Source: https://www.benglasslaw.com/library/doctor-wins-wrongful-birth-case-appeal.cfm
Timestamp: 2019-04-21 13:20:32+00:00

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In this situation, the mother and father of twin daughters afflicted with Down syndrome alleged that the defendants, Dr. Jan Paul Fruiterman et al., breached the standard of care by failing to provide the mother with information about first trimester testing known as chorionic villus sampling, which would have revealed that her twin fetuses were afflicted with Down syndrome. The mother, Julie Granata, said she would have decided to terminate the pregnancy if she had been aware of this information.
The parents of the twins alleged that the defendant physicians undertook to provide obstetrical services and prenatal care to the couple, thereby establishing a physician-patient relationship with both parents. The parents calimed they were trying to recover for mental and emotional distress, medical and hospital bills for the care of the twins, and lost family income.
The defense tried to strike the evidence because there was not a reasonable degree of medical probability that the testing results would have been positive for Down syndrome. However, the circuit court ruled in the mother's favor. In the husband's case, the circuit court granted the physicians' motion to strike and dismissed his case, concluding that the husband was not a patient and could not reasonably have expected to be a patient.
The doctors appealed the case, and won on the basis that the circuit court erred in refusing to set aside the jury verdict in Julie's favor because the judgment was without evidence to support it.
The full brief below is quite long, so if you are looking for some quick and helpful information on medical malpractice in Virginia, you should download a FREE copy of my book, Why Most Medical Malpractice Victims Never Recover a Dime, here.
JAN PAUL FRUITERMAN, M.D., ET AL.
Lemons, and Goodwyn, JJ., and Carrico, S.J.
In two separate but identical wrongful birth lawsuits by the mother and father of twin daughters afflicted with Down syndrome, these plaintiffs alleged that the defendant physicians undertook to provide obstetrical services and prenatal care to the couple, thereby establishing a physician-patient relationship with both parents, and that defendants breached the standard of care by failing to provide the mother with information about first trimester testing known as chorionic villus sampling, which would have revealed that her twin fetuses were afflicted with Down syndrome. Additionally, they alleged that if the mother had known about the condition of her fetuses during the first trimester she would have elected to terminate the pregnancy. The parents sought damages for, among other things, mental and emotional distress, medical and hospital bills for the care of the twins, and lost family income. The two actions were tried together before the same jury. The circuit court overruled defense motions to strike the evidence for failure to prove to a reasonable degree of medical [Page 630] probability that the testing results would have been positive for Down syndrome, and sustained the jury verdict in the mother's favor, reduced to the malpractice recovery cap limits. In the husband's case the circuit court granted the physicians' motion to strike and dismissed his case, concluding that in the absence of an affirmative undertaking by the treating doctor, the husband was not a patient and could not reasonably have expected to be a patient as defined in Code § 8.01-581.1. These appeals followed.
1. A plaintiff armed with a jury verdict approved by the trial court stands in the most favored position known to the law. When a trial court has refused to strike a plaintiff's evidence or to set aside a jury verdict, the standard of appellate review requires a determination of whether the evidence presented at trial, taken in the light most favorable to the plaintiff, was sufficient to support the jury verdict. A trial court's judgment sustaining a jury verdict will not be set aside unless it is plainly wrong or without evidence to support it.
2. In any medical malpractice action, one of the elements that a plaintiff must prove is a causal connection between the breach of duty and any claimed injury or damage. Although the issue of proximate causation is normally a question of fact for the jury to determine, a court may decide the issue when reasonable persons could not differ.
3. Expert testimony is generally required to establish not only the appropriate standard of care and a deviation from the standard, but also that such a deviation was the proximate cause of the claimed damages.
4. In this case, the mother did not prove to a reasonable degree of medical probability that, if she had undergone the specified testing, the result would have shown the chromosomal abnormality indicative of Down syndrome. None of her medical expert witnesses opined about what the result of the testing would have been if she had undergone the procedure, and there exists no such evidence in the record. Thus she failed to establish that the defendants' breach of the standard of care was a proximate cause of the wrongful birth of her twin daughters.
5. This wrongful birth case is not one of those rare instances in which expert testimony is not required to prove that breach of the standard of care was a proximate cause of the claimed damages. Whether the result of the testing would have been positive for Down syndrome if the mother had undergone that procedure is not a matter within the common knowledge and experience of a jury. Furthermore, plaintiffs' expert evidence showed that many patients require a follow-up amniocentesis after receiving positive testing results. Plaintiffs, through their medical experts, also presented evidence about the risks of false positive and false negative results of the subject testing. Thus the circuit court erred in refusing to set aside the jury verdict in the mother's favor as it was without evidence to support it.
7. Whether a physician-patient relationship exists is a question of fact, turning upon a determination whether the patient entrusted his treatment to the physician and the physician accepted the case.
8. A physician's duty arises only upon the creation of a physician-patient relationship; that relationship springs from a consensual transaction, a contract, express or implied, general or special.
9. Under Code § 8.01-581.1 the term “patient” means any natural person who receives or should have received health care from a licensed health care provider. Under the Act, “health care” means any act, professional services in nursing homes, or treatment performed or furnished, or which should have been performed or furnished, by any health care provider for, to, or on behalf of a patient during the patient's medical diagnosis, care, treatment or confinement.
11. In this case testimony concerned events that occurred during one of the mother's medical appointments early in the pregnancy in which the father accompanied her to the doctors' office, assisted her in filling out a genetic screening questionnaire, and responded to questions from one of the doctors about his family background as to genetic disorders. Although one of the defendant doctors discussed and/or recommended amniocentesis and genetic counseling, the evidence demonstrates the diagnosis, care, or treatment on that day was directed to the mother, not to the father. There is no evidence that the father entrusted his treatment to the physician and the physician accepted the case.
12. Plaintiffs did not allege that the doctors breached the standard of care by failing to advise them as a couple about genetic counseling or to recommend genetic screening tests that either the father alone or both of them would need to undergo. Instead, they asserted a failure to inform the mother about the availability of certain testing during the first trimester of her pregnancy. Obviously, the mother is the only person who could consent to and undergo that procedure. Information about that testing was not an “act . . . which should have been . . . furnished” to the father as provided in the statutory definition of health care.
13. The medical expert witnesses' testimony about what constitutes health care does not alter this conclusion. In the context of a pregnancy, a husband may be entitled to receive such information about a fetus' risk of having genetic abnormalities. The question whether the father here had a physician-patient relationship with that doctor, however, turns solely on the facts surrounding the specific appointment.
14. The evidence, as a matter of law, was insufficient to show a consensual transaction giving rise to a physician-patient relationship and a duty to perform the service contemplated.
15. One who assumes to act, even though gratuitously, may thereby become subject to the duty of acting carefully, if he acts at all. A physician can, in certain circumstances, affirmatively undertake to provide health care to an individual, [Page 632] who prior to that moment was not the physician's patient, and thereby assume the duty to comply with the applicable standard of care. In such circumstances the physician-patient relationship arises by implication because the doctor takes affirmative action to participate in the care and treatment of a patient.
16. Whether particular evidence adduced at trial was sufficient to prove a physician undertook to provide health care to a non-patient, thereby assuming the duty to comply with the standard of care, turns on whether the physician personally engaged in some affirmative act amounting to a rendering of services to another.
17. Here the evidence of an affirmative undertaking to provide health care was insufficient as a matter of law. The father did not establish an affirmative act of the doctor during the appointment he attended that would amount to the rendering of health care to the father. Thus the doctor assumed no duty to comply with the applicable standard of care with regard to him. Therefore the circuit court did not err in granting the motion to strike the evidence in the father's case.
Record No. 071894 — Reversed and final judgment.
Record No. 071897 — Affirmed.
JUSTICE KINSER delivered the opinion of the Court.
Julie Granata and Joseph Granata (the Granatas) each filed a separate but identical motion for judgment in the circuit court, alleging that Jan Paul Fruiterman, M.D., Eleni Solos-Kountouris, M.D., and their professional corporation, Drs. Fruiterman and Solos-Kountouris, P.C. (collectively, the Doctors), undertook to provide obstetrical services and prenatal care to the couple, thereby establishing a physician-patient relationship with both Julie and Joseph. The Granatas further alleged that the Doctors breached the standard of care by failing to provide Julie with information about first trimester testing known as chorionic villus sampling (CVS),1 which would have revealed that her twin fetuses were afflicted with Down syndrome. Additionally, the Granatas alleged that, if Julie had known about the condition of her fetuses during the first trimester, she would have elected to terminate the pregnancy. As a direct and proximate result of the Doctors' alleged negligence, Julie and Joseph claimed damages for, among other things, mental and emotional distress, medical and hospital bills for the care of the twins, and lost family income.
The two actions were tried together before the same jury. In motions to strike both at the close of the Granatas' evidence and at the close of all the evidence, the Doctors argued, among other things, that the Granatas failed to prove by expert testimony to a reasonable degree of medical probability that, if Julie had undergone CVS testing, the result would have been positive for Down syndrome. The Doctors also asserted that Joseph failed to prove the existence of a physician-patient relationship. Therefore, they argued his claim was, at most, only derivative of Julie's claim.
The circuit court took all the motions to strike under advisement and elected to decide them, if needed, after the jury returned verdicts. In separate verdicts, the jury found in favor of Julie and awarded damages in the amount of $4,000,000. The jury also found in favor of Joseph and awarded $500,000 in damages.
In post-trial motions, the Doctors renewed their motions to strike the Granatas' evidence. They also asked the circuit court to set aside the jury verdicts and either enter judgment in their favor or grant them a new trial. The Doctors alternatively moved the circuit court to [Page 634] reduce the verdicts in accordance with the statutory cap for recoveries in medical malpractice actions pursuant to Code § 8.01-581.15.
At the post-trial hearing, the Doctors presented the same arguments that they raised in the motions to strike the evidence. With respect to whether the Granatas proved by expert testimony that the results of CVS would have been positive for Down syndrome, the circuit court asked whether “there was any evidence that if a CVS had been done it would have returned a positive result.” The Granatas acknowledged there was no such evidence in the record. Regardless, the circuit court overruled the Doctors' motions and sustained the jury verdict in Julie's favor. The court did, however, reduce the award to $1.6 million pursuant to Code § 8.01-581.15.
The Doctors and Joseph filed separate appeals from the respective judgments of the circuit court. With regard to the Doctors' appeal, the dispositive issue is whether Julie proved through expert testimony to a reasonable degree of medical probability that, if CVS testing had been conducted, the result would have shown the chromosomal abnormality associated with Down syndrome. Joseph assigns two errors to the circuit court's judgment. He first claims the court erred in ruling that he failed to prove a physician-patient relationship with Dr. Solos-Kountouris or her professional corporation. Second, Joseph asserts that the court erred in failing to find that Dr. Solos-Kountouris undertook to provide health care to him by advising about genetic testing.
In February 2002, Julie met with Dr. Solos-Kountouris for pre-conception counseling and a gynecological examination. Dr. Solos-Kountouris discussed the risks associated with conceiving a child when the mother is past the age of 35, in particular the risk of having a fetus with a chromosomal abnormality.3 According to Dr. Solos-Kountouris, she emphasized the importance of screening tests, including CVS and amniocentesis,4 and explained how such procedures are performed, the risks associated with them, and the time frame during a pregnancy when the mother can undergo the tests.
Julie further testified that Dr. Solos-Kountouris told her amniocentesis was the “only way” to determine whether a fetus has a chromosomal abnormality. Moreover, Julie insisted that no one at the Doctors' office mentioned CVS during either her initial appointment or her subsequent appointments.
Soon after the pre-conception counseling visit, Julie became pregnant and returned to the Doctors in March 2002 to confirm her pregnancy. At that appointment, she saw Dr. Fruiterman, who, like Dr. Solos-Kountouris, recommended that Julie undergo amniocentesis. According to Julie, she again rejected amniocentesis because, in her view, it is performed too far along in the pregnancy.
Throughout her pregnancy, Dr. Fruiterman and Dr. Solos-Kountouris also recommended that Julie receive genetic counseling. Despite their recommendations, Julie never attended genetic counseling. [Page 636] Additionally, she never underwent amniocentesis, despite a positive alpha-fetoprotein blood test result in June 2002. The result signaled that the fetuses had a high risk for Down syndrome. In September 2002, Julie gave birth to identical twin girls, both of whom are afflicted with Down syndrome.
During cross-examination, Dr. Williams admitted that there is a possibility of receiving a false result from CVS, but claimed such a result is “extremely rare.” When asked if there are instances of positive CVS results that have been disproved by later tests indicating a fetus is normal, Dr. Williams explained that there are occasions when there is a “mixture of normal and abnormal cells, and in that situation better than 90 percent of the time the fetus is not affected.” He also stated that about 1-in-100 patients would require a follow-up amniocentesis to “sort things out” after receiving a positive CVS. At no time during his testimony did Dr. Williams state his opinion as to whether CVS would have been positive for Down syndrome if Julie had undergone that test.
 In addressing the Doctors' challenge to the sufficiency of the evidence to prove that, if Julie had undergone CVS, the result would have shown the chromosomal abnormality associated with Down syndrome, we apply established principles of appellate review. A plaintiff who is “[a]rmed with a jury verdict approved by the trial court, . . . stands in ‘the most favored position known to the law.’” Bitar v. Rahman, 272 Va. 130, 137, 630 S.E.2d 319, 323 (2006) (quoting Ravenwood Towers, Inc. v. Woodyard, 244 Va. 51, 57, 419 S.E.2d 627, 630 (1992)). When a trial court has refused to strike a plaintiff's evidence or to set aside a jury verdict, the well-established standard of appellate review requires this Court to determine whether the evidence presented at trial, taken in the light most favorable to the plaintiff, was sufficient to support the jury verdict in favor of the plaintiff. Id. at 141, 630 S.E.2d at 325-26. We will not set aside a trial court's judgment sustaining a jury verdict unless it is “plainly wrong or without evidence to support it.” Code § 8.01-680; see also Bitar, 272 Va. at 137, 630 S.E.2d at 323.
[2-3] In Julie's wrongful birth case, as in any medical malpractice action, one of the elements that a plaintiff must prove is “a causal connection between the breach of duty and any claimed injury or damage.” Naccash v. Burger, 223 Va. 406, 414, 290 S.E.2d 825, 829 (1982); see also Bryan v. Burt, 254 Va. 28, 34, 486 S.E.2d 536, 539-40 (1997) (“[A] plaintiff must establish not only that a defendant violated the applicable standard of care, and therefore was negligent, the plaintiff must also sustain the burden of showing that the negligent acts constituted a proximate cause of the injury.”); Brown v. Koulizakis, 229 Va. 524, 532, 331 S.E.2d 440, 446 (1985) (same).
Although the issue of proximate causation is normally a question of fact for the jury to determine, a court may decide the issue “when reasonable persons could not differ.” Jenkins v. Payne, 251 Va. 122, 128, 465 S.E.2d 795, 799 (1996); accord Hadeed v. Medic-24, Ltd., 237 Va. 277, 285, 377 S.E.2d 589, 593 (1989). Expert testimony is [Page 638] generally required to establish not only the appropriate standard of care and a deviation from the standard, but also “‘that such a deviation was the proximate cause of the claimed damages.’” Perdieu v. Blackstone Family Practice Ctr., Inc., 264 Va. 408, 420, 568 S.E.2d 703, 710 (2002) (quoting Raines v. Lutz, 231 Va. 110, 113, 341 S.E.2d 194, 196 (1986)); accord Bitar, 272 Va. at 138, 630 S.E.2d at 323.
In the case before us, Julie claimed the Doctors breached the standard of care by failing to inform her about the availability of CVS either prior to or during her pregnancy. She further alleged that, if she had known about CVS at a time during the pregnancy when she could have had the test, she would have done so and would have terminated her pregnancy if the result had been positive for Down syndrome.
 Julie, however, did not prove to a reasonable degree of medical probability that, if she had undergone CVS, the result would have shown the chromosomal abnormality indicative of Down syndrome. None of Julie's medical expert witnesses opined about what the result of CVS would have been if Julie had undergone the procedure. Moreover, the Granatas acknowledged before the circuit court that no such evidence existed in the record. Thus, Julie failed to establish that the Doctors' breach of the standard of care was a proximate cause of the wrongful birth of her twin daughters.
Julie, nevertheless, contends Dr. Williams' testimony, read from medical literature that classified CVS as a “definitive diagnostic test,” provided the requisite proximate cause. Julie argues on appeal that the term “definitive” means CVS results would have been positive if she had undergone the procedure. We are not persuaded by her argument. The term “definitive” means “serving to supply a final answer, solution, or evaluation and to end an unsettled unresolved condition.” Webster's Third New International Dictionary 592 (1993). The term does not signify that a certain answer will be provided; it indicates only that some answer will be ascertained.
 This wrongful birth case is not one of those “rare instances” in which expert testimony is not required to prove, among other things, that breach of the standard of care was a proximate cause of the claimed damages. Beverly Enterprises Virginia, Inc. v. Nichols, 247 Va. 264, 267, 441 S.E.2d 1, 3 (1994); see also Coston v. Bio-Medical Apps. of Va., 275 Va. 1, 5, 654 S.E.2d 560, 562 (2008). Whether the result of CVS would have been positive for Down syndrome if Julie had undergone that procedure is not a matter within the common knowledge and experience of a jury. See Perdieu, 264 Va. at 420-21, 568 S.E.2d at 710-11. Furthermore, the Granatas' evidence from their medical expert witnesses showed that many patients require a follow-up amniocentesis after receiving a positive CVS. The Granatas, through their medical experts, also presented evidence about the risks of false positive and false negative results with CVS.
Thus, we conclude that the circuit court erred in refusing to set aside the jury verdict in Julie's favor.5 The judgment was without evidence to support it. Code § 8.01-680.
With regard to the questions whether Joseph proved a physician-patient relationship with Dr. Solos-Kountouris and if not, whether Dr. Solos-Kountouris nevertheless undertook to provide Joseph with health care, Joseph acknowledges that he must rely on the events that transpired during Julie's April 19, 2002 appointment to establish that Dr. Solos-Kountouris owed him a duty of care. Joseph testified that he first accompanied Julie to the Doctors' office on that date and conceded at trial and before this Court that all the alleged negligence occurred on or before April 19, 2002. Therefore, we focus on the facts surrounding Julie's April 19, 2002 appointment.
A. [Joseph] I do. April 19th was the first time I went to the doctor with Julie. It was at the Burke office. I remember going in the office and waiting in a chair next to Julie.
We filled out some paperwork. We also filled out a genetic screening questionnaire, and then they came to get Julie and I started to walk back to be with her for the exam, and they asked me to wait outside until they would call me at a later time.
Q. What happened then when they brought you back?
A. I went back. Dr. Sol[o]s, myself and Julie were discussing her pregnancy. I remember discussing the genetic questionnaire. I remember when Julie was filling out the questionnaire my nephew had something called Prader-Willi, and Julie was writing down that it was a form of Down syndrome, and I remember telling her I don't think it's a form of Down syndrome.
I wouldn't put it there in a spot where it had, I guess, any genetic Down syndrome-related children or relatives. We spoke about that genetic screening sheet for a while. I remember the doctor mentioning amniocentesis. I remember that we talked about if the twins were in one egg or in two sacs . . . .
A. When we were discussing the genetic screening form, I remember her asking some questions about my nephew, about my ethnicity. If there was any other history in my family background that had any kind of genetic disorder.
Q. Why were you there at the appointment with Julie?
A. Well, because I was — you know, we were a family. That was part of what we were going through together. This was my children as well.
Q. What recommendations, if any, did Dr. Sol[o]s make to the two of you?
A. Again, I believe she recommended amniocentesis, and I believe she recommended a geneticist.
A. I never heard that word ever until after the twins were born.

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