Title: Macy v. Blatchford

State: oregon

Issuer: Oregon Supreme Court

Document:

Filed:  August 3, 2000
IN THE SUPREME COURT OF THE STATE OF OREGON

DANITA J. MACYand LAWRENCE B. MACY,
	Petitioners on Review,
	v.
DOUGLAS M. BLATCHFORD, M.D.,
	Respondent on Review,
	and
PHILLIP S. ALBERTS, M.D.,
	Defendant.
(CC 9407-04746; CA A93045; SC S45678)

	En Banc
	On review from the Court of Appeals.*
	Argued and submitted September 10, 1999.
	Kathryn H. Clarke, Portland, argued the cause and filed the
brief for petitioners on review.
	Lindsey H. Hughes, of Keating Jones Bildstein Hughes &
Yelnosky, P.C., Portland, argued the cause and filed the brief
for respondent on review.
	D. Lawrence Wobbrock, Michael Banks, and Robert K. Udziela,
of Pozzi Wilson Atchison LLP, Portland, filed the briefs for
amicus curiae Oregon Trial Lawyers Association. 
	GILLETTE, J.
	The decision of the Court of Appeals is affirmed in part and
reversed in part.  The judgment of the circuit court is reversed,
and the case is remanded to the circuit court for further
proceedings.
	*Appeal from Multnomah County Circuit Court, 
	 Harl H. Haas, Judge.
	 154 Or App 313, 961 P2d 873 (1998).
		GILLETTE, J.
	In this medical malpractice action, plaintiffs Danita
and Lawrence Macy challenge a trial court ruling that prevented
them from introducing evidence at trial that Dr. Blatchford
(defendant) had a sexual relationship with Danita Macy (1) at the
time when the Macys assert that he negligently treated her for
persistent and debilitating pelvic pain.  The Court of Appeals
affirmed that ruling, specifically holding that the trial court
did not err in granting defendant's motion in limine to exclude
any evidence that he and Macy had a relationship of that kind.
Macy v. Blatchford, 154 Or App 313, 329, 961 P2d 873 (1998).  The
Macys sought review by this court, and we allowed their petition
to consider whether and how evidence of a sexual relationship
might be relevant to a claim that a physician's treatment of a
patient was negligent.  We conclude that such evidence is
relevant to one of the Macys' allegations, viz., that defendant
was negligent in failing to obtain Macy's informed consent to
recommended surgery.  We therefore reverse the decision of the
Court of Appeals on that ground.
		In January 1992, Macy consulted with defendant, a
gynecologist, about severe and persistent pelvic pain.  Macy had
complained to defendant about pelvic pain previously, in 1982 and
in 1985.  Dr. Alberts examined Macy and performed a laparoscopy
in February 1992, in the course of which he removed an
endometrioma (an abnormal growth of uterine tissue outside the
uterus) from Macy's left ovary.  After reviewing Dr. Alberts'
report and a videotape made during the laparoscopic surgery,
defendant diagnosed endometriosis, a condition marked by growth
of uterine tissue outside the uterus. 
 		In May 1992, Macy again complained to defendant about
pelvic pain.  Defendant recommended additional laparoscopic
surgery, including removal of Macy's left ovary and fallopian
tube.  On June 3, 1992, defendant performed that surgery. 
Afterwards, Macy continued to suffer pelvic pain.  Defendant then
discussed with Macy the possibility of removing her right ovary
and fallopian tube, along with her uterus.  Macy agreed to the
additional surgery, which defendant performed on August 20, 1992. 
		Macy's pelvic pain did not subside after the second
surgery.  In fact, she began to suffer from new pain in her left
side and back.  Ultimately, Macy consulted a different physician,
Dr. Ellis, about the latter pain.  Ellis determined that Macy's
left ureter -- the tube connecting the kidney to the bladder --
was obstructed, and performed surgery to correct the problem. 
Ellis believed that defendant inadvertently had stapled Macy's
ureter during the June 1992 surgery, thereby causing the
obstruction and related pain. (2)  
		In 1994, the Macys filed the present malpractice action
against defendant.  In their complaint, they alleged four
specifications of negligence -- that defendant had been negligent
in:  (1) stapling Macy's ureter during the June 1992 surgery; (2)
failing to ascertain that Macy's continuing pain after the June
1992 surgery arose from the obstructed ureter; (3) recommending
the August 1992 surgery; and (4) failing to obtain Macy's
informed consent for the August 1992 surgery.  Defendant's answer
denied all four specifications of negligence.  
		Shortly before trial, the Macys moved to amend their
complaint to include a fifth specification -- that defendant had
been negligent in continuing his physician-patient relationship
with Macy after entering into a personal, sexual relationship
with her.  In submitting their motion, the Macys asserted that
defendant would not be prejudiced by the addition of that
specification, because he and his attorneys had been aware from
the beginning that the Macys intended to make an issue of the
alleged personal relationship.
		Defendant opposed the motion to amend, arguing that the
amendment was time-barred, that its inclusion would be unfairly
prejudicial, and that the Macys had failed to allege any injury
related to that amendment.  Defendant also filed a motion in
limine to exclude any evidence of a sexual relationship between
Macy and defendant.  Defendant argued that any such evidence was
unfairly prejudicial, OEC 403, and that it was irrelevant to the
specifications of negligence that the Macys had pleaded, OEC 402. 
Ultimately, the trial court denied the Macys' motion to amend and
granted defendant's motion in limine. (3)  A jury thereafter
returned a verdict in favor of defendant.  
		The Court of Appeals affirmed the trial court's rulings
concerning the motion to amend and the motion in limine.  With
regard to the motion in limine, the court opined that the
evidence of a sexual relationship between defendant and Macy was
not admissible, because it was not relevant to any of the
specifications of negligence that the Macys had pleaded.  Macy,
154 Or App at 326-29.  The Court of Appeals also concluded that,
even if erroneous, the denial of the Macys' motion to amend could
not amount to reversible error, because the Macys had suffered no
actual prejudice from that ruling.  The court explained that the
theory underlying the amendment -- that Macy would not have
undergone the August 1992 surgery if she had been referred to
another physician -- was defeated by a special finding by the
jury that defendant's surgery recommendation was one that could
have been made in compliance with the applicable standard of
care.  Id. at 331. 
		In their petition to this court, the Macys challenge
only the Court of Appeals' affirmance of the trial court's order
granting defendant's motion in limine.  They argue that, contrary
to the Court of Appeals' reasoning, evidence of a sexual
relationship between defendant and Macy was relevant to the third
(negligence in recommending the August 1992 surgery) and fourth
(negligence in failing to obtain informed consent) specifications
of negligence in their complaint. (4)  In considering those
arguments, we are mindful of the relatively low threshold of
relevance that is required under the Oregon Evidence Code.  Under
OEC 401, evidence is relevant if it has "any tendency to make the
existence of any fact that is of consequence to the determination
of the action more probable or less probable than it would be
without the evidence."  (Emphasis added.)
		The Macys argue that evidence of a sexual relationship
between defendant and Macy is relevant to their third
specification, because it supports an inference that, at the time
that he recommended additional surgery, defendant lacked the
objectivity that is required of physicians in their treatment of
patients.  The Court of Appeals rejected that theory, reasoning
that the standard of care for medical practitioners does not
delve into the practitioner's state of mind and requires only
that his or her treatment of patients be objectively reasonable:
"The question presented by the third specification was
whether defendant's recommendation of the August 1992
surgery was objectively reasonable given the totality
of plaintiff's medical circumstances. * * * Factors
bearing on defendant's subjective state of mind were
irrelevant to that objective inquiry."
Macy, 154 Or App at 326-27 (emphasis in original).
		The Macys argue that the foregoing reasoning is "just
plain wrong."  They contend that, because defendant's conduct
must be measured against a standard set by his own profession and
because "everyone," including the medical profession as a whole,
understands that physicians must be dispassionate and objective
when making treatment decisions, maintaining an objective mental
state is part of the standard of care that is applicable in this
case.  Thus, they conclude, any fact suggesting that defendant
lacked objectivity in making his treatment recommendations to
Macy is relevant and admissible to show that he was negligent.    
		We are not persuaded.  The standard of care that is
applicable to the medical profession requires physicians to "use
that degree of care, skill and diligence that is used by
ordinarily careful physicians * * * in the same or similar
circumstances in the community of the physician * * * or a
similar community."  ORS 677.095(1); see also Creasey v. Hogan,
292 Or 154, 163, 637 P2d 114 (1981) (stating standard).  That
standard is an objective one; it provides no ground for delving
into a physician's subjective state of mind.  Physicians may
violate their ethical duties if they fail to maintain the
requisite clear and objective state of mind -- for example, if
they work while intoxicated or while their judgment is clouded by
a relationship with a patient.  But if, despite their less than
optimal mental and emotional condition, their actual treatment of
a patient reflects the appropriate degree of care, they cannot be
held liable in negligence.
		This court has suggested as much in its cases.  For
example, in Eckleberry v. Kaiser Foundation et al, 226 Or 616,
624, 359 P2d 1090 (1961), the court considered a plaintiff's
requested instruction to the effect that a specialist has a duty
to "possess[] that degree of learning and skill ordinarily
possessed by specialists * * * in the same * * * field."  The
court concluded:
	"The plaintiff's requested instruction was clearly
erroneous.  Under the requested instruction, the test
of whether or not the practitioner was negligent is
based upon his knowledge of his professed art.  A
licensed practitioner of the healing art of medicine is
presumed to have the necessary medical knowledge to
practice his profession.  The law cannot equate the
mental ability of various individuals; it seeks only to
fix a standard by which a jury may determine whether or
not the practitioner has properly performed his duties
toward his patient."
Id. at 624-25 (emphasis added).
		Similarly, in Rogers v. Meridian Park Hospital, 307 Or
612, 772 P2d 929 (1989), the court considered the correctness of
the then-standard error-of-judgment instruction.  That
instruction provided, inter alia, that, when there are
differences of opinion among members of the medical profession as
to the proper course of treatment, a physician must exercise
"reasonable judgment."  Id. at 615.  The court concluded that the
instruction in question was confusing and that its use was
reversible error.  It explained that the instruction "makes it appear that reasonable judgment is the
crucial issue.  It is not.  In fact, reasonable
judgment is irrelevant if the treatment option selected
provides reasonable care.  A doctor may not know that
there is more than one treatment option, or the doctor
may adhere only to one option, unreasonably rejecting
all others.  In both of these instances the doctor, by
ignoring or rejecting all other treatment options, may
not be exercising reasonable judgment.  Nevertheless,
the doctor is not liable for negligence if the
treatment furnished is consistent with reasonable
care."
Id. at 619 (emphasis in original).		  
		In the present case, the jury had to determine in
addressing the Macys' third specification of negligence whether
defendant's recommendation for the August 1992 surgery was
objectively reasonable, i.e., whether that recommendation
departed from the treatment that other gynecologists in the
community exercising ordinary care would have offered. 
Defendant's subjective frame of mind in making that
recommendation was not relevant to that issue.  Thus, at least
insofar as the Macys sought to offer evidence of a sexual
relationship to prove something about defendant's state of mind
in the context of that specification, the trial court properly
excluded it from the jury's consideration.  In that respect, the
trial court and Court of Appeals did not err. (5)        
		The Macys next argue that the excluded evidence was
relevant to their fourth specification, which alleged negligence:
"[i]n failing to obtain Plaintiff Danita Macy's
informed consent to surgical removal of her uterus and
right ovary, in that Defendant * * * did not advise her
that there were medical and conservative surgical
treatment options available as alternatives to
sterilization and menopause, and he did not ask if she
wanted detailed information about each of these
alternatives."
		The Macys contend that the duty of physicians to obtain
informed consent includes a duty to explain that there may be
alternative methods of treatment and that the duty presupposes
that the patient is in a condition to understand the information
that is being conveyed.  In view of that presupposition, the
Macys argue, evidence that shows that a physician was aware that
a patient was not capable of understanding a physician's
explanation is relevant to whether the physician's actions met
the applicable standard of care.  In the Macys' view, evidence of
a sexual relationship between defendant and Macy thus is
relevant, because it would support a conclusion that Macy lacked
the state of mind that the standard of care implies, i.e., such
evidence would tend to prove that Macy would trust defendant's
treatment choice implicitly and would be incapable of listening
objectively to any information about alternatives that defendant
might have presented.        
		The Court of Appeals did not address that argument.  
It concluded on a different ground that the evidence at issue was
irrelevant, focusing on what it perceived as an inadequacy in the
Macys' pleading:
"[P]laintiff's state of mind -- her subjective
willingness to seek additional information -- is
irrelevant to her informed consent claim, as that claim
is pleaded.  As noted, plaintiffs' informed consent
specification focuses solely on defendant's conduct,
particularly whether defendant told plaintiff that
'there were medical and conservative surgical treatment
options available * * *.'  Thus, even assuming that
evidence pertaining to the alleged relationship might
bear on plaintiff's state of mind, her state of mind
was irrelevant to the informed consent specification." 
Macy, 154 Or App at 329 (emphasis added). 
		We do not agree with that interpretation of the Macys'
informed consent specification.  The Macys pleaded that defendant
failed to "obtain Plaintiff Danita Macy's informed consent" -- words
that relate to Macy's state of mind when she consented to the second
surgery.  The issues were whether Macy "consented" and whether her
consent was "informed."  A physician's failure to "advise" of
treatment alternatives may arise solely out of a physician's
silence, but it also may arise in circumstances when the physician
mouths the words to a patient who, for whatever reason, at that time
lacks the capacity to listen to or to understand the significance of
what is being said.  In short, we are not persuaded by the Court of
Appeals' conclusion that the Macys' pleadings are a barrier to
considering their theory.  We turn to the theory itself.  
		The standard of care with respect to informed consent in
medical malpractice cases is codified at ORS 677.097.  See Zacher v.
Petty, 312 Or 590, 593, 826 P2d 619 (1992) (so stating).  ORS
677.097 provides, in part:
	"(1) In order to obtain the informed consent of a
patient, a physician * * * shall explain the following:
		"(a) In general terms the procedure or treatment to
be undertaken;
		"(b) That there may be alternative procedures or
methods of treatment, if any; and, 
		"(c) That there are risks, if any, to the procedure
or treatment.
		"(2) After giving the explanation specified in
subsection (1) of this section, the physician * * * shall
ask the patient if the patient wants a more detailed
explanation.  If the patient requests further explanation,
the physician * * * shall disclose in substantial detail
the procedure, the viable alternatives and the material
risks unless to do so would be materially detrimental to
the patient."
		Because the legislature defined informed consent by
statute, we must attempt to determine its intent with regard to the
relevance of the patient's state of mind.  To do so, we employ the
analysis set out in PGE v. Bureau of Labor and Industry, 317 Or 606,
859 P2d 1143 (1993).  Under PGE, we first consider the text and
context of ORS 677.097, and proceed to other considerations only if
text and context are inconclusive.  Id. at 610-11.           
		In our view, it is significant that the statute requires a
physician to "explain" the treatment, alternatives, and risks to his
or her patient.  "Explain" means "to make plain or understandable: 
clear of complexities or obscurity: * * * provide an understanding
of [something]."  Webster's Third New Int'l Dictionary, 801
(unabridged ed 1993).  Explanation implies more than a mere correct
statement of the facts.  An explanation clarifies an issue or makes
it understandable to the recipient and, almost by definition, takes
into account the mental state and capabilities of the recipient. 
For example, a physician can mouth words to an infant, or to a
comatose person, or to a person who does not speak his or her
language but, unless and until such patients are capable of
understanding the physician's point, the physician cannot be said to
have "explained" anything to any such person.  
		We also find it significant that the "explanation"
requirement occurs in the context of describing what must be done to
obtain a patient's informed consent.  An "explanation" is "something
that explains or that results from the act or process of
explaining."  Id.  In that context, it is clear that the whole point
of explaining the required information is to ensure that patients
have the information that they need to decide whether to agree to
the recommended treatment.  The concept presupposes that the patient
is capable not only of understanding the risks of and alternatives
to a proposed treatment, but of using that information in a rational
decision-making process.     
		It follows that evidence that a patient did not, for
whatever reason, have the capacity to understand and use what a
physician told her would be relevant to show that the physician
failed to obtain the patient's informed consent.  That inquiry is
not limited to evidence that purports to demonstrate an absolute
inability to process a physician's words.  In the context of the
present case, for example, a reasonable juror might believe that a
sexual relationship between defendant and Macy would undermine
Macy's ability to listen objectively to and utilize information
provided by the physician, in making an independent and informed
decision about her health care. (6) 
		For the foregoing reasons, we conclude that evidence of a
sexual relationship between a physician and patient may be relevant
to show that the physician failed to obtain the patient's informed
consent for treatment, and that the evidence that the Macys offered
here was relevant in that respect. (7)  The trial court therefore erred
when it concluded that any evidence respecting a sexual relationship
between defendant and Macy was irrelevant to the Macys' fourth
specification of negligence.    
		Defendant contends that, even if the evidence at issue was
relevant to the Macys' fourth specification of negligence, it was so
unfairly prejudicial that the trial court cannot be faulted for
excluding it.  See OEC 403 (relevant evidence may be excluded if its
probative value is substantially outweighed by the danger of unfair
prejudice).  In that regard, defendant argues that admitting the
evidence would have complicated the case unduly by inviting the jury
to decide the case on a highly inflammatory and nonmedical ground. 
Defendant suggests, moreover, that the trial court in this case in
fact did rule that the evidence was inadmissible under OEC 403 and
that such a determination should not be reversed unless it amounts
to an abuse of discretion.    
		Turning to the latter argument first, we do not agree with
defendant's characterization of the trial court's rulings.  Although
the trial court expressly labeled the evidence as "highly
inflammatory" and "prejudicial," it never decided that the evidence
was unfairly prejudicial or that it ought to be excluded under OEC
403.
		On the merits, defendant's argument respecting OEC 403 is
not well taken.  The evidence in question is central to the Macys'
theory under their fourth specification of negligence.  Its
admission may be harmful, even devastating, to defendant's position,
but relevant evidence often has that effect.  On remand, the Macys
are entitled to have the evidence considered by the trier of fact.
		We hold that the trial court erred in granting defendant's
motion to exclude for all purposes any evidence suggesting the
existence of a sexual relationship between defendant and Macy. 
Although such evidence is not relevant to the Macys' other
specifications of negligence, it is relevant to the fourth
specification pertaining to informed consent and, particularly, to
the question whether, under the circumstances, Macy was in a
condition to understand and to utilize medical information that the
informed consent statute, ORS 677.097, presumes.  The Macys are
entitled to a new trial under their fourth specification of
negligence. (8)   
		The decision of the Court of Appeals is affirmed in part
and reversed in part.  The judgment of the circuit court is
reversed, and the case is remanded to the circuit court for further
proceedings.

1. 	Hereafter, we refer to plaintiff Danita Macy as "Macy"
and to plaintiffs collectively as "the Macys."

2. 	Macy continued to suffer from pelvic pain after Ellis
corrected the obstructed ureter.  She consulted a new
gynecologist, Dr. Redwine, about her continuing pelvic pain. 
Like defendant, Redwine suspected endometriosis.  With Macy's
consent, Redwine performed a final surgery to remove endometrial
tissue.  As of February 1996, Macy's pelvic pain substantially
had resolved.

3. 	The Macys made an offer of proof that included:  (1)
testimony by a medical expert about the various ways that a
sexual relationship between a patient and physician might affect
the physician's ability to comply with the standard of care
applicable to physicians; and (2) Macy's testimony that she and
defendant had been intimate physically and that that relationship
might have affected her ability to make decisions about her own
health care. 

4. 	The Macys do not assert that they are entitled to a new
trial respecting their first and second specifications of
negligence.

5. 	The Macys also suggest that evidence of a sexual
relationship might be relevant to the third specification to
resolve any factual dispute about Macy's "medical circumstances"
at the time of treatment.  In particular, the Macys argue, that
the evidence at issue might raise questions in the minds of the
jurors about the accuracy of defendant's evaluation of Macy's
medical history and symptoms.  However, because the Macys never
made that argument to the trial court, we decline to consider it.
		The Macys assert that they did raise this "credibility
argument" with regard to both the third and fourth
specifications, because it is inherent in one of the central
arguments that they made to the trial court -- that the evidence
at issue showed that defendant lacked the objectivity that was
required of him as a physician when he recommended the August
1992 surgery.  However, after having examined the Macys'
memorandum in opposition to the motion in limine and the
transcript of the proceedings during which the motion was
discussed, we are persuaded that the relevance of the evidence to
the credibility of defendant's story was not raised in the trial
court, either expressly or as a necessary corollary to the
"objectivity" argument that the Macys did articulate. 

6. 	In fact, the Macys' offer of proof included Macy's
testimony that her relationship with defendant might have
interfered with her ability to make decisions about her health
care. 

7. 	Our holding that the evidence was relevant on this
issue makes it unnecessary for this court to resolve whether the
evidence also was relevant for other purposes, such as cross
examination, and we therefore do not address that question.

8. 	The foregoing concludes our discussion of the sole
question that the Macys raised in their petition to this court.
In their brief on the merits, the Macys raise a different
question, one pertaining to the trial court's denial of their
motion to amend their complaint.  Although this court has
discretion to consider that question, which was before the Court
of Appeals, we decline to exercise that discretion in this case. 
ORAP 9.20(2).  See State v. Castrejon, 317 Or 202, 211-12, 856
P2d 616 (1993) (explaining scope of court's discretion under
rule).