Case Title: Jean Matthies v. Edward D. Mastromonaco, D.O

Citation: 

Docket Number: a-9-98

State: new-jersey

Court: New Jersey Supreme Court

Date: 1999-07-08T00:00:00Z

Document:
(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please note that, in the interests of brevity, portions of any opinion may not have been summarized). POLLOCK, J., writing for a unanimous Court. The issues before the Court are: whether the doctrine of informed consent requires a doctor to obtain the patient's consent before implementing a nonsurgical procedure; and whether a doctor, in discussing with the patient treatment alternatives that he or she recommends, should discuss medically reasonable alternative courses of treatment that the doctor does not recommend. On August 26, 1990, Jean Matthies fell in her apartment and fractured her right hip. At the time, Matthies was eighty-one years old and living alone in a senior citizen residence in Union County. She maintained an independent lifestyle. Dr. Mastromonaco, an osteopath and board-certified orthopedic surgeon, was called in to consult on Matthies's care and treatment. Dr. Mastromonaco reviewed Matthies's medical history, condition and x rays and decided against pinning her hip. He based that decision on three factors: 1) Matthies was elderly, frail, and in a weakened condition making surgery risky; 2) Matthies had osteoporosis, leading Dr. Mastromonaco to conclude that Matthies's bones were too porous to hold the steel screws; and 3) forty years earlier, Matthies had suffered a stroke that left her partially paralyzed on her right side, resulting in its limited use. Dr. Mastromonaco concluded that bed rest would enable Matthies's right hip to heal sufficiently to restore her right leg to its limited function. Matthies's orthopedic expert testified at trial that, under the circumstances, bed rest was an inappropriate treatment unless the patient does not expect to walk again and because of the risk of dislocation of the hip. In fact, shortly after Matthies began her bed rest treatment, the head of the right femur displaced, resulting in a shortening of the right leg and her continued inability to walk. Even Dr. Mastromonaco's expert agreed that pinning Matthies's hip would have decreased the risk of displacement; however, the expert also agreed that Matthies's bones were too porous to withstand insertion of the pins. Five years after her initial injury, Matthies had two hip replacement surgeries. Nonetheless, the unequal lengths of her legs have continued to prevent her from walking. She lives in a nursing home, is confined to a bed or chair, and is completely dependent on others. Matthies sued Dr. Mastromonaco on two theories: 1) he deviated from accepted standards of medical care by failing to pin her hip at the time of her injury; and 2) he negligently failed to obtain her informed consent to bed rest as an alternative treatment by specifically failing to disclose the alternative of surgery. At trial, Dr. Mastromonaco argued that informed consent is irrelevant in noninvasive treatment cases. The trial court accepted that argument. The court refused to charge the jury on the issue of lack of informed consent and did not allow Matthies's attorney to question Dr. Mastromonaco on the issue of disclosure of alternative procedures. The jury concluded that Dr. Mastromonaco had not deviated from accepted standards of medical care and, therefore, returned a verdict of no cause of action. The Appellate Division reversed, finding that the doctrine of informed consent applies to noninvasive, as well as invasive, procedures. Concluding that the restriction on the presentation of evidence on the informed consent claim affected Matthies's medical malpractice claim, the court remanded the matter to the trial court for a new trial on both issues. The Supreme Court granted Dr. Mastromonaco's petition for certification. HELD: To obtain a patient's informed consent to one of several alternative courses of treatment, the physician should explain the medically reasonable invasive and noninvasive alternatives, including the risks and the likely outcomes of those alternatives, even when the chosen course is noninvasive. 1. A patient has a duty to disclose to his or her doctor all information necessary for the doctor to make a diagnosis and determine a course of treatment. In turn, the doctor has the duty to evaluate the relevant information and disclose all courses of treatment that are medically reasonable under the circumstances. It is for the patient to make the ultimate decision regarding treatment based on the doctor's recommendation. Informed consent applies to invasive and noninvasive procedures. (pp. 10-12) 2. Under the negligence theory of informed consent, the analysis focuses on the physician's deviation from the standard of care rather than on an unauthorized touching required under the battery theory. The decisive factor is whether the physician adequately presents the material facts so that the patient can make an informed decision. That disclosure is limited by the reasonable patient standard: the physician is obligated to disclose only that information material to a reasonable patient's informed decision. (pp. 12-14) 3. To insure informed consent, the physician must inform patients of medically reasonable treatment alternatives and their attendant probable risks and outcomes. Physicians do not adequately discharge that duty by disclosing only treatment alternatives that they recommend. The test for measuring the materiality of the risk of a treatment is whether a reasonable patient in the patient's position would have considered the risk material. A physician should discuss the medically reasonable courses of treatment, including nontreatment. (pp. 14-17) 4. A cause of action based on the doctor's breach of the standard of care does not adequately protect the patient's right to be informed of treatment alternatives. Like the deviation from the standard of care, the doctor's failure to obtain informed consent is a form of medical negligence. Recognition of a separate duty emphasizes the doctor's obligation to inform, as well as treat, the patient. (pp. 18-20) 5. The jury did not have the opportunity to consider whether Dr. Mastromonaco had obtained Matthies's informed consent to the treatment he recommended. Because the issues of informed consent and deviation from the standard of care are interrelated, the jury should consider both issues on retrial. (pp. 20-21) Judgment of the Appellate Division is AFFIRMED. CHIEF JUSTICE PORITZ and JUSTICES HANDLER, O'HERN, GARIBALDI, STEIN and COLEMAN join in JUSTICE POLLOCK'S opinion. SUPREME COURT OF NEW JERSEY A- 9 September Term 1998 JEAN MATTHIES, Plaintiff-Respondent, v. EDWARD D. MASTROMONACO, D.O., Defendant-Appellant. Argued February 16, 1999 -- Decided July 8, 1999 On certification to the Superior Court, Appellate Division, whose opinion is reported at 310 N.J. Super. 572 (1998). Melvin Greenberg argued the cause for appellant (Greenberg Dauber & Epstein, attorneys; Mr. Greenberg and Michael H. Freeman, on the briefs). Arthur J. Messineo, Jr., argued the cause for respondent (Messineo & Messineo, attorneys; Nancy C. Ferro, on the brief). The opinion of the Court was delivered by POLLOCK, J. The medical profession likewise recognizes the physician's obligation to explain all medically reasonable alternatives to the patient. The American Medical Association's Code of Medical Ethics states: The patient's right of self-decision can be effectively exercised only if the patient possesses enough information to enable an intelligent choice. The patient should make his or her own determination on treatment. The physician's obligation is to present the medical facts accurately to the patient or to the individual responsible for the patient's care and to make recommendations for management in accordance with good medical practice. . . . Social policy does not accept the paternalistic view that the physician may remain silent because divulgence might prompt the patient to forego needed therapy. Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment. NO. A-9 JEAN MATTHIES, Plaintiff-Respondent, v. EDWARD D. MASTROMONACO, D.O., Defendant-Appellant. DECIDED