Case Title: Fruiterman v. Granata

Citation: 

Docket Number: 071894

State: virginia

Court: Virginia Supreme Court

Date: 2008-10-31T00:00:00Z

Document:
Present:  Hassell, C.J., Keenan, Koontz, Kinser, Lemons, and 
Goodwyn, JJ., and Carrico, S.J. 
 
JAN PAUL FRUITERMAN, M.D., ET AL.  
 
v.  Record No. 071894 
OPINION BY JUSTICE CYNTHIA D. KINSER 
October 31, 2008 
JULIE GRANATA  
 
 
JOSEPH GRANATA 
 
v.  Record No. 071897 
 
JAN PAUL FRUITERMAN, M.D., ET AL. 
 
FROM THE CIRCUIT COURT OF FAIRFAX COUNTY  
Jonathan C. Thacher, Judge 
 
In these wrongful birth cases filed by the parents of twin 
daughters afflicted with Down syndrome, the circuit court 
sustained a jury verdict in favor of the mother.  We will 
reverse that judgment because the evidence was insufficient as 
a matter of law to prove the element of proximate causation.  
With regard to the father’s case, the circuit court granted a 
motion to strike the evidence because the father failed to 
prove a physician-patient relationship.  We will affirm that 
judgment. 
I. PROCEDURAL HISTORY 
Julie Granata and Joseph Granata (the Granatas) each filed 
a separate but identical motion for judgment in the circuit 
court, alleging that Jan Paul Fruiterman, M.D., Eleni Solos-
Kountouris, M.D., and their professional corporation, Drs. 
Fruiterman and Solos-Kountouris, P.C. (collectively, the 
Doctors), undertook to provide obstetrical services and 
prenatal care to the couple, thereby establishing a physician-
patient relationship with both Julie and Joseph.  The Granatas 
further alleged that the Doctors breached the standard of care 
by failing to provide Julie with information about first 
trimester testing known as chorionic villus sampling (CVS),1 
which would have revealed that her twin fetuses were afflicted 
with Down syndrome.  Additionally, the Granatas alleged that, 
if Julie had known about the condition of her fetuses during 
the first trimester, she would have elected to terminate the 
pregnancy.  As a direct and proximate result of the Doctors’ 
alleged negligence, Julie and Joseph claimed damages for, among 
other things, mental and emotional distress, medical and 
hospital bills for the care of the twins, and lost family 
income. 
The two actions were tried together before the same jury.  
In motions to strike both at the close of the Granatas’ 
evidence and at the close of all the evidence, the Doctors 
argued, among other things, that the Granatas failed to prove 
                     
1 CVS is a procedure by which a sample of the chorionic 
villi, or placental tissue, is obtained from the expectant 
mother and the cells are tested for genetic disorders such as 
Down syndrome.  CVS may be performed between the tenth and 
thirteenth week of a pregnancy. 
2 
by expert testimony to a reasonable degree of medical 
probability that, if Julie had undergone CVS testing, the 
result would have been positive for Down syndrome.  The Doctors 
also asserted that Joseph failed to prove the existence of a 
physician-patient relationship.  Therefore, they argued his 
claim was, at most, only derivative of Julie’s claim. 
The circuit court took all the motions to strike under 
advisement and elected to decide them, if needed, after the 
jury returned verdicts.  In separate verdicts, the jury found 
in favor of Julie and awarded damages in the amount of 
$4,000,000.  The jury also found in favor of Joseph and awarded 
$500,000 in damages. 
In post-trial motions, the Doctors renewed their motions 
to strike the Granatas’ evidence.  They also asked the circuit 
court to set aside the jury verdicts and either enter judgment 
in their favor or grant them a new trial.  The Doctors 
alternatively moved the circuit court to reduce the verdicts in 
accordance with the statutory cap for recoveries in medical 
malpractice actions pursuant to Code § 8.01-581.15. 
At the post-trial hearing, the Doctors presented the same 
arguments that they raised in the motions to strike the 
evidence.  With respect to whether the Granatas proved by 
expert testimony that the results of CVS would have been 
positive for Down syndrome, the circuit court asked whether 
3 
“there was any evidence that if a CVS had been done it would 
have returned a positive result.”  The Granatas acknowledged 
there was no such evidence in the record.  Regardless, the 
circuit court overruled the Doctors’ motions and sustained the 
jury verdict in Julie’s favor.  The court did, however, reduce 
the award to $1.6 million pursuant to Code § 8.01-581.15. 
With regard to Joseph, the circuit court granted the 
Doctors’ motion to strike and dismissed his case.  In a letter 
opinion, the court concluded that, in the absence of an 
undertaking by Dr. Solos-Kountouris, Joseph was not a patient 
and could not reasonably have expected to be a patient as 
defined in Code § 8.01-581.1.2  The court explained, “[i]f 
someone who merely accompanied a patient on a visit to the 
patient’s physician was able to recover for emotional distress, 
the end result would be an extension of the physician’s 
liability beyond all reasonable or logical bounds.” 
The Doctors and Joseph filed separate appeals from the 
respective judgments of the circuit court.  With regard to the 
Doctors’ appeal, the dispositive issue is whether Julie proved 
through expert testimony to a reasonable degree of medical 
probability that, if CVS testing had been conducted, the result 
                     
2 During the hearing on the Doctors’ post-trial motions, 
Joseph stipulated that the verdict in his favor against Dr. 
Fruiterman should be set aside because he had no interaction 
with Dr. Fruiterman on certain relevant dates. 
4 
would have shown the chromosomal abnormality associated with 
Down syndrome.  Joseph assigns two errors to the circuit 
court’s judgment.  He first claims the court erred in ruling 
that he failed to prove a physician-patient relationship with 
Dr. Solos-Kountouris or her professional corporation.  Second, 
Joseph asserts that the court erred in failing to find that 
Dr. Solos-Kountouris undertook to provide health care to him by 
advising about genetic testing. 
We will now present the relevant facts and then address 
the issues raised in each appeal, starting with the Doctors’ 
appeal. 
II. DOCTORS’ APPEAL 
A. Relevant Facts 
In February 2002, Julie met with Dr. Solos-Kountouris for 
pre-conception counseling and a gynecological examination.  Dr. 
Solos-Kountouris discussed the risks associated with conceiving 
a child when the mother is past the age of 35, in particular 
the risk of having a fetus with a chromosomal abnormality.3  
According to Dr. Solos-Kountouris, she emphasized the 
                     
3 Julie was 37 years of age at the pre-conception 
appointment with Dr. Solos-Kountouris. 
5 
importance of screening tests, including CVS and amniocentesis,4 
and explained how such procedures are performed, the risks 
associated with them, and the time frame during a pregnancy 
when the mother can undergo the tests.  
Julie’s testimony about the initial appointment differed 
from that of Dr. Solos-Kountouris.  Julie stated that Dr. 
Solos-Kountouris discussed and recommended only amniocentesis.  
Julie testified about how she explained to Dr. Solos-Kountouris 
that, since amniocentesis is performed 16 to 18 weeks into the 
pregnancy, she felt the pregnancy would be too far along to 
terminate if the procedure revealed an abnormality.  According 
to Julie, after the first trimester she would feel and look 
pregnant, and “it’s a baby, not a fetus” at that point.  To 
Julie, “anything past the first trimester is . . . when my 
responsibility is to manage the pregnancy.” 
Julie further testified that Dr. Solos-Kountouris told her 
amniocentesis was the “only way” to determine whether a fetus 
has a chromosomal abnormality.  Moreover, Julie insisted that 
no one at the Doctors’ office mentioned CVS during either her 
initial appointment or her subsequent appointments.  
                     
4 During amniocentesis, a large needle is inserted into the 
amniotic sac and a small amount of the fluid is removed.  The 
cells in the fluid are then tested to determine certain genetic 
disorders, such as Down syndrome.  Amniocentesis is not 
performed earlier than the sixteenth week of a pregnancy. 
6 
Soon after the pre-conception counseling visit, Julie 
became pregnant and returned to the Doctors in March 2002 to 
confirm her pregnancy.  At that appointment, she saw Dr. 
Fruiterman, who, like Dr. Solos-Kountouris, recommended that 
Julie undergo amniocentesis.  According to Julie, she again 
rejected amniocentesis because, in her view, it is performed 
too far along in the pregnancy. 
Throughout her pregnancy, Dr. Fruiterman and Dr. Solos-
Kountouris also recommended that Julie receive genetic 
counseling.  Despite their recommendations, Julie never 
attended genetic counseling.  Additionally, she never underwent 
amniocentesis, despite a positive alpha-fetoprotein blood test 
result in June 2002.  The result signaled that the fetuses had 
a high risk for Down syndrome.  In September 2002, Julie gave 
birth to identical twin girls, both of whom are afflicted with 
Down syndrome. 
At trial, Julie insisted that, if the Doctors had advised 
her about the availability of CVS either before or during the 
first trimester of her pregnancy, she would have undergone the 
test.  Julie stated she would not have bonded with her fetuses 
before the test could have been performed.  She further 
testified that, if the test result had been positive, meaning 
her twin fetuses were afflicted with Down syndrome, she “would 
have to have had a double abortion.” 
7 
The Granatas presented testimony from two medical expert 
witnesses.  The first witness, John Williams, III, M.D., an 
expert in the field of obstetrics and gynecology, testified to 
the standard of care for an obstetrician to inform his patients 
about the availability of CVS.  In forming his opinions, 
Dr. Williams relied upon medical literature, one of which 
described amniocentesis and CVS as “definitive diagnostic 
test[s].” 
During cross-examination, Dr. Williams admitted that there 
is a possibility of receiving a false result from CVS, but 
claimed such a result is “extremely rare.”  When asked if there 
are instances of positive CVS results that have been disproved 
by later tests indicating a fetus is normal, Dr. Williams 
explained that there are occasions when there is a “mixture of 
normal and abnormal cells, and in that situation better than 90 
percent of the time the fetus is not affected.”  He also stated 
that about 1-in-100 patients would require a follow-up 
amniocentesis to “sort things out” after receiving a positive 
CVS.  At no time during his testimony did Dr. Williams state 
his opinion as to whether CVS would have been positive for Down 
syndrome if Julie had undergone that test. 
Similarly, the Granatas’ other medical expert witness, 
Ronald J. Wapner, M.D., also an expert in the field of 
obstetrics and gynecology, expressed no opinion on that 
8 
particular issue.  Dr. Wapner, like Dr. Williams, acknowledged 
that one of the risks associated with undergoing either CVS or 
amniocentesis is the possibility of having “false positives and 
false negatives, and sometimes information that just won’t be 
interpretable at all.” 
One of the Doctors’ witnesses, Mary E. D’Alton, M.D., who 
testified as an expert in the field of obstetrics and 
gynecology, stated there is a problem in using CVS in the case 
of twin fetuses because of the potential for “cross-
contamination . . . between the placentas” or two samples from 
only one fetus.  Thus, in her opinion, a 1-in-20 chance exists 
that a CVS in a pregnancy with twin fetuses will provide mixed 
information, thereby requiring further testing such as 
amniocentesis.  Additionally, Dr. D’Alton testified that there 
is a “potential for misdiagnosis with CVS that is not there 
with amniocentesis.” 
B. Analysis 
In addressing the Doctors’ challenge to the sufficiency of 
the evidence to prove that, if Julie had undergone CVS, the 
result would have shown the chromosomal abnormality associated 
with Down syndrome, we apply established principles of 
appellate review.  A plaintiff who is “[a]rmed with a jury 
verdict approved by the trial court, . . . stands in ‘the most 
favored position known to the law.’ ”  Bitar v. Rahman, 272 Va. 
9 
130, 137, 630 S.E.2d 319, 323 (2006) (quoting Ravenwood Towers, 
Inc. v. Woodyard, 244 Va. 51, 57, 419 S.E.2d 627, 630 (1992)).  
When a trial court has refused to strike a plaintiff’s evidence 
or to set aside a jury verdict, the well-established standard 
of appellate review requires this Court to determine whether 
the evidence presented at trial, taken in the light most 
favorable to the plaintiff, was sufficient to support the jury 
verdict in favor of the plaintiff.  Id. at 141, 630 S.E.2d at 
325-26.  We will not set aside a trial court’s judgment 
sustaining a jury verdict unless it is “plainly wrong or 
without evidence to support it.”  Code § 8.01-680; see also 
Bitar, 272 Va. at 137, 630 S.E.2d at 323.  
In Julie’s wrongful birth case, as in any medical 
malpractice action, one of the elements that a plaintiff must 
prove is “a causal connection between the breach of duty and 
any claimed injury or damage.”  Naccash v. Burger, 223 Va. 406, 
414, 290 S.E.2d 825, 829 (1982); see also Bryan v. Burt, 
254 Va. 28, 34, 486 S.E.2d 536, 539–40 (1997) (“[A] plaintiff 
must establish not only that a defendant violated the 
applicable standard of care, and therefore was negligent, the 
plaintiff must also sustain the burden of showing that the 
negligent acts constituted a proximate cause of the injury.”); 
Brown v. Koulizakis, 229 Va. 524, 532, 331 S.E.2d 440, 446 
(1985) (same). 
10 
Although the issue of proximate causation is normally a 
question of fact for the jury to determine, a court may decide 
the issue “when reasonable persons could not differ.”  Jenkins 
v. Payne, 251 Va. 122, 128, 465 S.E.2d 795, 799 (1996); accord 
Hadeed v. Medic-24, Ltd., 237 Va. 277, 285, 377 S.E.2d 589, 593 
(1989).  Expert testimony is generally required to establish 
not only the appropriate standard of care and a deviation from 
the standard, but also “ ‘that such a deviation was the 
proximate cause of the claimed damages.’ ”  Perdieu v. 
Blackstone Family Practice Ctr., Inc., 264 Va. 408, 420, 
568 S.E.2d 703, 710 (2002) (quoting Raines v. Lutz, 231 Va. 
110, 113, 341 S.E.2d 194, 196 (1986)); accord Bitar, 272 Va. at 
138, 630 S.E.2d at 323. 
In the case before us, Julie claimed the Doctors breached 
the standard of care by failing to inform her about the 
availability of CVS either prior to or during her pregnancy.  
She further alleged that, if she had known about CVS at a time 
during the pregnancy when she could have had the test, she 
would have done so and would have terminated her pregnancy if 
the result had been positive for Down syndrome. 
Julie, however, did not prove to a reasonable degree of 
medical probability that, if she had undergone CVS, the result 
would have shown the chromosomal abnormality indicative of Down 
syndrome.  None of Julie’s medical expert witnesses opined 
11 
about what the result of CVS would have been if Julie had 
undergone the procedure.  Moreover, the Granatas acknowledged 
before the circuit court that no such evidence existed in the 
record.  Thus, Julie failed to establish that the Doctors’ 
breach of the standard of care was a proximate cause of the 
wrongful birth of her twin daughters. 
Julie, nevertheless, contends Dr. Williams’ testimony, 
read from medical literature that classified CVS as a 
“definitive diagnostic test,” provided the requisite proximate 
cause.  Julie argues on appeal that the term “definitive” means 
CVS results would have been positive if she had undergone the 
procedure.  We are not persuaded by her argument.  The term 
“definitive” means “serving to supply a final answer, solution, 
or evaluation and to end an unsettled unresolved condition.”  
Webster’s Third New International Dictionary 592 (1993).  The 
term does not signify that a certain answer will be provided; 
it indicates only that some answer will be ascertained. 
Because her twin daughters unquestionably have Down 
syndrome, Julie also contends she is entitled to an inference 
that if she had undergone CVS, the result would have been 
positive for Down syndrome.  This is so, according to Julie, 
because in CVS, the laboratory technician has only to count the 
number of chromosomes to determine whether there is an extra 
12 
copy of chromosome 21, meaning the presence of Down syndrome.  
Again, we do not agree. 
This wrongful birth case is not one of those “rare 
instances” in which expert testimony is not required to prove, 
among other things, that breach of the standard of care was a 
proximate cause of the claimed damages.  Beverly Enterprises 
Virginia, Inc. v. Nichols, 247 Va. 264, 267, 441 S.E.2d 1, 3 
(1994); see also Coston v. Bio-Medical Apps. of Va., 275 Va. 1, 
5, 654 S.E.2d 560, 562 (2008).  Whether the result of CVS would 
have been positive for Down syndrome if Julie had undergone 
that procedure is not a matter within the common knowledge and 
experience of a jury.  See Perdieu, 264 Va. at 420–21, 568 
S.E.2d at 710–11.  Furthermore, the Granatas’ evidence from 
their medical expert witnesses showed that many patients 
require a follow-up amniocentesis after receiving a positive 
CVS.  The Granatas, through their medical experts, also 
presented evidence about the risks of false positive and false 
negative results with CVS. 
Thus, we conclude that the circuit court erred in refusing 
to set aside the jury verdict in Julie’s favor.5  The judgment 
was without evidence to support it.  Code § 8.01-680. 
                     
5 In light of our decision, we will not address the 
Doctors’ other assignments of error. 
13 
III. JOSEPH’S APPEAL 
A. Relevant Facts 
With regard to the questions whether Joseph proved a 
physician-patient relationship with Dr. Solos-Kountouris and if 
not, whether Dr. Solos-Kountouris nevertheless undertook to 
provide Joseph with health care, Joseph acknowledges that he 
must rely on the events that transpired during Julie’s April 
19, 2002 appointment to establish that Dr. Solos-Kountouris 
owed him a duty of care.  Joseph testified that he first 
accompanied Julie to the Doctors’ office on that date and 
conceded at trial and before this Court that all the alleged 
negligence occurred on or before April 19, 2002.  Therefore, we 
focus on the facts surrounding Julie’s April 19, 2002 
appointment. 
In that regard, Joseph provided the only relevant 
testimony.6  During his direct examination, the following 
exchange occurred: 
Q.  [Counsel for the Granatas] I direct your 
attention then, Mr. Granata, specifically to the date 
of April 19th.  Do you recall anything at all that 
was significant? 
 
A.  [Joseph] I do.  April 19th was the first 
time I went to the doctor with Julie.  It was at the 
                     
6 Julie’s testimony confirmed that Joseph accompanied her 
to the April 19th appointment but provided no specific 
information concerning any interaction between Dr. Solos-
Kountouris and Joseph.  Dr. Solos-Kountouris did not mention 
Joseph in connection with the April 19th appointment.  
14 
Burke office.  I remember going in the office and 
waiting in a chair next to Julie. 
 
We filled out some paperwork.  We also filled 
out a genetic screening questionnaire, and then they 
came to get Julie and I started to walk back to be 
with her for the exam, and they asked me to wait 
outside until they would call me at a later time. 
 
Q.  What happened then when they brought you 
back? 
 
A.  I went back.  Dr. Sol[o]s, myself and Julie 
were discussing her pregnancy.  I remember discussing 
the genetic questionnaire.  I remember when Julie was 
filling out the questionnaire my nephew had something 
called Prader-Willi, and Julie was writing down that 
it was a form of Down syndrome, and I remember 
telling her I don’t think it’s a form of Down 
syndrome. 
 
I wouldn’t put it there in a spot where it had, 
I guess, any genetic Down syndrome-related children 
or relatives.  We spoke about that genetic screening 
sheet for a while.  I remember the doctor mentioning 
amniocentesis. I remember that we talked about if the 
twins were in one egg or in two sacs . . . . 
 
Q.  Can you tell us what Dr. Sol[o]s told the 
two of you when she was discussing the genetic 
screening form[?] 
 
A.  When we were discussing the genetic 
screening form, I remember her asking some questions 
about my nephew, about my ethnicity.  If there was 
any other history in my family background that had 
any kind of genetic disorder. 
 
Q.  Why were you there at the appointment with 
Julie? 
 
A.  Well, because I was – you know, we were a 
family.  That was part of what we were going through 
together.  This was my children as well. 
 
Q.  What recommendations, if any, did Dr. 
Sol[o]s make to the two of you? 
15 
 
A.  Again, I believe she recommended 
amniocentesis, and I believe she recommended a 
geneticist. 
 
Q.  Let me ask you specifically if you can tell 
us whether or not the word “CVS” was mentioned by 
her. 
 
A.  I never heard that word ever until after the 
twins were born. 
 
. . . . 
 
Q.  Let me ask [w]hat was your reason for being 
there to discuss these issues? 
 
A.  Because I was an active participant in the 
pregnancy.  I wanted to support Julie, and I was 
seeking guidance from her doctors. 
 
Joseph gave the following relevant testimony during cross-
examination: 
Q.  [Counsel for the Doctors]  When you attended 
the visit on April 19th, 2002, that was conducted by 
Dr. Sol[o]s-Kountouris, was advanced maternal age 
discussed? 
 
A.  [Joseph]  Yes.  When I was in the room there 
was a portion of the time when I was outside.  When I 
was invited into the room to discuss the 
questionnaire, that was certainly a topic that was 
discussed as well as the twins being a potentially 
high-risk pregnancy because of those things. 
 
Q.  So the risks were discussed of this 
pregnancy? 
 
A.  That’s correct. 
 
Q.  You also, I think, indicated to us Dr. 
Sol[o]s-Kountouris discussed the possibility or 
recommended amniocentesis at that time; is that 
correct? 
 
16 
A.  That’s correct . . . she also said there was 
plenty of time, but she wanted to put it out there so 
we had an opportunity to consider it. 
 
. . . . 
 
Q.  Did Dr. Sol[o]s-Kountouris also talk to you 
about genetic counseling at that time? 
 
A.  I remember the conversation about genetic 
counseling.  I don’t remember specifically back and 
forth – it was during the time we were actually 
discussing the genetic questionnaire, and I remember 
questions about my nephew.  I remember questions 
about my ethnicity. 
 
. . . . 
 
Q.  And you participated in the completion of 
the genetic screening sheet on the April 19th visit? 
 
A.  Could you define what you mean by 
“completion.”  Did I help fill it out? Yes. 
 
Q.  You provided input to that form? 
 
A.  Yes. 
 
In addition to Joseph, two of the Granatas’ expert 
witnesses, Dr. Williams and Dr. Wapner, provided testimony 
relevant to the issues in Joseph’s appeal.  They opined about 
the relationship between an obstetrician and a father.  Dr. 
Williams did not consider a husband to be an obstetric patient 
because there is no treatment or service of an obstetrical or 
gynecological nature that can be provided to a male individual.  
Dr. Williams, however, did state that when a physician takes 
care of a pregnant woman, the physician is “taking care of a 
couple[, s]o in that case the husband is not specifically an OB 
17 
patient, but we’re taking care of the family.”  According to 
Dr. Williams, when a husband accompanies “his wife as the 
husband,” they are “entitled to receive information regarding 
care of the pregnancy as well.”  Dr. Wapner stated, “[W]hen 
you’re counseling about genetic risks to a fetus you are 
counseling the couple which includes – the woman and – and the 
man.”  Finally, Dr. Williams acknowledged that, if the term 
“medical care” is defined as the “giving of advice,” then a 
husband should receive medical care. 
B. Analysis 
Although the circuit court granted the Doctors’ motion to 
strike the evidence in Joseph’s case, it did so after the jury 
had returned a verdict in his favor.  Regardless, the standard 
of appellate review is the same: whether the evidence viewed in 
the light most favorable to the plaintiff is sufficient to 
sustain a jury verdict in favor of the plaintiff.  Bitar, 272 
Va. at 141, 630 S.E.2d at 325-26. 
The decision as to whether a physician-patient 
relationship exists “is a question of fact, turning upon a 
determination whether the patient entrusted his treatment to 
the physician and the physician accepted the case.”  Lyons v. 
Grether, 218 Va. 630, 633, 239 S.E.2d 103, 105 (1977).  “A 
physician’s duty arises only upon the creation of a physician–
patient relationship; that relationship springs from a 
18 
consensual transaction, a contract, express or implied, general 
or special.”  Id.; accord Washburn v. Klara, 263 Va. 586, 590, 
561 S.E.2d 682, 685 (2002) (“[T]he physician-patient 
relationship is a consensual one.”) (citing Pugsley v. 
Privette, 220 Va. 892, 899, 263 S.E.2d 69, 74 (1980)); see also 
Harris v. Kreutzer, 271 Va. 188, 198, 624 S.E.2d 24, 30 (2006); 
Didato v. Strehler, 262 Va. 617, 626, 554 S.E.2d 42, 47 (2001). 
Joseph first argues he meets the definition of the 
term “patient” as defined in Virginia’s Medical 
Malpractice Act, (the Act), Code §§ 8.01-581.1 through -
581.20:1, and therefore, Dr. Solos-Kountouris owed him a 
duty of care as a patient.  In relevant part, the term 
“ ‘[p]atient’ means any natural person who receives or 
should have received health care from a licensed health 
care provider.”  Code § 8.01-581.1.  Under the Act, the 
term “ ‘[h]ealth care’ means any act, professional 
services in nursing homes, or treatment performed or 
furnished, or which should have been performed or 
furnished, by any health care provider for, to, or on 
behalf of a patient during the patient’s medical 
diagnosis, care, treatment or confinement.”  Code § 8.01-
581.1. 
Relying on these definitions and the testimony of Dr. 
Williams and Dr. Wapner, Joseph contends that a 
19 
physician’s advice about genetic testing constitutes 
“health care” under the Act and that Dr. Solos-Kountouris’ 
failure to advise about the availability of CVS was an 
“act . . . which should have been . . . furnished.”  
Code § 8.01-581.1.  Continuing, Joseph asserts he was a 
person who should have received information from Dr. 
Solos-Kountouris about CVS and was, therefore, a 
“patient.” 
Joseph’s argument, however, ignores the language 
included at the end of the definition of “health care,” 
referring to any act or treatment which should have been 
furnished “during the patient’s medical diagnosis, care, 
treatment or confinement.”  Code § 8.01-581.1 (emphasis 
added).  As already noted, only the events that occurred 
during Julie’s April 19, 2002 appointment are relevant to 
the question whether Dr. Solos-Kountouris diagnosed, cared 
for, or treated Joseph, in addition to Julie, on that 
date.  The facts surrounding the appointment, viewed in 
the light most favorable to Joseph, show that Joseph 
accompanied Julie to the Doctors’ office, assisted Julie 
in filling out the genetic screening questionnaire, and 
responded to questions from Dr. Solos-Kountouris about his 
family background as to genetic disorders.  Joseph was 
excluded from the initial portion of Julie’s appointment 
20 
with Dr. Solos-Kountouris and was, in Joseph’s words, 
“invited into the room to discuss the questionnaire.” 
Although Dr. Solos-Kountouris discussed and/or 
recommended amniocentesis and genetic counseling, the 
evidence demonstrates her “diagnosis, care, [or] 
treatment” on that day was directed to Julie, not to 
Joseph.  Code § 8.01-581.1.  In other words, there is no 
evidence that Joseph “entrusted his treatment to [Dr. 
Solos-Kountouris] and the physician accepted the case.”  
Lyons, 218 Va. at 633, 239 S.E.2d at 105; cf. Gray v. 
INOVA Health Care Servs., 257 Va. 597, 599-600, 514 S.E.2d 
355, 356 (1999) (physician had no duty of care to the 
mother of a patient because the mother was not the 
physician’s patient upon whom the procedure was being 
performed and any negligence was a breach of duty to the 
patient, not the mother); Bulala v. Boyd, 239 Va. 218, 
230, 389 S.E.2d 670, 676 (1990) (stating that “the father, 
of course, was not the [obstetrician’s] ‘patient,’ within 
the meaning of the Act”); Dehn v. Edgecombe, 865 A.2d 603, 
615 (Md. 2005) (“A duty of care does not accrue purely by 
virtue of the marital status of the patient alone; some 
greater relational nexus between doctor and patient’s 
spouse must be established.”). 
21 
Furthermore, Joseph and Julie did not allege that the 
Doctors breached the standard of care by failing to advise 
them as a couple about genetic counseling or to recommend 
genetic screening tests that either Joseph alone or both 
of them would need to undergo. Instead, they asserted that 
the Doctors breached the standard of care by failing to 
inform Julie about the availability of CVS during the 
first trimester of her pregnancy.  Obviously, Julie is the 
only person who could consent to and undergo that 
procedure.  Information about CVS was not an “act . . . 
which should have been . . . furnished” to Joseph.  Code 
§ 8.01-581.1. 
The medical expert witnesses’ testimony about what 
constitutes health care does not alter our conclusion.  In the 
context of a pregnancy, a husband may be entitled to receive 
such information about a fetus’ risk of having genetic 
abnormalities.  The question whether Joseph had a physician-
patient relationship with Dr. Solos-Kountouris, however, turns 
solely on the facts surrounding the April 19, 2002 appointment.  
See Lyons, 218 Va. at 633, 239 S.E.2d at 105. 
Thus, we conclude the evidence, as a matter of law, was 
insufficient to show “a consensual transaction giving rise to a 
physician-patient relationship and a duty to perform the 
service contemplated.”  Id.; see also Harris, 271 Va. at 199-
22 
200, 624 S.E.2d at 30-31 (finding a limited physician-patient 
relationship exists in the context of a Rule 4:10 examination 
because the physician expressly consents to the relationship 
when he agrees to conduct the examination and the patient’s 
consent is implied); Prosise v. Foster, 261 Va. 417, 423, 544 
S.E.2d 331, 334 (2001) (refusing to impose a duty of care on an 
on-call physician in a teaching hospital in the absence of 
proof that the doctor agreed to accept responsibility for the 
care of the patient). 
Relying on this Court’s decision in Didato, Joseph next 
argues that even in the absence of a physician-patient 
relationship, Dr. Solos-Kountouris undertook to provide health 
care to him and was thus required to act in accordance with the 
standard of care.  See Code § 8.01-581.20.  In Didato, we noted 
the legal principle that “one who assumes to act, even though 
gratuitously, may thereby become subject to the duty of acting 
carefully, if he acts at all.”  262 Va. at 628, 554 S.E.2d at 
48 (quoting Nolde Bros. v. Wray, 221 Va. 25, 28, 266 S.E.2d 
882, 884 (1980)).  The Court concluded the plaintiffs had “pled 
sufficient facts which, if proven at trial, would permit the 
finder of fact to conclude that the defendants assumed the 
duty” to provide health care.  Didato, 262 Va. at 629, 554 
S.E.2d at 48.  Additionally, we rejected “[t]he defendants’ 
contention that they could not assume a duty to a non-patient 
23 
to comply with the standard of care in Code § 8.01-581.20.”  
Id. 
As we recognized in Didato, a physician can, in certain 
circumstances, affirmatively undertake to provide health care 
to an individual, who prior to that moment was not the 
physician’s patient, and thereby assume the duty to comply with 
the applicable standard of care.  But see Code § 8.01-225.  
Such a scenario is in contrast to the more traditional 
situation where the patient “knowingly and voluntarily seeks 
the professional assistance of the physician, and the physician 
knowingly agrees to treat the patient.”  Kelley v. Middle Tenn. 
Emergency Physicians, P.C., 133 S.W.3d 587, 593 (Tenn. 2004).  
Nevertheless, in the former circumstance, the physician-patient 
relationship arises by implication because “the doctor takes 
affirmative action to participate in the care and treatment of 
a patient.”  Sterling v. Johns Hopkins Hosp., 802 A.2d 440, 455 
(Md. Ct. Spec. App. 2002); see also Lownsbury v. VanBuren, 762 
N.E.2d 354, 360 (Ohio 2002) (“[A] physician-patient 
relationship, and thus a duty of care, may arise from whatever 
circumstances evince the physician’s consent to act for the 
patient’s medical benefit.”). 
In Didato, the trial court sustained the defendants’ 
demurrers, so we based our decision solely on the plaintiffs’ 
pleadings.  262 Va. at 630, 554 S.E.2d at 49.  We have not had 
24 
the occasion before today to decide whether particular evidence 
adduced at trial was sufficient to prove a physician undertook 
to provide health care to a non-patient, thereby assuming the 
duty to comply with the standard of care.  We agree with the 
holding in Jenkins v. Best, 250 S.W.3d 680, 693 (Ky. Ct. App. 
2007), requiring a physician to “personally engage[] in some 
affirmative act amounting to a render[ing of] services to 
another.”  Id. at 693 (second alteration in original; internal 
quotation marks omitted); see also Stanley v. McCarver, 92 P.3d 
849, 853 (Ariz. 2004) (in the absence of the traditional 
physician-patient relationship, the court nevertheless imposed 
a duty of care because the physician undertook, for 
consideration, to interpret the patient’s x-rays); Dekens v. 
Underwriters Laboratories Inc., 132 Cal. Rptr. 2d 699, 702 
(Cal. Ct. App. 2003) (in applying the “negligent undertaking 
doctrine,” the actor “must specifically have undertaken to 
perform the task that he is charged with having performed 
negligently, for without the actual assumption of the 
undertaking there can be no correlative duty to perform that 
undertaking carefully”). 
Applying these principles to Joseph’s claim that Dr. 
Solos-Kountouris affirmatively undertook to provide him with 
health care, we again conclude the evidence was insufficient as 
a matter of law.  As demonstrated by our prior discussion, 
25 
Joseph did not establish an affirmative act by Dr. Solos-
Kountouris during the April 19, 2002 appointment that would 
amount to the rendering of health care to Joseph.  See Jenkins, 
250 S.W.3d at 693.  Thus, Dr. Solos-Kountouris assumed no duty 
to comply with the applicable standard of care with regard to 
Joseph.  We therefore hold that the circuit court did not err 
in granting the Doctors’ motion to strike the evidence in 
Joseph’s case. 
IV. CONCLUSION 
 
We will reverse the judgment of the circuit court in the 
Doctors’ appeal.  The evidence was insufficient as a matter of 
law to prove to a reasonable degree of medical probability that 
if Julie had undergone CVS, the result would have been positive 
for Down syndrome. 
We will affirm the judgment of the circuit court in 
Joseph’s appeal.  The evidence was insufficient as a matter of 
law to prove that either he had a physician-patient 
relationship with Dr. Solos-Kountouris or Dr. Solos-Kountouris 
engaged in an affirmative act amounting to the rendering of 
health care. 
Record No. 071894 – Reversed and final judgment. 
 Record No. 071897 – Affirmed. 
26