Source: https://casetext.com/case/titchnell-v-united-states
Timestamp: 2018-11-17 11:40:17
Document Index: 228288500

Matched Legal Cases: ['§ 247', '§ 2', '§ 247', '§ 202', '§ 1346', '§ 2671', '§ 247', '§ 1395', '§ 1395']

Titchnell v. United States, 681 F.2d 165 | Casetext
681 F.2d 165 (3d Cir. 1982)
United States Court of Appeals, Third CircuitMay 28, 1982
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Argued February 19, 1982.
Mark B. Aronson (argued), Behrend, Aronson Morrow, Pittsburgh, Pa., for appellees.
J. Alan Johnson, U.S. Atty., Pittsburgh, Pa., J. Paul McGrath, Asst. Atty. Gen., Mary Ann Murphy, Jeffrey Axelrad (argued), Attys., Civ. Div., U.S. Dept. of Justice, Washington, D.C., for appellant.
Before ADAMS and SLOVITER, Circuit Judges, and Van ARTSDALEN, District Judge.
Honorable Donald W. Van Artsdalen, United States District Judge for the Eastern District of Pennsylvania, sitting by designation.
This is an appeal from a judgment entered in favor of the plaintiffs, Lonnie F. Titchnell and Ella Titchnell, his wife, on a medical malpractice cause of action for negligent administration of a swine flu immunization inoculation provided to Mr. Titchnell pursuant to the National Swine Flu Immunization Program of 1976, 42 U.S.C. §§ 247b(j)-247b( l) (1976). The judgment will be affirmed.
Pennsylvania case law requires a plaintiff in a medical malpractice action to prove by expert testimony (1) the prevailing standard of medical care accepted by the medical profession, and (2) that the care provided plaintiff deviated from and fell below such accepted standard. Among the witnesses who testified in this case as to medical practices were the following: (1) the supervising nurse at the Suismon Street Clinic, where Mr. Titchnell received the inoculation; (2) a district health officer of the Allegheny County Health Department who had administrative and supervisory duties in respect to the swine flu immunization program provided at several Allegheny County Public Health Clinics, including the Suismon Street Clinic; (3) a psychiatrist; (4) an internist-pathologist; and (5) a neurologist. In addition, the Allegheny County Health Department's Guidelines for Mass. Clinics for the General Population and District Office Clinics for the High Risk Population (Guidelines) applicable to the swine flu immunization program were received in evidence.
The nurse who administered the vaccine did not ask any questions of the plaintiffs. There was no physician in attendance. The nurse took the signed forms from the Titchnells and administered the vaccine while the plaintiffs were standing. Each received the bivalent vaccine in the left arm by hypodermic injection. The nurse instructed the plaintiffs to proceed to another room — the resting room — and to wait there for a period of time.
Persons over 65 years of age were to receive bivalent inoculations by hypodermic injection, and were not to be injected by jet injector guns. Guidelines, Plaintiffs Exhibit 12.
Under the National Swine Flu Immunization Program of 1976 (Swine Flu Act), Pub.L. No. 94-380, § 2, 90 Stat. 1113 (codified at 42 U.S.C. §§ 247b(j)-247b( l) prior to the enactment of the Health Services and Centers Amendments of 1978, Pub.L. No. 95-626, § 202, 92 Stat. 3574), Congress established a procedure for the filing and determination of all claims alleging personal injury or death arising out of the administration of the swine flu vaccine. The Swine Flu Act provides that the United States shall be liable for all such claims based upon the act or omission of a program participant in the same manner and to the same extent as the United States would be liable in any action brought against it under 28 U.S.C. § 1346(b) (1976) and the related tort claims procedures of the Federal Tort Claims Act, 28 U.S.C. §§ 2671-2680 (1976). The Swine Flu Act further provides that state law shall be applicable in actions brought thereunder.
The Swine Flu Act was Congress's hurried response to a perceived threat of an imminent nationwide swine flu epidemic. Hunt v. United States, 636 F.2d 580, 589-90 (D.C.Cir. 1980); Barnes v. United States, 516 F. Supp. 1376, 1378-79 (W.D.Pa. 1981); Wolfe v. Merrill Nat'l Laboratories, Inc., 433 F. Supp. 231, 233 (M.D.Tenn. 1977); Sparks v. Wyeth Laboratories, Inc., 431 F. Supp. 411, 415 (W.D.Okla. 1977). See generally 122 Cong.Rec. 26, 793-817 (1976). In order to make the program operational, and in response to the reluctance of insurance companies to provide liability coverage to the drug manufacturers involved in the program. Congress provided that all claims should be brought directly against the United States. The Swine Flu Act reserves the right of the United States to recover that portion of any damages which may be awarded resulting, inter alia, from any negligent conduct on the part of any program participant in carrying out any obligation or responsibility in connection with the program. 42 U.S.C. § 247b(k)(7).
the manufacturer or distributor of the swine flu vaccine used in an inoculation under the swine flu program, the public or private agency or organization that provided an inoculation under the swine flu program without charge for such vaccine or its administration and in compliance with the informed consent form and procedures requirements . . . and the medical and other health personnel who provided or assisted in providing an inoculation under the swine flu program without charge for such vaccine or its administration and in compliance with such informed consent form and procedures requirements.
[T]he liability of the United States arising out of the act or omission of a program participant may be based on any theory of liability that would govern an action against such program participant under the law of the place where the act or omission occurred, including negligence, strict liability in tort, and breach of warranty . . . .
Understandably, at the trial, counsel, the parties and the trial judge concentrated primarily on the very close and factually difficult issue of causation. The trial court heard extensive testimony from medical experts as to whether, given Mr. Titchnell's medical history, the procedures followed by clinic personnel in administering the swine flu vaccine to him were the proximate cause of his subsequent cerebrovascular accident. The testimony was highly technical and the matter vigorously contested. The court relied on the Pennsylvania Supreme Court case of Hamil v. Bashline, 481 Pa. 256, 392 A.2d 1280 (1978), in concluding that the plaintiffs had met their burden of proof as to causation. On review of the entire record, we cannot conclude that the trial court's finding — that Mr. Titchnell's stroke was proximately caused by the administration of the vaccine — was clearly erroneous.
Expert testimony serves to establish the measure of professional skill required of the defendant under the circumstances of a given case. While there is no per se requirement for expert testimony in all cases of medical malpractice, the facts of the case before us do not permit an inference of negligence without adequate expert testimony. See Jones v. Harrisburg Polyclinic Hospital, 496 Pa. 465, ___, 437 A.2d 1134, 1138 (1981) (application of the doctrine of res ipsa loquitur in medical malpractice actions). In the instant case there is no fund of common knowledge as to the administration of swine flu vaccine from which a non-expert fact finder could infer negligence nor any expert testimony that the stroke would not have occurred absent negligence. See id.
The duties imposed by law on the defendant physicians are to employ such reasonable skill and diligence as is ordinarily exercised in their profession . . . .
It has been uniformly held that expert testimony is necessary to establish negligent practice in any profession. . . .
[T]o make out a case, the plaintiff must show by expert testimony that there was a deviation from proper practices in the administration of the [medical treatment] . . . .
The plaintiff had the burden of proving [the doctor's] negligence and in a case such as this it could be proved only by expert testimony to establish negligence in the operation or a procedure which was not in accord with standard medical practice. . . .
A long and uniform line of cases from the Supreme Court of Pennsylvania has firmly established that expert testimony is required to establish the recognized standard of care and that there was a deviation from that standard.
See Brannan, supra at 595, 417 A.2d at 199; Chandler v. Cook, 438 Pa. 447, 471, 265 A.2d 794, 796 (1970); Lambert v. Soltis, 422 Pa. 304, 309-10, 221 A.2d 173, 175 (1966); Robinson v. Wirts, 387 Pa. 291, 295-96, 127 A.2d 706, 708-09 (1956); Powell v. Risser, 375 Pa. 60, 65-67, 99 A.2d 454, 456-57 (1953); Scacchi v. Montgomery, 365 Pa. 377, 75 A.2d 535, 536 (1950); Bierstein v. Whitman, 360 Pa. 537, 541, 62 A.2d 843, 845 (1949).
In measuring the degree of skill required of a physician and other professional medical personnel, the law does not demand "extraordinary skill . . . but that degree which ordinarily characterizes the profession. And in judging of this degree of skill . . . regard is to be had to the advanced state of the profession at the time." McCandless v. McWha, 22 Pa. 261, 269 (1853). The basic tenets of McCandless have been refined but not altered by the passage of time. In Donaldson v. Maffucci, 397 Pa. 548, 156 A.2d 835 (1959), the Pennsylvania Supreme Court reiterated the principle set forth in McCandless:
[W]e find that the defendant in failing to make proper inquiries regarding Mr. Titchnell's health and hence failing to use proper precautionary procedures in administering the swine flu shot to him deviated from, acceptable standards of medical practice. . . . [H]ad a proper history been taken of Mr. Titchnell, the clinic personnel should then have taken certain precautionary measures before administering the shot to Mr. Titchnell.
The Guidelines adopted by the Allegheny County Health Department required certain specific oral inquiries be made of persons prior to being inoculated. The district health officer, Edna Goerner, testified that asking only if the person was allergic to eggs "would be a deviation" from standard procedure, and that she "couldn't conceive" of any circumstances where such would be the sole oral inquiry. The clinic supervising nurse testified that asking only the single question was "not right" and was not in accord with the instructions she had given. Although it is apparent that any answers that Mr. Titchnell would have given to the inquiries suggested by the Guidelines would not in and of themselves have mandated any additional or alternative precautions or procedures, the manner of response or possible additional questions Mr. Titchnell might have asked could have placed Clinic personnel on notice of a need for special care. The trial judge's finding that "had a proper history been taken . . . the clinic personnel should then have taken precautionary measures" is not clearly erroneous. A proper medical history within the meaning of the district judge's decision does not necessarily mean a full and complete personal medical history. The Guidelines and testimony of clinic personnel established that oral questions that should have been asked were not asked. Upon this, a fact finder could and did predicate a finding of negligence, a deviation from standard accepted medical practice.
4. Ascertain that the vaccine (or his guardian) understands the Information/Registration Form by asking the following questions:
Dr. Walsh classified persons over 65 years of age as "high risk" and stated "we ought to take special pains with these people and make sure they're protected as much as possible. . . ." Appendix at 393. He continued:
THE WITNESS: Yes. If you don't think I'm out of order, I participate in the blood collection program that we have in Greensburg from the Johnstown Blood Bank and we specifically — We have hundreds of paramedical and volunteer people who take the history and do all the work but we always have a doctor sitting right there and any time they get an abnormal historical fact, they come right over to us and ask us so I think that would have been the proper way to do it. I have no idea how they did it but they should have had a medical screening of some sort and a doctor there when he or his wife said yes, I have had high blood pressure and I have taken medicine and I have had a stroke and they should have taken the guy right in the room and said: Should we give the guy a shot?
[By counsel for the plaintiffs:]
The question directed to Dr. Rosen by the court was aimed at eliciting a response as to whether the care given Mr. Titchnell was in conformity with "good medical practice." The question by plaintiffs' counsel asked for an opinion as to "proper" taking of a history. Although Dr. Rosen failed to articulate in a precise fashion the standard by which he measured the care given Mr. Titchnell, he stated that the practice at a blood collection program with which he was familiar was to take medical histories. The blood collection program served at least in part as the basis for his opinion. Although Dr. Rosen failed to testify that the standard of care at the time for swine flu vaccine administration corresponded or should have corresponded with the practice at the particular blood collection program with which he was familiar, the trial court could properly so conclude. Dr. Walsh's opinion was based on his assumption that Mr. Titchnell was a "high risk" person in part because he disclosed in answer to the written questionnaire that he was over 65 years old. Dr. Merkow's opinion was qualified by "for a patient who was his age and a high risk and with his history" (Appendix at 427), and further by "[i]f a history were obtained." Dr. Rosen's opinion was that it would have been good medical practice to take a history (Appendix at 757) and that it would have been good medical practice "in view of his medical history to have him lie down." Appendix at 758. In the context of this case, the trial court could properly equate a physician's opinion as to what was "good medical practice" as the acceptable standard of care.
Pennsylvania, as well as many other states, permits an injured party to recover medical expenses from a tort-feasor, notwithstanding reimbursement of such expenses by the injured party from a third party, if such reimbursement is from a "collateral source" and not from the tort-feasor. Frequently such payments are from health and accident insurance policies carried by or on behalf of the injured party. Under Pennsylvania law, evidence of receipt of such payment is not admissible in a trial for recovery of damages against a tort-feasor. Trump v. Capek, 267 Pa. Super. 355, 406 A.2d 1079 (1979).
The defendant concedes that Medicare Part A is largely financed from compulsory taxes. However, the defendant contends that, since Medicare Part B is financed from premium payments by enrollees together with contributions from funds appropriated by the federal government, the payments received by Mr. Titchnell were not from a "collateral source."
See 42 U.S.C. § 1395i(a) (1976).
Id. § 1395j.
In Smith v. United States, 587 F.2d 1013 (3d Cir. 1978), this Court held that Social Security Survivor benefits paid a widow and children should not be deducted from the widow's damages award from the government under the Federal Tort Claims Act (FTCA). This decision followed United States v. Harue Hayashi, 282 F.2d 599 (9th Cir. 1960), in which the Ninth Circuit held that payment for awards under FTCA come out of unfunded general revenues of the United States whereas Social Security benefits come from a special fund supplied in part by social security tax payments made by the beneficiary or a relative upon whom the beneficiary is dependent. Id. at 603-04. In Smith, this Court stated that "FTCA recoveries come out of general revenues; Social Security benefits are funded almost entirely from employee and employer contributions." 587 F.2d at 1016.
In Feeley v. united States, 337 F.2d 924 (3d Cir. 1964), this court held that the plaintiff was not entitled to both Veterans' Administration hospital benefits and Federal Tort Claims Act recovery since both came out of the general revenues of the United States. In Smith, the narrowness of this holding was again recognized. "This decision casts neither approval nor disapproval on such possibly distinguishable situations as where the payment is out of a specially funded source . . . or where the plaintiff has paid a part or all of the premiums necessary to establish the source or fund." Smith v. United States, 587 F.2d at 1015, quoting Feeley v. United States, 337 F.2d 924, 934 (3d Cir. 1964) (citations omitted).
Somewhat at divergence with Smith stands the Tenth Circuit's decision in Steckler v. United States, 549 F.2d 1372 (10th Cir. 1977), which held that Social Security payments, to the extent traceable to contributions by the worker and employers constitute a "collateral source," but that a claimant had the burden of making "some effort to ascertain the percentage or part contributed by the government . . . so as to permit a determination of the contributions of the employer and employee and their exclusion as collateral sources." Id. at 1379. In Smith, this Court, analyzing Steckler, stated:
Nevertheless, we are constrained to note our disagreement with the Tenth Circuit in Steckler, . . . and decline therefore to adopt its approach. We believe that the government's payments are so minimal and so difficult to trace that such an approach would be impractical.
The Eighth Circuit in Overton v. United States, 619 F.2d 1299 (8th Cir. 1980), held, under the applicable "collateral source" rule of Missouri, that Medicare Part A payments received by a widow had to be deducted from the widow's "swine flue" damage award. Overton is factually distinguishable from the present case in a critical respect. Overton noted that the issue in that case was "whether the district court erred in concluding that the Medicare benefits of a noncontributing recipient should be considered collateral to his FTCA damage award." Id. at 1305 (emphasis added). The Court ruled that it was essential that plaintiff "show he has contributed to the fund he claims as a collateral source." Id. at 1305-06. Because the record failed to reveal that either plaintiff or her deceased husband had "paid any of the taxes that determine the level of appropriations for the Part A [Medicare] trust fund" and because both were over age 65 when Medicare legislation was enacted, the inclusion of the Medicare payments in the damage award was held improper notwithstanding the "collateral source" doctrine. Id.
[I]t would seem that the burden of demonstrating the proportion of plaintiff's collateral benefit that is due to general taxation instead of special levy or fee should be upon the government, not the plaintiff, since the government, not the plaintiff, since the government has the benefit of the set-off and is presumably in the best position to marshal the relevant data.
Overton v. United States, supra, 619 F.2d at 1309 n. 16. Whether or not the government is entitled to a partial set-off to the extent that Medicare benefits received by Mr. Titchnell are attributable to government contributions to the Medicare fund need not be decided since the government has not raised this issue and no evidence on this issue was presented to the trial court.
Judge Adams agrees with the majority opinion on the collateral source point because of the holding in Smith v. United States. In the absence of such a precedent, he would decide the issue otherwise, because he is not persuaded that there is a valid basis for permitting a plaintiff such as Mr. Titchnell to recover twice for the same damage.