IN THE SUPREME COURT OF IOWA 

No. 115 / 04–2081 

Filed February 22, 2008 

GEORGIA M. RATHJE, KELLY RATHJE and RICHARD RATHJE, 

 Appellants, 

vs. 

MERCY HOSPITAL, CEDAR RAPIDS, IOWA, and 

DWIGHT J. SCHROEDER,

 Appellees. 

Appeal from the Iowa District Court for Linn County, Thomas M. 

Horan, Judge. 

 District court granted summary judgment for defendants in a 

medical malpractice action. REVERSED AND REMANDED.

James P. Hayes and Karen A. Lorenzen of Hayes Lorenzen Lawyers 

PLC, Iowa City, and Richard H. Doyle of Galligan, Doyle & Reid, PC, 

Des Moines, for appellants. 

David A. Elderkin and Robert M. Hogg of Elderkin & Pirnie, P.L.C., 

Cedar Rapids, for appellees. 
2

CADY, Justice. 

 In this appeal, we must decide if the district court correctly 

granted summary judgment in a medical malpractice action based on a 

claim that the plaintiffs failed to file their petition within the statute of 

limitations. Although the district court relied on our line of prior cases in 

reaching its decision, we now conclude the statute of limitations for 

medical malpractice actions does not begin to run until discovery of both 

the injury and its factual cause. On our review, we reverse the decision 

of the district court and remand for further proceedings. 

I. Background Facts and Proceedings. 

 On March 19, 1999, Kelly and Richard Rathje admitted their 

sixteen-year-old daughter, Georgia, to an outpatient alcohol abuse 

treatment center at Mercy Hospital in Cedar Rapids. Part of the 

treatment plan developed for Georgia called for the administration of a 

drug called Antabuse. This drug causes the body to produce an alcohol 

sensitivity that results in a highly unpleasant reaction to the ingestion of 

beverages containing alcohol. The treatment plan called for Georgia to 

receive a liquid dose of Antabuse, administered by a nurse at the 

treatment center, twice each week. 

 Around a week later, Georgia began to feel sick and nauseated. 

She also began to experience cramps and was constipated. Georgia 

reported these symptoms to the nurse who administered the Antabuse at 

the treatment center, and the nurse suggested she consume food prior to 

taking Antabuse in the future. 

 On April 5, Kelly contacted the family’s physician, Dr. Jerome 

Janda, to report Georgia was nauseated and frequently expelled an acidlike fluid from her stomach. Dr. Janda subsequently examined Georgia, 

and ordered an upper gastrointestinal test. The results of the test were 
3

consistent with peptic disease and duodenitis, but revealed no definite 

ulcer or reflux disease. Dr. Janda prescribed medication for Georgia’s 

stomach pain. 

 On April 20, Georgia would not eat or drink. She was suffering 

from abdominal pain and was vomiting a green substance. She was also 

fatigued. Kelly reported these symptoms to a nurse in Dr. Janda’s office. 

 On April 23, Georgia was seen by Dr. Janda with continued 

complaints of nausea and constipation. Dr. Janda ordered x-rays, 

together with a liver function test, a blood test, and a test used to 

diagnose various intestinal diseases and problems. The x-rays were 

taken, but the other tests were not performed due to a mix-up. 

 On April 26, Georgia returned to Dr. Janda’s office. She had been 

bedridden for most of the time since the previous office visit on April 23. 

She was nauseated, vomiting, and constipated. At this visit, Dr. Janda 

noticed Georgia’s skin color was “mildly yellow or jaundiced and the 

whites of her eyes were yellowish or icteric.” He again ordered the prior 

tests and added a test to determine the presence of any inflammation. 

 Georgia had blood drawn for testing at Mercy Hospital. The blood 

tests were performed by the hospital lab, with abnormal results. 

Dr. Janda informed Kelly of the test results, and Georgia was admitted to 

St. Luke’s Hospital on April 27. 

 Dr. Janda consulted with a surgeon about his concern that 

Georgia could have gallbladder stones. A CAT scan revealed some 

enhancement of the gallbladder wall and some fluid around the 

gallbladder, but no other abnormalities. The surgeon then consulted 

with a gastroenterologist. 

 The gastroenterologist determined the jaundice and elevated liver 

enzymes experienced by Georgia were secondary to hepatitis. He 
4

believed Georgia’s condition might be a “drug-induced hepatitis 

secondary to Antabuse.” He recommended Georgia stop taking all prior 

medications. 

 Georgia was discharged from St. Luke’s Hospital, but promptly 

readmitted on April 29. She still appeared jaundiced, and her condition 

continued to deteriorate over the passing days. On May 5, she was 

transferred to the University of Iowa Hospitals and Clinics Pediatric 

Intensive Care Unit. She later received a liver transplant as a result of 

end-stage liver disease secondary to Antabuse. 

 On April 26, 2001, Georgia and her parents filed a petition against 

numerous health care providers, including Mercy and Dr. Dwight 

Schroeder, the medical director at the Alcohol Treatment Center at 

Mercy. The lawsuit claimed Dr. Schroeder and the hospital were 

negligent in prescribing Antabuse and in their treatment of Georgia for 

alcohol abuse, and this negligence was the cause of her irreversible liver 

damage and transplant. The Rathjes eventually dismissed all defendants 

from the lawsuit except Mercy Hospital and Dr. Schroeder. 

 Mercy Hospital and Dr. Schroeder filed answers to the petition and 

later were permitted to amend their answers to claim the statute-oflimitations defense. They both then subsequently moved for summary 

judgment based on the two-year statute of limitations. 

 Mercy Hospital and Dr. Schroeder claimed the statute of 

limitations began to run when Georgia began to experience symptoms of 

her injury prior to April 26, 1999. Georgia and her parents claimed the 

statute of limitations began to run when Georgia learned after April 26, 

1999, her liver was irreversibly damaged, or, at the earliest, when her 

condition worsened on April 26, 1999, to include symptoms of jaundice. 
5

 The district court granted summary judgment for Mercy Hospital 

and Dr. Schroeder. It found the facts were undisputed that Georgia’s 

injury had physically manifested itself well prior to April 26, 1999, more 

than two years before the Rathjes filed suit. Consequently, it concluded 

the lawsuit filed by the Rathjes was barred by the statute of limitations 

contained in Iowa Code section 614.1(9)(a) (2001). 

 The Rathjes appealed. They argue the district court erred in 

allowing Mercy to amend its answer to include a statute-of-limitations 

defense and further argue the district court erred in granting summary 

judgment for Mercy Hospital and Dr. Schroeder.1 

II. Standard of Review. 

 We review a district court ruling granting a motion for summary 

judgment for correction of errors at law. Kragnes v. City of Des Moines, 

714 N.W.2d 632, 637 (Iowa 2006). 

III. Statute of Limitations for Medical Malpractice Actions.

 This case requires us once again to visit the medical malpractice 

statute of limitations and apply it to the facts of a particular case. We 

have done this on a number of occasions since the special statute was 

enacted in 1975, and have developed a body of interpretative law in the 

process. Yet, this law has raised some questions about the fairness of 

 

1We conclude the district court did not abuse its discretion in allowing the 

hospital and Dr. Schroeder to amend their petitions. See Rife v. D.T. Corner, Inc., 641 

N.W.2d 761, 766 (Iowa 2002) (“We afford district courts considerable discretion in 

ruling on motions for leave to amend pleadings. Consequently, we will reverse only if 

the record indicates the court clearly abused its discretion.” (Citations omitted.)). The 

Rathjes raised two primary arguments in support of their claim that the district court 

erred in granting summary judgment. In addition to arguing their lawsuit was filed 

within two years of the date the injury was discovered, the Rathjes claimed their lawsuit 

should survive the statute of limitations under the continuing treatment and 

continuum of negligent treatment doctrines. We only address the issue concerning the 

date of discovery of the injury in this appeal. Our resolution of this issue in favor of the 

Rathjes makes it unnecessary to address their claim that the district court erred in 

failing to adopt the continuing treatment and continuum of negligent treatment 

doctrines. 
6

the outcome of a number of these cases. This perception has not gone 

unnoticed by us, for we have freely acknowledged the statute can 

“severely restrict[] the rights of unsuspecting patients.” Schlote v. 

Dawson, 676 N.W.2d 187, 194 (Iowa 2004). Nevertheless, we have 

declined to change course, recognizing it is the role of the legislature to 

“address this problem.” Id. 

 It is, of course, the role of the legislature to write statutes, and it is 

our role to interpret them based on their application in the course of 

litigation. Moreover, the legislature can rewrite a statute to reflect its 

intent when it does not believe our interpretation in a particular case has 

accomplished this goal. Yet, these general principles of separation of 

powers and fundamental duties do not totally absolve us from our 

continued responsibility to interpret applicable statutes in each case 

and, more importantly, to revisit our past interpretations if we are 

convinced they have not clearly captured the intent of our legislature. 

We adhere to precedent, but also remain committed to clarifying the law 

as we work with our precedent. When our interpretation of a statute has 

created problems in the application of the statute to subsequent cases, 

we should be willing to reexamine our precedent to see if our 

understanding of the legislative intent can be better articulated. See 

Ruth v. Dight, 453 P.2d 631, 634 (Wash. 1969) (reexamining past 

interpretation of statue of limitations in light of “constant intellectual 

bombardment”). 

 We begin the task of revisiting our interpretation of section 

614.1(9) by returning to the original statute of limitations for personal 

injury actions enacted by our legislature in the Nineteenth Century. This 

journey is necessary to put the issue we face today in perspective and to 

help understand the intent of our legislature in choosing the language it 
7

used to write the statute of limitations for medical malpractice actions. 

As originally enacted, the statute of limitations provided: 

 “The following actions may be brought within the times 

herein limited, respectively, after their causes accrue, and 

not afterwards, except when otherwise specially limited: (1) 

Actions founded on injuries to the person . . ., whether based 

on contract or tort, . . . within two years.” 

Fadden v. Satterlee, 43 F. 568, 568–69 (S.D. Iowa 1890) (quoting Iowa 

Code § 2529). Thus, our legislature selected the prescriptive period of 

time to bring a personal injury action based on tort and used the accrual 

of the claim as a starting point for the limitation period. In doing so, the 

legislature determined a two-year period was sufficient for a reasonably 

diligent person to file a claim with the judicial system.2 See Estate of 

Kuhns v. Marco, 620 N.W.2d 488, 491 (Iowa 2000) (“Statutes of 

limitations establish a reasonable period of time for plaintiffs to file their 

claims.”). The statute was designed primarily to protect the courts and 

defendants from the multitude of problems that can occur in dealing 

with stale claims. Id.; see Schulte v. Wageman, 465 N.W.2d 285, 286 

(Iowa 1991) (recognizing the burdens of defending a claim after memories 

have faded, witnesses have died or disappeared, and evidence is lost). 

 While the legislature prescribes the period of limitation, courts 

have generally been called upon to determine when a claim accrues to 

start the running of the statute of limitations. See Roberts v. Sw. Cmty. 

Health Servs., 837 P.2d 442, 446 (N.M. 1992) (recognizing that, absent 

instructions from the legislature, courts must determine when a cause of 

 

2All states have enacted a statute of limitations for tort victims and nearly all 

such statutes require the action to be filed within one to three years of the accrual of 

the action. David W. Feeder II, When Your Doctor Says, “You Have Nothing to Worry 

About,” Don’t Be Sure: The Effect of Fabio v. Bellomo on Medical Malpractice Actions in 

Minnesota, 78 Minn. L. Rev. 943, 950 (1994). The vast majority of states, like Iowa, 

have adopted a two-year limitation period. Id. 
8

action accrues under a statute of limitations); see also Developments in 

the Law of the Statute of Limitations, 63 Harv. L. Rev. 1177, 1203–05 

(1950). This task has been formidable, largely due to the manifold 

sequences in which the elements of a tort action can unfold and become 

discernible to a plaintiff as a signal to pursue a legal remedy for a wrong. 

See Ruth, 453 P.2d at 634 (recognizing that the application of statutes of 

limitation in medical malpractice cases has been a vexing and 

continuous source of judicial uncertainty).3 

 The first rule to emerge from our early statute-of-limitations cases 

was that a claim accrued when the injured party had a “right to institute 

and maintain a suit.” Chrischilles v. Griswold, 260 Iowa 453, 461, 150 

N.W.2d 94, 99 (1967), superseded by statute, 1975 Iowa Acts ch. 239, 

§ 26, as recognized in Langner v. Simpson, 533 N.W.2d 511 (Iowa 1995); 

see Dean v. Iowa-Des Moines Nat’l Bank & Trust Co., 227 Iowa 1239, 

1242, 281 N.W. 714, 717 (1938) (explaining a cause of action does not 

“accrue” until the plaintiff is entitled to sue). This approach meant the 

statute was triggered when the commission of a tortious act caused a 

legally recognized injury. See Schnebly v. Baker, 217 N.W.2d 708, 721 

(Iowa 1974) (“The general rule in tort cases is that the period of 

limitations commences when the tort is committed.”), overruled on other 

grounds by Franke v. Junko, 366 N.W.2d 536 (Iowa 1985). It reflected 

the general rule of law around the country. Id. 

We also observed early on that the tortious act committed by a 

defendant was not always immediately followed by the resulting injury. 

 

3“Like most general rules of law,” the rules “pertaining to ‘limitations’ become 

less than profound when an attempt is made to apply them to specific cases.” Mattingly 

v. Hopkins, 253 A.2d 904, 907 (Md. 1969). This complexity primarily results when the 

elements of a cause of action unfold sequentially (rather than simultaneously) and can 

be further compounded by additional factors unique to professional malpractice. Id. 
9

Ogg v. Robb, 181 Iowa 145, 155–56, 162 N.W. 217, 220–21 (1917); see 

also United States v. Kubrick, 444 U.S. 111, 122, 100 S. Ct. 352, 359, 62 

L. Ed. 2d 259, 269 (1979) (noting “[t]hat [the plaintiff is] injured in fact 

may be unknown or unknowable until the injury manifests itself” and 

thus recognizing, at least implicitly, that the tortious act does not always 

temporally coincide with the injury); Hansen v. A.H. Robins, Inc., 335 

N.W.2d 578, 580 (Wis. 1983) (“Although the negligence and resulting 

injury are often simultaneous, occasionally an injury will not be 

sustained until a subsequent date.”). Thus, in response to a number of 

statute-of-limitations cases in which the injury did not occur until long 

after the wrongful act, our general rule for the accrual of a claim was 

more specifically described to commence the running of the statute of 

limitations for personal injury actions at the time the injury occurred. 

Ogg, 181 Iowa at 155–56, 162 N.W. at 220–21; Gustin v. County of 

Jefferson, 15 Iowa 158, 160 (1863) (declaring the statute of limitations 

commences to run from the time the injury is done); see also Fadden, 43 

F. at 568–69 (concluding Iowa’s statute of limitations in malpractice 

cases begins to run at the time of the injury). 

This approach was logical because the injury would not always 

occur at the same time as the wrongful act, but no cause of action could 

accrue until the injury occurred. Ogg, 181 Iowa at 155–56, 162 N.W. at 

220–21 (recognizing a cause of action accrues when damages are 

sustained in those cases in which the wrongful act itself does not cause 

an immediate legal injury, but when damages subsequently occur as a 

result of the act); see also Hansen, 335 N.W.2d at 580 (holding the injury 

is the triggering event because the injury may occur after the negligent 

act). Thus, we transformed the general rule to more accurately describe 

that a claim did not accrue under the statute of limitations until the 
10

injury occurred. Of course, there was no change in the rule that the 

statute of limitations began to run even if the plaintiff had not discovered 

the injury or its cause. The early case of Ogg illustrates this approach. 

In Ogg, the plaintiff suffered burns on his arms as a result of xrays taken by the doctor after he broke his wrist. 181 Iowa at 147, 162 

N.W. at 218. This event occurred in 1901. Id. In 1912, the plaintiff 

developed cancer in his arm, resulting in amputation. Id. In 1915, he 

brought a negligence action against the doctor, alleging the x-rays 

caused the cancer. Id. at 147, 162 N.W. at 219. After finding no 

evidence of fraudulent concealment of the tort by the physician, the court 

concluded the cause of action accrued at the time of the burn in 1901, 

and the action was therefore barred by the statute of limitations. Id. at 

155–65, 162 N.W. at 220–21. This approach reaffirmed the bright-line 

rule, but frequently left victims who were unable to discover their injuries 

within the statute-of-limitations period, through no fault of their own, 

without any remedy. 

 Application of the general statute of limitations based on the 

occurrence of the injury was followed well into the Twentieth Century. 

The individual hardship visited on those plaintiffs who failed to discover 

the injury before the end of the statute-of-limitations period was largely 

considered to be the price paid to achieve the greater societal goals of the 

statute of limitations. See W. Page Keeton, et al., Prosser and Keeton on 

the Law of Torts § 30, at 165 (5th ed. 1984). Yet, the Iowa legislature was 

not totally unsympathetic to litigants who were unaware of their rights 

until after the statute of limitations had run. In 1860, the legislature 

enacted a separate statute of limitations for actions based on fraud that 

delayed the accrual of the action until the fraud was discovered. Iowa 
11

Code § 2741 (1860). The statute was consistent with the established 

English statute of limitations 

that where the party against whom a cause of action existed 

in favor of another, by fraud or actual fraudulent 

concealment prevented such other from obtaining knowledge 

thereof, the statute would only commence to run from the 

time the right of action was discovered, or might, by the use 

of diligence, have been discovered. 

Dist. Twp. of Boomer v. French, 40 Iowa 601, 607 (1875). The Iowa 

statute was later amended to add actions for trespass to property to the 

exception, see 1868 Iowa Acts ch. 167, § 9, and still later, in 1873, to 

add actions grounded on mistake, see Iowa Code § 2530 (1873). See 

Beerman v. Beerman, 225 Iowa 48, 51–52, 279 N.W. 449, 450–51 (1938) 

(tracing the evolution of what was then Iowa Code section 11010 

(1935)).4 

 During the time we maintained allegiance to the bright-line rule 

that the statute of limitations for personal injury actions commenced at 

the time the injury occurred, we began to develop a body of law 

surrounding the common-law discovery rule. In applying the discovery 

rule to the specific legislative exceptions, we held that actual knowledge 

of the fraud and other wrongs was not required before the statute of 

limitations began to run. Instead, we declared: 

The “discovery” of the fraud or wrong which will set the 

statute in motion does not necessarily mean actual and 

direct personal knowledge by the complaining party. It is 

sufficient if such party has such knowledge or notice as 

would lead a man of reasonable prudence to make inquiries 

which would disclose the fraud. 

Van Wechel v. Van Wechel, 178 Iowa 491, 496, 159 N.W. 1039, 1041 

(1916) (citing E.B. Piekenbrock & Sons v. Knoer, 136 Iowa 534, 538, 114 

 

4Statutory exceptions for actions based on fraud, mistake, and trespass to land 

remain today and are codified in section 614.4. 
12

N.W. 200, 201 (1907)). Thus, we introduced into our discovery rule 

jurisprudence the concept that the knowledge needed to start the statute 

of limitations only meant that the plaintiff needed that amount of 

information to allow a reasonably prudent person to discover the fraud or 

wrong by making inquiries. This concept later became known as “inquiry 

notice.” See Franzen v. Deere & Co., 377 N.W.2d 660, 662 (Iowa 1985). 

 While the discovery rule began to take root in Iowa, its impact on 

the general statute of limitations remained limited. Other jurisdictions, 

however, began to apply the “discovery rule” to the general statute of 

limitations for personal injury tort claims. This broader application of 

the discovery rule was in response to the harshness of the prevailing rule 

to unsuspecting plaintiffs who were blamelessly ignorant of their legal 

rights. In the same year we rejected the discovery rule in Ogg, Maryland 

became the first, or arguably the first, state in the nation to apply the 

discovery rule to a medical malpractice case. See Note, The Statute of 

Limitations in Actions for Undiscovered Malpractice, 12 Wyo. L.J. 30, 34 

(1957) (suggesting Maryland was the first court to adopt a discovery rule 

in malpractice claims). In Hahn v. Claybrook, 100 A. 83 (Md. 1917), a 

plaintiff brought a malpractice action against her doctor, claiming the 

doctor negligently prescribed argentum oxide for a six-year period 

between 1904 and 1910. Hahn, 100 A. at 84. The plaintiff claimed the 

excessive quantities of the drug caused silver poisoning, a chronic 

discoloration of the skin. Id. The Maryland court determined the 

discoloration of her skin was apparent by 1908, and 

was a sufficient indication of an injury, to have put her upon 

notice and inquiry, and it is clear from the evidence that if 

she had exercised ordinary care and diligence to have 

ascertained her rights, she could have discovered the cause 

of her alleged injury. 
13

Id. at 86. Consequently, the court held the statute of limitations began 

to run at the time the plaintiff first noticed her skin discoloration in 

1908, not when the doctor began prescribing the drug. Id. 

 The application of the discovery rule to the general statute of 

limitations grew in popularity throughout the Twentieth Century, 

although not all jurisdictions utilized the same event to trigger the 

statute of limitations under the discovery rule. See Roberts, 837 P.2d at 

449 (recognizing a shift in the weight of authority towards the discovery 

rule); A. Sonerstein, A Discovery Rule in Medical Malpractice: 

Massachusetts Joins the Fold, 3 W. New Eng. L. Rev. 433, 433–34 & n.1 

(1981) (listing forty-one jurisdictions that adopted the discovery rule in 

some form); W. Page Keeton, et al., Prosser & Keeton on the Law of Torts

§ 30 (5th ed. 1984 & Supp. 1988) (recognizing a wave of decisions and 

legislative enactments adopting the discovery rule). The decision that 

gave the movement its greatest thrust was Urie v. Thompson, 337 U.S. 

163, 69 S. Ct. 1018, 93 L. Ed. 1282 (1949), an action under the Federal 

Employers Liability Act in which the plaintiff contracted silicosis from his 

work environment over a ten-year period, but his condition was not 

diagnosed until two weeks after he became too ill to work. Urie, 337 U.S. 

at 165–66, 59 S. Ct. at 1022–23, 93 L. Ed. at 1290. The Court rejected 

the claim that the injury occurred years prior to a diagnosis and held the 

claim did not accrue until the disease manifested itself. Id. at 169–70, 

69 S. Ct. at 1024, 93 L. Ed. at 1292–93. 

 In 1967, Iowa joined the parade of states to apply the discovery 

rule to the general statute of limitations. In Chrischilles, we recognized 

the national trend toward adopting the discovery rule as the better 

approach for claims based on negligence. 260 Iowa at 461, 150 N.W.2d 

at 100. We also observed with approval that the discovery rule as 
14

defined in other jurisdictions meant the statute of limitations did not 

begin to run until the date “the wrongful act” was discovered or should 

have been discovered. Id. Yet, we ultimately held that actions for 

negligence do not accrue until the plaintiff discovers or should have 

discovered “the injury to his interest.” Id. The distinction between “the 

wrongful act” and “the injury” as the triggering event went unnoticed. 

 Seven years later, we applied the discovery rule to the general 

statute of limitations in a medical malpractice action. In Baines v. 

Blenderman, 223 N.W.2d 199 (Iowa 1974), superseded by statute, 1975 

Iowa Acts ch. 239, § 26, as recognized in Langner, 533 N.W.2d 511, the 

plaintiff, Baines, awoke from surgery on a herniated disk and was unable 

to see out of his right eye. Baines, 223 N.W.2d at 202. The surgery took 

place on March 30, 1970. Id. at 200. A treating physician told Baines 

the condition was temporary. Id. Baines, however, was eventually 

examined by another doctor on July 15, 1970. Id. at 201. This doctor 

informed Baines his vision loss could have been caused by the 

deprivation of blood to his eye during the surgery and his condition was 

permanent. Id. Baines filed an action against the surgeon more than 

two years after the surgery but less than two years after he was informed 

of the probable cause of his condition and that his condition was 

permanent. Id. at 200–01. 

 The doctor moved for summary judgment based on the statute of 

limitations, and Baines invoked the discovery rule. Id. at 201. Baines 

claimed he was unaware of his cause of action under the discovery rule 

adopted in Chrischilles until he was informed on July 15, 1970, that his 

injury was permanent and he learned how it likely occurred. Id. The 

doctor claimed the statute of limitations began to run when Baines 

awoke from surgery because this was the date he knew of his injury 
15

(blindness) and knew it resulted from surgery. Id. Thus, the question 

was whether discovery of the cause of action, to commence the running 

of the statute of limitations, should include the element of the negligence 

of the physician. 

 We resolved the dispute over the application of the discovery rule 

by holding that a claim did not accrue under the discovery rule to trigger 

the statute of limitations until the plaintiff knew or should have known of 

the existence of the cause of action. Id. at 202. More specifically, we 

held a plaintiff must not only discover the injury and its cause, but must 

also discover the physician was negligent. Id. Yet, we reached this 

conclusion without acknowledging the rule followed in other jurisdictions 

that discovery of the injury and its factual cause triggers the statute of 

limitations. See Kubrick, 444 U.S. at 122, 100 S. Ct. at 359, 62 L. Ed. 2d 

at 269 (setting forth the rule that discovery of the injury and its factual 

cause triggers the statute of limitations); Maestas v. Zager, 152 P.3d 141, 

147 (N.M. 2007) (clarifying that their cases since the adoption of the 

discovery rule to the medical malpractice statute of limitations were 

consistent with the holding in Kubrick). As in Chrischilles, we simply 

assumed the discovery rule meant the statute of limitations was triggered 

upon discovery of the cause of action, which included the negligence of 

the physician, and gave no consideration to a discovery rule that would 

trigger commencement of the limitations period upon actual or imputed 

knowledge of the injury and its cause. 

 Importantly, at the time Baines was decided, two movements had 

surfaced in courts around the nation as a result of the discovery-rule 

trend sweeping the country. First, two main distinct legal theories 

emerged from our nation’s state and federal courts to govern the 

triggering event for the discovery rule. Conceptually, the national 
16

movement responsible for introducing the discovery rule into the statute 

of limitations merely transformed the commencement of the limitation 

period from the date the elements of the cause of action occurred to the 

date the elements were discovered. The difficult subissue, however, was 

how the discovery rule should be applied to the elements of the claim, 

i.e., whether or not it should be applied to all of the elements. Most state 

courts, as we did in Baines, triggered the discovery rule upon knowledge 

of the cause of action, including at least some knowledge that the 

conduct of the physician was negligent or wrongful. See Baines, 223 

N.W.2d at 202; see also Bussineau v. President & Dirs. of Georgetown 

Coll., 518 A.2d 423, 428 (D.C. 1986) (noting that all states that have 

considered the question of when a statute of limitations is triggered 

under the discovery rule require either knowledge of some evidence of 

wrongdoing or knowledge of all elements of a cause of action); Mastro v. 

Brodie, 682 P.2d 1162, 1168 (Colo. 1984) (observing “[t]he overwhelming 

majority” of state courts have interpreted “the injury” that triggers a 

medical malpractice action to mean discovery of “legal injury”); Lillicrap v. 

Martin, 591 A.2d 41, 46 (Vt. 1989) (explaining that the “clear trend 

among the courts of the nation” is to commence medical malpractice 

statutes of limitation upon discovery of “legal injury,” so that the plaintiff 

must discover the injury and the fact that it was caused by the 

defendant’s negligence). Other courts interpreted the discovery rule more 

narrowly to require only knowledge of the injury and its factual cause, 

without requiring discovery of any negligence or possible wrongdoing. 

See Kubrick, 444 U.S. at 122, 100 S. Ct. at 359, 62 L. Ed. 2d at 269; 

Maestas, 152 P.3d at 147; see also Lindsay v. Romano, 696 N.E.2d 520, 

522 (Mass. 1998) (holding it is not necessary for plaintiff to have notice 

defendant was actually responsible for the injury, only that plaintiff have 
17

notice the medical care may have caused the injury). In fact, many 

courts made the choice between the two theories without recognizing 

there was even a choice to be made, and others vacillated back and forth 

with little recognition they were doing so. See Roberts, 837 P.2d at 448 

(recognizing the existence of conflicting cases). 

 More importantly, many courts failed to precisely describe the full 

meaning of their rule governing the breadth of knowledge required to 

trigger the statute of limitations, which has made it difficult at times to 

discern which rule was actually followed. Instead, courts in the 

discovery rule era would refer to their accrual rule in shorthand, just as 

we did in describing when a cause of action accrued prior to the adoption 

of the discovery rule. For instance, courts would simply declare the 

statute of limitations commenced upon discovery of the “injury,” when a 

full articulation of the rule would have revealed whether they required 

discovery of all the elements of the cause of action, or merely discovery of 

the injury and its cause. This phenomenon was aptly described by the 

New Hampshire Supreme Court: 

 One might read several discovery cases and conclude 

that the courts are applying two substantively distinct rules. 

In most cases the courts frame the rule in terms of the 

plaintiff’s discovery of the causal relationship between his 

injury and the defendant’s conduct. In some cases, . . . a 

court will state simply that, under the discovery rule, a 

cause of action accrues when the plaintiff discovers or 

should have discovered his injury. Still other courts use 

both statements of the rule within the same case. The 

reason for these apparent differences is that in most cases in 

which the court states the rule in terms of the discovery of 

the injury, the injury is the kind that puts the plaintiff on 

notice that his rights have been violated. Thus, there is no 

reason for the court to express the rule in terms of the 

discovery of the causal connection between the harm and the 

defendant’s conduct. In a case, such as the one before us, in 

which the injury and the discovery of the causal relationship 

do not occur simultaneously, it is important to articulate 

exactly what the discovery rule means. We believe that the 
18

proper formulation of the rule and the one that will cause 

the least confusion is the one adopted by the majority of the 

courts: A cause of action will not accrue under the discovery 

rule until the plaintiff discovers or in the exercise of 

reasonable diligence should have discovered not only that he 

has been injured but also that his injury may have been 

caused by the defendant’s conduct. 

Raymond v. Eli Lilly & Co., 371 A.2d 170, 174 (N.H. 1977). 

 The national trend of using the term “injury” to describe the 

triggering event under the discovery rule not only meant the term 

continued in its former capacity as a designation of the time of accrual, 

but it continued to reflect a larger meaning than the concept of physical 

harm. Yet, on occasion, this background was not fully captured, which 

gave rise to the suggestion from time to time that the discovery rule only 

looked to the injury to commence the running of the period of limitation, 

without any requirement of knowledge of its cause or the physician’s 

wrongdoing. See Lillicrap, 591 A.2d at 45 (citing Allen v. Newport, 427 

F. Supp. 42, 44 (M.D. Tenn. 1976); Layton v. Allen, 246 A.2d 794, 798 

(Del. 1968); Condon v. A.H. Robins Co., 349 N.W.2d 622, 627 (Neb. 

1984)); see also Mastro, 682 P.2d at 1167 (recognizing a statute of 

limitations that uses discovery of the “injury” to trigger the limitation 

period can be interpreted to mean the date the injury manifests itself in a 

physical, objective manner). However, this interpretation was 

consistently rejected, when properly scrutinized, as inconsistent with the 

purpose of the discovery rule. See Lillicrap, 591 A.2d at 45–46; Borello v. 

United States Oil Co., 388 N.W.2d 140, 145 (Wis. 1986) (“[M]ere 

knowledge of the fact of an injury and nothing more will not trigger the 

commencement of the period of limitations.”). The cases cited from time 

to time for the proposition that the statute of limitations commences 

upon discovery of the injury did not include a supporting rationale. 

Instead, the cases expressed the concept in the context of circumstances 
19

where factual causation was known by the plaintiff or where the court 

intended to include causation in fact as an element of the discovery of 

the injury without specifically mentioning it. See Allen, 427 F. Supp. at 

44–45 (holding statute of limitations commenced upon discovery of 

“physical injury, rather than an act of negligence”; yet the element of 

factual causation was never at issue in the case because the nature of 

the injury was such that the discovery of the factual cause would have 

occurred at the same time as the discovery of the injury); Bussineau, 518 

A.2d at 426 (“Although the language of our [prior] holding . . . refers only 

to the time when a plaintiff has or should have ‘knowledge of injury,’ the 

facts of the case and the analysis engaged in by the court make it clear 

that we required a finding of more than mere knowledge of injury . . . .”); 

Booth v. Wiley, 839 N.E.2d 1168, 1172 (Ind. 2005) (citing example of one 

of its prior medical malpractice statute-of-limitations cases that 

“summarily referred to a plaintiff’s discovery of injury without any 

specific reference to the discovery of the malpractice itself,” but without 

intending to retreat from its rule that requires knowledge of the 

malpractice and resulting injury to trigger the statute of limitations). No 

court at the time expressed a principled notion that the cause of action 

accrued under the discovery rule based on mere knowledge of the injury. 

 The second circumstance of importance at the time Baines was 

decided was the concomitant drumbeat of tort reform sweeping the 

country, predicated on claims of a mounting medical malpractice crisis. 

See generally Anderson v. Wagner, 402 N.E.2d 560, 563–64 (Ill. 1979) 

(discussing “medical malpractice crisis” and discovery rule). One 

common reform centered on the need to tighten the statute of limitations 

to reduce a physician’s exposure to future liability for malpractice 

lawsuits. In particular, as the popularity of the discovery rule (that often 
20

delayed the running of the statute of limitations that otherwise would 

have commenced under the former bright-line occurrence-of-injury rule) 

picked up steam in the 1960s, the medical malpractice insurance 

industry began to increase premiums to protect against the resulting 

“long tail” of potential liability. Id.; Austin v. Litvak, 682 P.2d 41, 44–45 

(Colo. 1984) (citing Howard A. Learner, Restrictive Medical Malpractice 

Compensation Schemes: A Constitutional “Quid Pro Quo” Analysis to 

Safeguard Individual Liberties, 18 Harv. J. on Legis. 143 (1981)). In 

response to this problem, “various state and national commissions 

recommended placing an outside limit on the discovery rule in medical 

malpractice cases.” Anderson, 402 N.E.2d at 565–66 (citing American 

Bar Association, Report of the Commission on Medical Professional 

Liability 140–43 (1977); Medical Injury Insurance Reparations 

Commission, Report and Recommendation to Governor Dan Walker and 

Members of the 79th General Assembly (Ill. 1976); Medical Malpractice: 

The Duke L.J. Symposium 253–54 (1977)). Iowa joined in with its own 

legislative study. See Koppes v. Pearson, 384 N.W.2d 381, 384 (Iowa 

1986) (noting the Iowa legislature undertook a comprehensive study, 

resulting in a malpractice injury study committee). As a result, statutes 

of repose, which bar medical malpractice claims after a specific period of 

time regardless of the date of discovery, were proposed “to reduce 

malpractice premiums by eliminating the insurance companies’ inability 

to predict future claims and losses.” Austin, 682 P.2d at 46. Clearly, the 

medical malpractice crisis was not a fight over the adoption and 

definition of the discovery rule, but a reform movement to achieve 

restrictions on the discovery rule to accommodate the problems it 

presented to the insurance industry and medical field due to the openended liability. See Koppes, 384 N.W.2d at 384 (noting the existence of a 
21

“critical situation . . . because of the high cost and impending 

unavailability of medical malpractice insurance”). 

 The reform became particularly relevant to Iowa after Baines made 

the discovery rule specifically applicable to medical malpractice cases. 

Thus, the Baines case set the stage for Iowa’s adoption of the national 

tort reform proposal of a statute to place an outside limit on the 

applicability of the discovery rule in medical malpractice actions. 

 In 1975, one year following Baines, the Iowa legislature enacted 

Iowa Code section 614.1(9)(a) as a specific exception to the general 

statute of limitations for malpractice actions against a specific group of 

medical personnel and medical facilities. See 1975 Iowa Acts ch. 239, 

§ 26. The statute maintained the two-year limitation period, adopted the 

discovery rule, and placed a six-year period of repose on the applicability 

of the discovery rule as proposed by the reform movement. The statute 

of repose provided an outside limitation for all lawsuits, even though the 

injury had not been discovered. 

 Since the enactment of the statute, the dispute in Iowa has not 

involved the adoption of the discovery rule or the six-year period of 

repose. Instead, the dispute has mostly centered on the extent to which 

the legislature intended to restrict the triggering event for the two-year 

limitation. While the Iowa legislature adopted the discovery rule concept, 

it defined the rule to begin the two-year statute of limitations when the 

patient “knew, or through the use of reasonable diligence should have 

known [of], . . . the injury or death for which damages are sought in the 

action.” Iowa Code § 614.1(9). In contrast, the definition of the discovery 

rule in Baines provided for the cause of action to accrue not only upon 

the discovery of the injury and its cause, but also the discovery of the 

negligent conduct. 
22

 In our first cases to address section 614.1(9) following its 

enactment, we observed the legislative purpose behind the statute was 

“to restrict the Baines discovery rule.” Schultze v. Landmark Hotel Corp., 

463 N.W.2d 47, 50 (Iowa 1990); see also Koppes, 384 N.W.2d at 387 

(citing Farnum v. G.D. Searle & Co., 339 N.W.2d 392, 395 (Iowa 1983)); 

Kohrt v. Yetter, 344 N.W.2d 245, 247 (Iowa 1984). Yet, we did not begin 

to analyze the specific statutory restriction placed on the discovery rule 

until Schultze. 

 In Schultze, a patient was admitted to a hospital for treatment of a 

hip fracture and died seventeen days later. 463 N.W.2d at 48. Her 

personal representative eventually sued the hospital and treating 

physicians for malpractice by filing a claim more than two years after the 

death, but less than two years after the plaintiff discovered the alleged 

negligence of the physicians. Id. We concluded the lawsuit was untimely 

under the statute because the discovery rule did not delay the running of 

the statute until the plaintiff discovered the wrongful act. Id. at 49–50. 

We focused on the triggering event used by the legislature under the 

statute—injury or death—and found neither the plain language of the 

statute nor the history of the statute permitted us to inject any modifying 

language that the injury or death be wrongful. Id. In reviewing the 

legislative history, however, we did not acknowledge or discuss the two 

different triggering events recognized around the country or how the 

concept of an injury in the context of a statute of limitations traditionally 

embraced other elements of the claim. Instead, we observed the 

discovery rule was generally inapplicable to wrongful-death claims 

because death from medical care is the type of event that should give rise 

to the duty to investigate a cause of action. Id. at 50. 
23

 Our first occasion to substantively address section 614.1(9)(a) in 

the context of a medical malpractice injury claim was Langner v. 

Simpson, 533 N.W.2d 511 (Iowa 1995). There, we said: 

Subsection 9 means the statute of limitations now begins to 

run when the patient knew, or through the use of reasonable 

diligence should have known, of the injury for which 

damages are sought. The statute begins to run even though 

the patient does not know the physician had negligently 

caused the injury. 

Id. at 517. We also formally read inquiry notice into the application of 

the statute and indicated the duty to investigate begins “once a person is 

aware that a problem exists.” Id. at 518. The “injury” claimed to have 

been suffered in Langner was posttraumatic stress disorder allegedly 

caused, in part, by the rude bedside statements of a treating 

psychiatrist. The plaintiff’s “problem” surfaced so as to give rise to a 

duty to investigate at the time the conduct of the psychiatrist hurt her 

feelings, even though she did not understand the medical reasons why 

the conduct adversely affected her. Id. 

We next made a passing reference to the statute of limitations for 

medical malpractice claims in McClendon v. Beck, 569 N.W.2d 382, 386 

(Iowa 1997). There, we referred to the plaintiff’s injury as “constant pain” 

following her surgery and found the “district court correctly concluded 

that the constant pain experienced by McClendon following the 

operations was sufficient to put her on notice of the injury” for which she 

claimed damages. Id. 

 We next faced the statute in Schlote v. Dawson, 676 N.W.2d 187 

(Iowa 2004). In that case, the patient brought a malpractice action 

against a physician based on a claim that the physician negligently 

treated a throat condition by unnecessarily removing his voice box. Id. at 

189. However, the patient did not discover the surgery may have been 
24

unnecessary until more than two years later and, consequently, filed the 

lawsuit more than two years after the voice box was removed. Id. 

Relying primarily on Schultze, we determined the legislature intended the 

word “injury,” to refer to its common dictionary meaning of physical 

harm, as opposed to its legal meaning involving the violation of a right or 

protected interest. Id. at 192–93. Additionally, we concluded the 

legislature must have intended for the statute, as a direct response to 

Baines, to exclude any consideration of wrongful conduct in applying the 

discovery rule. Id. at 194. Consequently, we found the statute of 

limitations began to run when the plaintiff knew the fact of his injury, 

even though the plaintiff did not know of the physician’s wrongful 

conduct. Id.

 We last considered the statute of limitations in Ratcliff v. Graether, 

697 N.W.2d 119 (Iowa 2005). In that case, the plaintiff experienced 

blurry vision following LASIK eye surgery. Id. at 121. Relying on our 

view in Schlote that “injury” for purposes of the discovery rule merely 

meant physical harm, apart from any notion that the harm was wrongful, 

we found Ratcliff was put on inquiry notice of his injury the day after his 

surgery and later gained actual knowledge as a result of his investigative 

finding that his doctor may have been legally responsible for the harm. 

Id. at 124. Because these events occurred more than two years prior to 

the time he filed his lawsuit, his claim was barred. Id.

As a whole, our cases interpreting section 614.1(9) have given rise 

to the rule that the statute of limitations begins to run when the plaintiff 

knows or, through the use of reasonable diligence, should have known of 

the physical harm. Langner, 533 N.W.2d at 517. Moreover, we have 

narrowly defined the injury as physical harm and have applied inquiry 

notice to commence the statute of limitations once symptoms of the 
25

physical harm are experienced by a patient during or after medical 

treatment, even though there is no indication of a cause or negligent 

conduct by the doctor. Consequently, we have severely restricted the 

discovery rule, essentially using it to require only inquiry notice of 

physical harm. See Schlote, 676 N.W.2d at 194 (recognizing our 

interpretation of section 614.1(9) effectively eliminates the discovery rule 

from medical malpractice actions). In narrowly construing the statute as 

not requiring discovery of the negligent conduct of the physician, we have 

not considered the role of any form of causation as a part of the analysis. 

In applying this case law to the undisputed facts of the summary 

judgment proceedings in this case, it is clear the Rathjes were placed on 

inquiry notice when Georgia was suffering from physical harm prior to 

April 26, 1999, more than two years prior to filing the petition. She was 

experiencing increasing signs of physical harm to her body, which an 

investigation revealed within two years from the time of the onset of the 

symptoms was caused by the administration of Antabuse. Under the 

rule applied in Schlote, the Rathjes failed to timely file their petition, even 

though they had no idea of the cause of the harm prior to the 

commencement of the statute of limitations. Thus, we are again faced 

with the prospect of applying the statute of limitations to deny an 

unsuspecting plaintiff of the right to pursue a claim for medical 

malpractice. 

Understanding the consequences of this state of the law, the 

Rathjes attempt to sidestep this result by arguing the relevant injury for 

the purpose of the statute of limitations is not the symptoms Georgia 

experienced prior to April 26, 1999, but the later damage to her liver. 

They claim the liver damage is the injury that is the basis for the lawsuit, 
26

and this injury was not discovered, or could not have been reasonably 

discovered, until after April 26, 1999. 

The approach advocated by the Rathjes gives rise to concerns 

about allowing plaintiffs to separate injuries and only leads to additional 

problems in an already troubled area of the law. See LeBeau v. Dimig, 

446 N.W.2d 800, 802–03 (Iowa 1989). Our law does not allow the 

splitting of a cause of action, and any effort to do so to avoid the 

commencement of the statute of limitations would be inconsistent with 

the purpose of cutting off stale claims. Id. 

 While we agree with our prior observation that the enactment of 

section 614.1(9) was a “direct response to our decision . . . in Baines,” 

the circumstances at the time of the enactment reveal the response was 

not primarily directed at the reasoning we used in Baines to support our 

adoption of the discovery rule. Instead, the legislature was largely 

reacting to the national movement for a statute of repose as a response 

to the prevailing trend toward the adoption of the discovery rule in 

medical malpractice cases. Baines, of course, made the movement 

particularly relevant in Iowa by 1975. Yet, there was no similar 

organized legislative movement that would indicate our legislature 

intended for the physical injury, alone, to serve as the triggering event 

under the discovery rule. 

 Nevertheless, the Baines decision did present a clear choice 

between two distinct triggering events. As mentioned, the doctor in 

Baines argued that the cause of action should accrue under the 

discovery rule when the patient knows or should know of the injury and 

that it was caused by medical care. Baines, 223 N.W.2d at 201. Instead, 

we adopted the rule that the cause of action accrued when the patient 

knew or should have known of the injury and that it was caused by the 
27

negligence of the medical provider. Id. at 202. Thus, the legislature 

could very well have intended to make its own choice by enacting the 

statutory language that tied the discovery rule to actual or implied 

knowledge of “the injury.” Yet, we cannot identify any outside 

circumstance to support an intention for our legislature to enact section 

614.1(9), in response to Baines, to strip the triggering event under the 

discovery rule down to the bare bones of the common definition of an 

“injury.” In fact, in an article written and published shortly after the 

enactment of section 614.1(9), the legislative counsel for the Iowa 

Medical Society explained the two-part effect of the new medical 

malpractice statute of limitations was to change the triggering event for 

the two-year statute-of-limitations period from “the time the injured 

person knew he had a cause of action, i.e., that the physician was 

negligent” to the “date of discovery of the injury . . . but not more than 

six years from the occurrence.” James B. West, Iowa Medical Liability 

Legislation—A Summary of House File 803, 65 Iowa Med. Soc’y J. 493, 

496 (1975). Clearly, the legislature intended to reject discovery of the 

physician’s negligence as a triggering event for the discovery rule, but 

there was no indication the legislature intended to also reject causation 

as a component of the discovery of the injury. 

 The actual debate over the triggering event reflected in the national 

case law at the time the legislature adopted section 614.1(9) in 1975 was 

not over discovery of the cause of action versus discovery of the existence 

of physical harm, but rather whether the discovery of the cause of action 

required actual or imputed knowledge that the physician breached a 

duty of care. There was no indication our legislature sought to narrow 

the triggering event to something other than the two prevailing schools of 

thought or something other than the two choices presented in Baines. 
28

This dispute over the triggering event was aptly illustrated in Kubrick, 

444 U.S. 111, 100 S. Ct. 352, 62 L. Ed. 2d 259. 

In Kubrick, a patient brought a medical malpractice action under 

the Federal Tort Claims Act to recover for a loss of hearing that allegedly 

resulted from prior treatment he received for an infection to his leg. Id.

at 113–15, 100 S. Ct. at 355, 62 L. Ed. 2d at 264. The patient knew of 

his hearing loss more than two years before filing his petition and knew 

it was most likely caused by the drug used to irrigate the leg infection. 

Id. However, the patient did not discover the treating physician should 

have known that using the drug to treat the infection would cause 

hearing loss until less than two years before filing the petition. Id. at 

115, 100 S. Ct. at 356, 62 L. Ed. 2d at 265. 

The district court and the United States Third Circuit Court of 

Appeals held the claim did not accrue under the two-year statute of 

limitations until the plaintiff discovered the possibility that the treatment 

provided by the physician was negligent (i.e., a breach of a legal duty), 

even though the patient knew of the injury and knew the physician was 

responsible for the injury. Id. at 115–16, 100 S. Ct. at 356, 62 L. Ed. 2d 

at 265–66. Thus, the only thing the patient did not know was that the 

responsible conduct constituted negligence. 

The United States Supreme Court rejected the concept that the 

discovery rule required knowledge of the actual legal cause before the 

statute of limitations began to run. It explained the rationale for only 

using discovery of the injury and its factual cause to trigger the discovery 

rule for purposes of the statute of limitations instead of also requiring 

knowledge of negligent treatment, as follows: 

That [the plaintiff] has been injured in fact may be unknown 

or unknowable until the injury manifests itself; and the facts 

about causation may be in the control of the putative 
29

defendant, unavailable to the plaintiff or at least very 

difficult to obtain. The prospect is not so bleak for a plaintiff 

in possession of the critical facts that he has been hurt and 

who has inflicted the injury. He is no longer at the mercy of 

the latter. There are others who can tell him if he has been 

wronged, and he need only ask. If he does ask and if the 

defendant has failed to live up to minimum standards of 

medical proficiency, the odds are that a competent doctor 

will so inform the plaintiff. 

Id. at 122, 100 S. Ct. at 359, 62 L. Ed. 2d at 269. For these reasons, the 

plaintiff’s lack of awareness that the “injury was negligently inflicted” 

does not postpone the commencement of the limitations period under 

this approach. Id. at 123, 100 S. Ct. at 360, 62 L. Ed. 2d at 270. 

 Importantly, the Kubrick case illustrates that the ongoing dispute 

over the application of the discovery rule to the statute of limitations was 

limited to the question of whether knowledge that the conduct of the 

doctor was negligent was needed to trigger the statute of limitations. 

There was no suggestion that knowledge of an injury, without more, 

triggered the statute of limitations. 

Considering the pervasive national adoption of the discovery rule 

at the time Iowa enacted its statute, we think our legislature had to be 

aware of the debate over the triggering event and whether the discovery 

rule should include discovery that the defendant’s conduct was 

negligent. See Roberts, 837 P.2d at 446 (considering the wide-ranging 

movement for medical malpractice legislation at the time and observing 

that the legislature must have canvassed the current trends). Moreover, 

this was the precise debate waged in Baines, the case that prompted our 

legislature to enact the statute of limitations for medical malpractice 

actions. Thus, it would have been reasonable for our legislature to 

intend to adopt what would become the rule in Kubrick, rejecting the rule 

in Baines. Additionally, it would have been reasonable for our legislature 

to adopt a Kubrick-type rule by using the term “injury” in the statute, 
30

since that term had been used for more than a century in the context of 

a statute of limitations to mean more than physical harm. The 

contemporary circumstances do not reasonably suggest our legislature 

actually sought to narrow the triggering event for the statute of 

limitations to discovery of a mere “physical injury.” Thus, our past cases 

have correctly observed that “the statute begins to run even though the 

patient does not know the physician had negligently caused the injury.” 

Langner, 533 N.W.2d at 517. Our past cases have also correctly 

identified that our legislature did not intend the word “injury” in the 

statute to mean legal injury, but only physical injury. Schlote, 676 

N.W.2d at 193 (determining the legislature had physical harm in mind 

when using the word “injury”). Legal injury encompasses the violation of 

the rights for which an action to recover damages may be brought. See 

id. at 192. This was the view we adopted in Baines and the view rejected 

by our legislature in enacting section 614.1(9). 

While we have correctly discerned that the legislature clearly 

narrowed the discovery rule under the statute to exclude any 

requirement that a plaintiff discover that the injury was caused by 

negligence or wrongdoing of the physician, our prior cases have failed to 

identify the role of factual causation as an element of the statutory 

discovery rule. As experienced in other jurisdictions from time to time, 

we have applied the discovery rule literally in terms of “the injury” and 

have neglected to affirmatively acknowledge the role and necessity of any 

type of causation in the analysis. Yet, this result is understandable 

because each time we have considered the statute since its enactment 

the factual cause of the injury was not at issue. Instead, the factual 

cause was known or discovered at the time the injury was discovered. In 

particular, when we stated in Langner that the statute began to run upon 
31

discovery of the injury, the plaintiff knew at the time the injury was 

discovered that it was caused by care provided by the physician. 533 

N.W.2d at 515. Similarly, even the injury identified in Schlote was 

known by the patient to be factually caused by the physician at the time 

the injury was discovered. 676 N.W.2d at 189. Accordingly, we have 

never had to address the continued necessity of knowledge of some form 

of causation until this case, in which the injury and its cause in fact 

were not known simultaneously. Thus, when we said in Langner that a 

patient only needs to be “aware that a problem exists” to commence the 

statute of limitations, the “problem” necessarily embraced the cause in 

fact of the injury. As identified in Kubrick, this type of causation is 

necessary so there are enough facts to alert a reasonable person that the 

injury and its cause should be investigated. Of course, it is not 

important in this case, for the purposes of the statute of limitations, to 

discover if the conduct was negligent, only that the conduct of the 

physician was factually responsible for the injury. 

 This view is also supported by our application of inquiry notice to 

the discovery rule. Inquiry notice plays a role in the medical malpractice 

statute due to the implied knowledge (“should have known”) component 

of the statute. This component charges a plaintiff with knowledge of 

those facts that a reasonable investigation would have disclosed. See 

Franzen, 377 N.W.2d at 662. Under the statute, once a plaintiff gains 

information sufficient to alert a reasonable person of the need to 

investigate “the injury,” the limitation period begins to run. Id. The 

acquisition of this information is notice that imposes a duty to make a 

factual inquiry into the existence of the injury. The statute of limitations 

is triggered upon the acquisition of this information because, once a 

plaintiff is “armed with the facts about the harm done to him, [the 
32

plaintiff] can protect himself [from the statute of limitations] by seeking 

advice in the medical and legal community.” See Kubrick, 444 U.S. at 

123, 100 S. Ct. at 360, 62 L. Ed. 2d at 270. 

 If the limitation period to file a lawsuit under the statute is 

interpreted to commence once plaintiffs gain sufficient information of the 

injury or physical harm without regard to its cause, some plaintiffs may 

not know enough to understand the need to seek expert advice about the 

possibility of a lawsuit to protect themselves from the statute. In some 

instances, the cause of medical malpractice injuries may be evident from 

facts of the injury alone, but in other cases it may not. Yet, in all cases, 

a plaintiff must at least know the cause of the injury resulted or may 

have resulted from medical care in order to be protected from the 

consequences of the statute of limitations by seeking expert advice from 

the medical and legal communities. The fundamental objective of 

applying the discovery rule to the statute of limitations is to put 

malpractice plaintiffs on comparable footing as “other tort claimants” to 

be able to “determine within the period of limitations whether to sue or 

not.” Id. at 124, 100 S. Ct. at 360, 62 L. Ed. 2d at 270. Thus, the 

discovery of relevant facts about the injury to commence the statute of 

limitations must include its cause in order to justify the commencement 

of the limitation period. The Iowa legislature could not have intended to 

commence the running of the statute of limitations through inquiry 

notice before inquiry is warranted. 

 We think it is clear our legislature intended the medical 

malpractice statute of limitations to commence upon actual or imputed 

knowledge of both the injury and its cause in fact. Moreover, it is equally 

clear this twin-faceted triggering event must at least be identified by 
33

sufficient facts to put a reasonably diligent plaintiff on notice to 

investigate. 

 This approach rejects the claim made by the Rathjes that “the 

injury” that will trigger the statute can be separated into different 

degrees of harm or different categories of harm that separately give rise 

to different triggering dates. The statute does not work in that manner. 

We adhere to the rule that a plaintiff does not need to know the full 

extent of the injury before the statute of limitations begins to run. See 

LeBeau, 446 N.W.2d at 803 (holding statute of limitations begins to run 

even though the plaintiff is unaware of the full extent of his injury); see 

also Murphy v. Aero-Med, Ltd., 345 F. Supp. 2d 40, 44 (D. Mass. 2004) 

(declaring plaintiff does not need to know the full extent of injury or need 

to identify the particular cause of the symptoms). 

The statute begins to run only when the injured party’s actual or 

imputed knowledge of the injury and its cause reasonably suggest an 

investigation is warranted. See Ralph V. Seep, Annotation, Accrual of 

Cause of Action for Purpose of Statute of Limitations in Medical Malpractice 

Actions Under Federal Tort Claims Act—Post-Kubrick Cases, 101 A.L.R. 

Fed. 27, 33 (1991) (“When the plaintiff has the knowledge of the “critical 

facts” concerning his or her injury and its cause, he or she is charged 

with the duty to investigate promptly and present any claim for relief.”). 

The symptoms experienced by a patient can be sufficient to alert a 

reasonable person to the existence of the injury, but those symptoms 

may not always alert the plaintiff to the cause of the injury. These 

elements must be considered together to allow the statute of limitations 

to operate in its intended manner to protect unsuspecting plaintiffs. 

 The general approach we adopt today is consistent with the 

framework followed in other jurisdictions that apply the discovery rule to 
34

statutes of limitation in medical malpractice cases. As previously 

indicated, nearly all jurisdictions in this country apply some form of the 

discovery rule to statutes of limitation in medical malpractice cases. 

David W. Feeder II, When Your Doctor Says, “You Have Nothing to Worry 

About,” Don’t Be Sure: The Effect of Fabio v. Bellomo on Medical 

Malpractice Actions in Minnesota, 78 Minn. L. Rev. 943, 953 (1994). 

While these jurisdictions reach different conclusions on the question 

whether discovery of causation involves the relationship between the 

injury and the factual cause or the relationship between the injury and 

negligence (or some evidence of wrongdoing), they all recognize causation 

to be an essential component of the analysis. See Bussineau, 518 A.2d 

at 430–35 (citing and reviewing cases from at least fifteen states that 

require either some evidence of wrongdoing to trigger the medical 

malpractice statute of limitations or require discovery of all elements of 

the cause of action); Mastro, 682 P.2d at 1167–68 (citing cases that have 

adopted the “legal injury” meaning of the word “injury” used in the 

statute of limitations governing medical malpractice actions); Catz v. 

Rubenstein, 513 A.2d 98, 102–03 (Conn. 1986) (same); see also Booth, 

839 N.E.2d at 1172 (medical malpractice statute of limitations triggered 

when patient knows or should know of the malpractice and resulting 

injury); Lagassey v. State, 846 A.2d 831, 844 (Conn. 2004) (plaintiff 

must discover, from a factual standpoint, the nature and extent of the 

injury and that the injury was caused by the wrongful conduct of 

another); Long v. Mem. Hosp., 969 So. 2d 35, 43 (Miss. 2007) (medical 

malpractice statute of limitations begins to run with knowledge of injury, 

cause of injury, and causal relationship between injury and conduct of 

physician); Stanbury v. Bacardi, 953 S.W.2d 671, 677 (Tenn. 1997) 

(medical malpractice statute of limitations begins to run when plaintiff 
35

discovers facts sufficient to give notice of an injury as a result of wrongful 

conduct). Although some courts appear to state a rule, from time to 

time, that the statute of limitations begins to run upon discovery of the 

injury alone, as we have done in the past, the validity of those holdings is 

suspect. Our review of all the authority from the other jurisdictions 

supports the approach we take today. 

 We emphasize the knowledge standard under the statute is 

predicated on actual or imputed knowledge of the facts to support the 

injury and of the facts to support a cause. See Kubrick, 444 U.S. at 124, 

100 S. Ct. at 360, 62 L. Ed. 2d at 270 (holding statute of limitations 

begins to run from plaintiff’s discovery of the relevant facts about the 

injury); Maestas, 152 P.3d at 147–48 (same). Importantly, we continue 

to adhere to the rule that the plaintiff does not need to discover that the 

doctor was negligent. 

 In applying the medical malpractice statute of limitations, as we 

now interpret it, to the undisputed facts in this case, it is clear the 

Rathjes knew Georgia was suffering from physical harm. However, a 

reasonable jury could find they did not know the cause of the harm until, 

at the earliest, April 27, 1999, the date the gastroenterologist made a 

diagnosis of “drug-induced hepatitis secondary to Antabuse.” Moreover, 

the jury could find that, until that time, no facts were available that 

would have alerted a reasonably diligent person that the cause of the 

injury may have originated in Georgia’s medical treatment so as to put 

the plaintiffs on notice of the need to investigate. Consequently, a 

reasonable jury could conclude the Rathjes filed their petition within the 
36

two-year limitation of section 614.1(9). The district court erred in 

granting summary judgment for the defendants.5

 The approach taken today departs from the direction we have 

taken in our prior cases since the time the statute was enacted. Yet, it is 

not necessarily inconsistent with the outcomes of our prior cases. 

Moreover, it better reflects the objective of the discovery rule to prevent 

the limitations period from commencing when blameless plaintiffs are 

unsuspecting of a possible claim.6 We choose this approach because it is 

consistent with the language of the statute when placed in proper 

historical context, consistent with the purposes and goals of the 

statutory discovery rule, fair to patients, doctors and the medical 

malpractice insurance industry, respectful of the trust and confidence 

essential to a doctor-patient relationship, and best meets the overall 

goals of a justice system. 

 Finally, if our interpretation of the medical malpractice statute of 

limitations is out of line with the original intent of the legislature, that 

body can respond to correct it. We have tried to define the triggering 

date for the discovery rule with more clarity, and this will allow our 

legislature to intervene if we have missed the mark. Yet, we firmly 

believe this interpretation resolves the basic systemic problem that has 

plagued our prior interpretation of the statute and should allow the 

statute to work to better achieve its purposes and goals. 

 

5The only issue presented to the district court was whether the defendants were 

entitled to summary judgment. The plaintiffs did not file a cross-motion for summary 

judgment. Thus, we are not presented with the question whether the Rathjes filed their 

petition within the two-year statute of limitations period as a matter of law. 

6In all of our prior medical malpractice statute-of-limitations cases under section 

614.1(9), the factual cause of the injury was known or should have been known at the 

time the injury was discovered. Thus, the absence of the factual-causation component 

adopted today from our prior analysis has not been responsible for any unfairness to a 

blameless, unsuspecting plaintiff. Any claims of past unfairness in the application of 

the discovery rule to the statute of limitations in medical malpractice cases must be 

analyzed under the injury component of the rule, a question not at issue in this case. 
37

IV. Conclusion.

 We reverse the decision of the district court and remand the case 

to the district court for further proceedings. 

REVERSED AND REMANDED. 

 All justices concur except Wiggins, J., who concurs specially, and 

Streit, J., who takes no part.