growth retardation. D arranged her transfer to the other Hospital, a perinatal facility better equipped than D's to care for underweight infants. D obtained telephonic acceptance. Dr. Downing at the transfer hospital, instructed Keining to administer magnesium sulfate intravenously and have Rivera transported by ambulance.D told Herman that Rivera represented more risk than he was willing to accept from a malpractice standpoint. Herman explained that Rivera could not be transferred unless D signed a DeTar transfer form attesting that he examined the patient, anddetermined that, based on the information available, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the patient's medical condition from effecting [the] transfer. D listed no basis for his conclusion. D did not order any medication or life support equipment for Rivera during her transfer. Rivera's healthy baby was delivered in the ambulance approximately 40 miles into the 170-mile trip. The nurse who delivered the baby directed the driver to nearby Ganado Hospital to get a drug called Pitocin to staunch Rivera's bleeding. The nurse telephoned D, who ordered her to continue the trip despite the birth. The nurse ordered the ambulance to return to D and D refused to see her because she failed to proceed to the other Hospital in accordance with his instructions. D discharged Rivera but another doctor ordered Rivera to stay for three days. Rivera left in good health. The Inspector General of DHHS demanded a $ 25,000 civil penalty from D for violating EMTALA. An administrative law judge (ALJ) found that D knowingly violated EMTALA in several ways but that mitigating circumstances warranted a reduction in the fine assessed against him to $ 20,000. D appealed to the Departmental Appeals Board (DAB). DAB issued its 'Final Decision' upholding the civil penalty. D appealed.

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