Title: Cobo v. Raba

State: north-carolina

Issuer: North Carolina Supreme Court

Document:

IN THE SUPREME COURT OF NORTH CAROLINA
No. 127A97
FILED: 6 FEBRUARY 1998
VIRGINIA COBO, Executrix of the Estate of MICHAEL COBO
v.
ERNEST A. RABA, M.D.
Appeal by plaintiff pursuant to N.C.G.S. § 7A-30(2)
from the decision of a divided panel of the Court of Appeals, 125
N.C. App. 320, 481 S.E.2d 101 (1997), finding error in a judgment
entered by Hight, J., on 5 July 1994 in Superior Court, Durham
County, and ordering a new trial.  Heard in the Supreme Court 16
October 1997. 
Maxwell, Freeman & Bowman, P.A., by James B. Maxwell,
for plaintiff-appellant.
Ragsdale, Liggett & Foley, by George R. Ragsdale and
David K. Liggett; and Anderson, Johnson, Lawrence,
Butler & Brock, by Lee B. Johnson, for defendant-
appellee.
Law Office of Martin A. Rosenberg, by Martin A.
Rosenberg, on behalf of North Carolina Academy of Trial
Lawyers, amicus curiae.
Golding, Meekins, Holden, Cosper & Stiles, by Elaine
Cohoon Miller, on behalf of North Carolina Association
of Defense Attorneys, amicus curiae.
LAKE, Justice.
This is a medical malpractice case which presents the
single issue of whether the asserted affirmative defense of
plaintiff's contributory negligence should have been submitted to
the jury.  The Court of Appeals majority concluded the trial
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court committed reversible error by refusing to instruct on and
submit this issue to the jury for its determination.  For the
reasons stated herein, we affirm the decision of the Court of
Appeals. 
At trial, the jury answered the single liability issue
of defendant’s negligence in plaintiffs’ favor and awarded
plaintiff, Dr. Michael Cobo, $850,000 in damages.  On 15 June
1994, the trial court entered judgment against the defendant, Dr.
Ernest Raba, in that amount.  Defendant appealed to the Court of
Appeals, which, in a divided panel, ordered a new trial.  Prior
to the decision of the Court of Appeals, Dr. Cobo died.  His
wife, Virginia Cobo, as Executrix of the Estate of Michael Cobo,
was substituted as plaintiff in this action.  The plaintiff
executrix now appeals to this Court from the dissent below. 
The record reflects the following evidence was before
the trial court.  The defendant was and is a practicing
psychiatrist in Durham, North Carolina.  Dr. Cobo began to see
defendant as a patient for his psychiatric problems in 1980 when
he moved to Durham to accept a job at Duke University Medical
School.  Dr. Cobo had a history of psychiatric counseling and had
previously been diagnosed and treated for depression with an
antidepressant drug which produced adverse side effects.  During
Dr. Cobo’s first visit with defendant, Dr. Cobo stated that he
did not want to be treated with medication because his previous
treatment with medication had “affected him badly” and had not
been helpful.  Since Dr. Cobo refused to give defendant a
complete medical history, defendant conducted extensive
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psychological testing under the guidance of Dr. William
Burlingame, a practicing psychologist.  Defendant diagnosed Dr.
Cobo as suffering from dysthymia, a form of depression less
severe than major depression.  Together, defendant and Dr. Cobo
decided that since Dr. Cobo refused to be treated with
medication, Dr. Cobo would be treated with psychoanalysis four
times a week.  Dr. Barry Ostrow, a board-certified psychiatrist
with extensive experience, testified that dysthymia was the
correct diagnosis and that psychoanalysis was the proper course
of treatment for Dr. Cobo.  Dr. Cobo’s previous psychiatrists,
Dr. Sam Bojar and Dr. O. Townsend Dann also treated and diagnosed
Dr. Cobo in exactly the same manner.  The psychoanalysis
continued until December 1988.  Throughout the patient-physician
relationship, Dr. Cobo refused medication; required 6:00 a.m.
appointments to avoid anyone seeing him with a psychiatrist; and
demanded that defendant take no notes during the treatment
sessions in order to protect Dr. Cobo’s identity and
confidentiality in the event his marriage fell apart and his wife
filed a lawsuit against him. 
The evidence before the jury further reflected that Dr.
Cobo had engaged in high-risk behavior, including drug abuse,
alcohol abuse and unprotected homosexual sex, for most of his
adult life.  Before seeking defendant’s medical assistance, Dr.
Cobo had multiple unprotected homosexual encounters with paid
prostitutes.  In 1981, Dr. Cobo’s unprotected homosexual
encounters increased, as he testified, to “easily a monthly
basis” through 1986.  Dr. Cobo acknowledged that “anyone in the
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early ‘80s who opened up a Newsweek magazine would know of the
risk” of unprotected sex and admitted that he may have contracted
acquired immunodeficiency syndrome (AIDS) after unprotected sex
with a prostitute in San Francisco in the early 1980s.  Defendant
advised Dr. Cobo that he “was making some very dangerous choices
[regarding sexual partners and homosexual activity] and
recommended they stop,” and defendant discussed with Dr. Cobo the
risk of sexually transmitted diseases.  Defendant also warned Dr.
Cobo of the effects of drug and alcohol abuse and specifically
with regard to their adverse impact on his psychoanalysis
treatment.  Although Dr. Cobo was an infectious disease expert
and knew his behavior was dangerous, he continued these high-risk
activities.
In December 1986, Dr. Cobo tested positive for human
immunodeficiency virus (HIV).  Defendant prescribed medication to
treat Dr. Cobo’s anxiety and depression and continued
psychoanalysis treatment sessions.  Defendant recommended that
Dr. Cobo seek medical treatment for HIV, but his advice went
unheeded until November 1989 when Dr. Cobo was diagnosed with
full-blown AIDS.  In December 1988, the doctor-patient
relationship was mutually terminated, and Dr. Cobo was treated by
another psychiatrist, who prescribed an antidepressant medication
which improved Dr. Cobo’s condition.  At the time of trial, Dr.
Cobo was in poor condition and testified by video deposition. 
At trial, Dr. John Monroe, plaintiff’s expert witness
in the field of psychiatry, testified that Dr. Cobo was suffering
from major depression, which was a “biologic disregulation” that
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has to do with “chemical imbalances.”  Dr. Monroe also testified
that there is no relationship between Dr. Cobo’s homosexual
activity and the treatment rendered for his depression.  Dr.
Monroe further testified that he was aware of no medical
literature which indicates that major depression contributes to
homosexual activity. 
On 20 December 1991, Dr. Cobo and his wife, Virginia
Cobo, filed a complaint against defendant seeking damages for
physical injury, psychological injury, emotional distress, loss
of standing in the medical community and damage to his
relationship with his family.  Plaintiffs alleged that defendant
was negligent in that he “failed to prescribe appropriate
medications”; “continued to treat Michael Cobo with psychotherapy
when he knew, or ought to have known, that it was either an
ineffective or less effective method of treating Michael Cobo’s
psychiatric condition”; and “failed to keep notes on his sessions
with Dr. Cobo in order to follow the course and effect, or lack
thereof, of his therapy.” 
Defendant filed his answer and asserted as an
affirmative defense that Dr. Cobo was contributorily negligent. 
Specifically, in this regard, defendant alleged that Dr. Cobo
“voluntarily sought and continued with psychoanalytic treatment
for his condition over a period of several years when he knew or
should have known that there were a variety of other treatments
available which were not psychoanalytically based”;
“deliberately, intentionally, recklessly, carelessly and
knowingly engage[d] in homosexual activities and alcohol and
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substance abuse which exposed him to physical, psychological,
social and professional injury”; and “failed and refused to seek
specialized medical treatment for his HIV.”
At the charge conference, defendant requested that the
trial court instruct the jury on contributory negligence, but
this was denied.  The trial court submitted the following single
issue of negligence to the jury:  “Was the plaintiff . . .
injured by the negligence of the defendant?”  The trial court
instructed the jury to answer this issue “yes” if it determined
that Dr. Cobo had met his burden of proving either negligent
diagnosis or negligent treatment.  The jury thus rendered a
general verdict answering “yes” as to this one liability issue. 
The trial court also instructed on the statute of limitations for
personal injury and on damages, but these issues are not before
this Court. 
We hold that in light of the evidence before the jury,
the trial court should have instructed on the issue of
contributory negligence.  In this state, a plaintiff's right to
recover in a personal injury action is barred upon a finding of
contributory negligence.  Brewer v. Harris, 279 N.C. 288, 298,
182 S.E.2d 345, 350 (1971).  The trial court must consider any
evidence tending to establish plaintiff’s contributory negligence
in the light most favorable to the defendant, and if diverse
inferences can be drawn from it, the issue must be submitted to
the jury.  Atkins v. Moye, 277 N.C. 179, 184, 176 S.E.2d 789, 793
(1970).  If there is more than a scintilla of evidence that
plaintiff is contributorily negligent, the issue is a matter for
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the jury, not for the trial court.  Boyd v. Wilson, 269 N.C. 728,
730, 153 S.E.2d 484, 486 (1967).  Therefore, any evidence that
Dr. Cobo was contributorily negligent in that he failed to use
ordinary care to protect himself from the asserted injury, or
that his behavior was a proximate cause of his injury, would
dictate the submission of this issue to the jury. 
  
This Court has held that “[i]n order for a contributory
negligence issue to be presented to the jury, the defendant must
show that plaintiff’s injuries were proximately caused by his own
negligence.”  McGill v. French, 333 N.C. 209, 217, 424 S.E.2d
108, 113 (1993).  “[I]t is not necessary that plaintiff be
actually aware of the unreasonable danger of injury to which his
conduct exposes him.  Plaintiff may be contributorily negligent
if his conduct ignores unreasonable risks or dangers which would
have been apparent to a prudent person exercising ordinary care
for his own safety.”  Smith v. Fiber Controls Corp., 300 N.C.
669, 673, 268 S.E.2d 504, 507 (1980). 
We hold that the record in the case sub judice provides
substantial evidence from which the jury could have determined
that Dr. Cobo’s injuries were proximately caused by his own
negligence, including ignoring and actually initiating
unreasonable dangers which would have been apparent to an
ordinary, prudent person.  The evidence indicates that Dr. Cobo’s
only physical injury was AIDS, which was proximately caused by
engaging in unprotected homosexual intercourse, and which he
admits he contracted because his “judgment at that time was
clouded and poor and self-destructive.”  Evidence that Dr. Cobo’s
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conduct was unreasonably dangerous includes:  his repeated
refusal to follow defendant’s advice with regard to his continued
unprotected homosexual intercourse, his alcohol and drug abuse;
and his substantial delay in seeking treatment for HIV.  Further
evidence of Dr. Cobo’s negligence includes the indicated
restrictions placed on treatment in refusing to allow defendant
to prescribe medication for the chronic depression and in
refusing to allow defendant to take notes during the treatment
sessions.  Additionally, as a highly educated medical doctor and
infectious disease expert, Dr. Cobo was actually aware that his
unprotected homosexual conduct was unreasonably dangerous. 
Expert testimony, although useful, is not needed in all
medical malpractice cases to establish proximate causation on the
issue of contributory negligence when the jury, based on its own
common knowledge and experience, is able to understand and judge
the patient’s actions.  McGill, 333 N.C. at 219, 424 S.E.2d at
114.  In McGill, this Court noted that a patient has an active
responsibility for his own care and well-being.  Id. at 220, 424
S.E.2d at 115.  The Court held that a patient’s failure to keep
his appointments and failure to report symptoms constituted
sufficient evidence of negligence for a jury to find these
actions were the proximate cause of his injuries.  Id.  Likewise,
in this case, the jury could have reasonably determined, based on
application of its own common knowledge and the expert testimony,
that the indicated restrictions Dr. Cobo placed on his treatment,
his unremitting alcohol and drug abuse, his actions in ignoring
and contravening his doctor’s recommendations to seek treatment
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for his HIV status for three years and his continued unprotected
homosexual conduct constituted sufficient evidence that Dr.
Cobo’s actions were negligent and contributed to and proximately
caused each of the injuries of which he complained, particularly
his physical injury. 
Plaintiff contends that Dr. Cobo’s actions in this
regard do not constitute a proper factual basis for the
submission of the issue of contributory negligence to the jury. 
She contends that Dr. Cobo’s alcohol abuse, drug abuse and
unprotected homosexual conduct occurred subsequent to the alleged
misdiagnosis and implementation of treatment and were part and
parcel of the condition for which he sought treatment. 
Therefore, plaintiff contends, Dr. Cobo’s injury could have been
avoided if he had been correctly diagnosed and appropriate
treatment had been initiated by defendant.  Contributory
negligence as a defense is inapplicable “where a patient’s
conduct provides the occasion for care or treatment that, later,
is the subject of a malpractice claim, or where the patient’s
conduct contributes to an illness or condition for which the
patient seeks the care or treatment on which a subsequent medical
malpractice [claim] is based.”  David M. Harney, Medical
Malpractice § 24.1, at 564 (3d ed. 1993).  However, in the case
sub judice, the evidence clearly indicates that the activities of
Dr. Cobo asserted as contributory negligence took place prior to
and contemporaneously with defendant’s treatment and that Dr.
Cobo directly contravened defendant’s specific advice during the
course of treatment.  Further, we find no evidence that Dr.
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Cobo’s malady, AIDS, was in any way caused by depression, the
condition for which Dr. Cobo sought treatment from defendant. 
The evidence shows Dr. Cobo had a history of
depression; sought treatment from defendant for this condition;
and consistent with prior diagnosis and treatment, was treated
for dysthymia, a form of depression.  The treatment rendered by
defendant for dysthymia had absolutely no connection to Dr.
Cobo’s AIDS, which ultimately caused his death.  Plaintiff’s own
expert, Dr. Monroe, admitted that homosexual conduct is unrelated
to depression and that he was aware of no medical literature
linking these conditions.  Furthermore, there is no evidence that
Dr. Cobo’s unprotected homosexual activities were caused by, or
related to, his depression.  Dr. Cobo testified that he began
having homosexual relations at the age of twenty and engaged in
unprotected homosexual relations for more than ten years before
he sought defendant’s treatment.  Dr. Cobo admitted that his
contraction of AIDS was caused by his own conduct, and he told
defendant that he thought his unprotected sex with a drug-
addicted prostitute in a San Francisco bathhouse had probably
caused his infection.  Dr. Cobo further acknowledged that he
engaged in unprotected homosexual sex “easily on a monthly basis”
in the early 1980s and that it takes only “one time” to contract
AIDS.  In McGill, this Court concluded that passive conduct by
the plaintiff in failing to keep his appointments was sufficient
to constitute contributory negligence.  McGill, 333 N.C. at 220,
424 S.E.2d at 115.  In the instance case, Dr. Cobo’s conduct was
clearly active and related directly to his physical complaint. 
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While the record here does not show, and we thus cannot
speculate, whether the verdict as to defendant’s negligence was
based on diagnosis or treatment or both, we conclude the record
does show evidence of Dr. Cobo’s conduct in both areas sufficient
to require an instruction on and submission of the issue of
contributory negligence to the jury. 
 Based upon the foregoing, there was sufficient
evidence from which the jury could have inferred that Dr. Cobo’s
injuries were proximately caused by his own negligence.  The
trial court thus erred in refusing to instruct the jury on the
issue of contributory negligence.  Accordingly, the decision of
the Court of Appeals is affirmed.
AFFIRMED.