Case Name: Marcella Sharon RITZ, Individually, by and through her legal guardians, Joseph L. Ritz and Margaret E. Ritz, Appellant, v. FLORIDA PATIENT'S COMPENSATION FUND, Florida Physicians Insurance Reciprocal, I. Basil Keller, M.D., and Keller & Sarnowski, M.D., P.A., d/b/a Melbourne Neurologic, Appellees
Court: Florida District Court of Appeal
Jurisdiction: Florida
Decision Date: 1983-08-04
Citations: 436 So. 2d 987
Docket Number: No. 81-1180
Parties: Marcella Sharon RITZ, Individually, by and through her legal guardians, Joseph L. Ritz and Margaret E. Ritz, Appellant, v. FLORIDA PATIENT’S COMPENSATION FUND, Florida Physicians Insurance Reciprocal, I. Basil Keller, M.D., and Keller & Sarnowski, M.D., P.A., d/b/a Melbourne Neurologic, Appellees.
Judges: COWART, J., concurs.
Reporter: Southern Reporter, Second Series
Volume: 436
Pages: 987–997

Head Matter:
Marcella Sharon RITZ, Individually, by and through her legal guardians, Joseph L. Ritz and Margaret E. Ritz, Appellant, v. FLORIDA PATIENT’S COMPENSATION FUND, Florida Physicians Insurance Reciprocal, I. Basil Keller, M.D., and Keller & Sarnowski, M.D., P.A., d/b/a Melbourne Neurologic, Appellees.
No. 81-1180.
District Court of Appeal of Florida, Fifth District.
Aug. 4, 1983.
Rehearing Denied Sept. 2, 1983.
Albert Yurko, Orlando, for appellant.
William B. Wilson of Maguire, Voorhis & Wells, P.A., Orlando, for appellees Florida Physicians Ins., Keller, M.D., Keller & Sar-nowski, and Melbourne Neurologic.
James F. Page, Jr., of Gray, Harris & Robinson, P.A., Orlando, for appellee Florida Patient’s Compensation Fund.

Opinion:
ORFINGER, Chief Judge.
Marcella Ritz, a mentally retarded woman, suing by and through her parents as legal guardians, appeals from a final judgment in favor of defendants in a malpractice case. Dr. Keller performed brain surgery known as a stereotactic amygdalo-tomy on Marcella. This is an operation in which electrodes or probes are inserted under x-ray observation through holes drilled in the skull, for the specific purpose of locating and destroying certain brain tissue which controls affected areas of the body. Marcella suffered paresis (slight paralysis or muscle weakness) and loss of voice volume after the surgery. She now has difficulty walking unassisted and can only whisper rather than talk. Her suit contended that the surgery was performed without consent, that any consent given was not informed consent, and that the operation had been negligently performed.
The jury determined the negligence and malpractice issues against Marcella. Although there was contrary evidence presented, we find no basis to overturn its verdict. After Marcella presented her case, the trial court directed a verdict against her on the issues of consent and informed consent, and Marcella contends that this was error warranting reversal.
In reviewing the entry of a directed verdict, we must consider the evidence and all allowable inferences in a light most favorable to the non-moving party. This is the test at the trial level, Levine v. Frank, 311 So.2d 708 (Fla. 3d DCA 1975), as well as the standard of review at the appellate level. McDonald v. McGowan, 402 So.2d 1197 (Fla. 5th DCA 1981). If, in applying this test, no view of the evidence could sustain a verdict for the party moved against, then the directed verdict was properly entered. Reams v. Vaughn, No. 82-803, 435 So.2d 879 (Fla.1983) [8 FLW 1803]; Tesher & Tesher, P.A. v. Rothfield, 387 So.2d 499 (Fla. 4th DCA 1980). Here, the father signed a consent to surgery. It is contended first that this is insufficient to constitute a valid consent because Marcella is an adult, and secondly, that it was not an informed consent. We will discuss those issues separately.
I. CONSENT BY PARENT
Marcella Ritz was thirty-two years old when this surgery was performed. She has been retarded both mentally and motor-wise since birth. Her condition worsened as she grew older and she began to show early signs of a severe form of epilepsy, experiencing both petit mal and grand mal seizures. She was hospitalized on several occasions in an effort to control these seizures with medication. Her parents gave the various consents to treatment. When she reached her mid-twenties in the early 1970's, her condition deteriorated even more. Her seizures became more frequent and her behavior began to be characterized by violence and rages. She came under Dr. Keller's care in 1974, and he attempted to treat her condition conservatively.
There was no conflict about Marcella's inability to understand or give her consent to this surgery. She had an I.Q. between 25 and 30. Her parents had cared for her all her life. They took her to various hospitals and doctors for treatment and signed consent forms for other procedures. They were also the parties who brought Marcella to Dr. Keller for treatment. Marcella's father signed the consent to surgery here.
Appellant argues that consent from Marcella should have been obtained prior to surgery and that her father's consent was of no effect because she was an adult and her father had not then been appointed her legal guardian. There seems to be no controlling precedent on this issue in Florida. The general rule in other jurisdictions is that a parent or next of kin may give an effective consent to medical treatment for a person who is not competent, without the necessity of being appointed a legal guardian. 70 C.J.S. Physicians & Surgeons § 48 (1951); Annot., 25 A.L.R.3d 1439 (1969).
In Farber v. Olkon, 40 Cal.2d 503, 254 P.2d 520 (1953), the California Supreme Court adopted the rule that when an adult child is incompetent and has no legally appointed guardian, the right to consent to medical treatment resides in the parent who has the legal responsibility to maintain such child. In Farber, a father had given his consent to electric shock treatments for his adult incompetent son. Like Marcella, the son became incompetent during his minority and his parents sought treatment for him in many homes, hospitals and sanitariums, and they continued to support him. He was thirty-one years old when he received the treatment complained about in his suit.
Florida courts have recognized the rule that a parent has a continuing legal duty to support an adult incompetent or otherwise dependent child. See Perla v. Perla, 58 So.2d 689 (Fla.1952); Kern v. Kern, 360 So.2d 482 (Fla. 4th DCA 1978). Section 743.07(2), Florida Statutes (1981), provides that a court may require parental support for a dependent child after it attains the age of majority. Support obligations for adult children mentally or physically disabled have been imposed on parents. See Fagan v. Fagan, 381 So.2d 278 (Fla. 5th DCA 1980); Fincham v. Levin, 155 So.2d 883 (Fla. 1st DCA 1963).
We agree with Farber v. Olkon, and hold that where an adult child is incompetent and has no legally appointed guardian, the right to consent to medical or surgical treatment resides in the parent who has the legal responsibility to maintain and support such child, not only in emergency situations, but where, as here, the treatment is deemed necessary to correct some ailment or disability. Therefore, the consent executed by Marcella's father was not invalid merely because he was not then officially her legal guardian.
II. INFORMED CONSENT
After Marcella came under Dr. Keller's care, the doctor recommended that she be sent to Sunland Center, hoping that the controlled environment and qualified personnel there might be of help. In the more than one-year period she was at Sunland, Marcie's condition worsened; her seizures became more severe and her behavior more uncontrollable. She was described as violent and psychotic. Stereotactic surgery as a potential solution to her problems had been discussed with Marcie's parents from 1974 until 1977. Dr. Keller was reluctant to consider such surgery until he had exhausted other modes of treatment. Both parents testified to Dr. Keller's reluctance to do the surgery until he could determine if medication could control the situation. There is no dispute that the surgery was recommended only after a course of conservative treatment over many years had proved unsuccessful. Neither is there any dispute that the surgery was needed or the proper procedure. Plaintiffs' expert witnesses testified that Marcella was a proper candidate for an amygdalotomy.
The sole point on which appellant urges us to find a jury issue on the question of informed consent is the alleged failure of Dr. Keller to tell the parents that death or paralysis was a potential risk of this surgery. Appellant urges that in the absence of such disclosure by the doctor, the patient or other person giving the consent is not fully informed of the risks and is thus incapable of making an informed decision. While we recognize that informed consent is necessary, we disagree for several reasons that a jury issue was made on that point.
The plaintiff offered no expert evidence as to the nature and extent of the material risks involved in the surgery, nor any expert testimony as to the disclosures of risk and complications which a reasonable surgeon would make under the same or similar circumstances. The operation performed here is neither rare nor unusual. The plaintiffs expert, Dr. Brown, had himself performed more than 150 amygdalotomies, and he referred to other surgeons who had performed many more. The surgery on plaintiff was performed in 1977, and Dr. Brown testified that surgeons had been performing stereotactic surgery for about 28-30 years. He testified that the amygdalotomy was a well-recognized surgical procedure; that the surgery ordinarily produced few side effects, and that paresis and loss of voice were not usual or customary results of this surgery.
The characterization in the dissent of Dr. Keller as "inexperienced" is unfair in the light of the record. He is a trained, experienced neurosurgeon, certified as qualified by the medical specialty board in his field. He has had extensive training in stereotactic surgery, has taught the procedure to other doctors, and had performed more than 80 such procedures before he operated on Marcie. He had not operated on the particular area of the brain, the amygdala, because he never had a patient who needed this specific relief, but had performed other operations in "deep brain" areas using the same equipment and the same surgical techniques as were used here.
In order to submit to a jury the issue of whether and to what extent specific risks of surgery should be disclosed to a patient in securing the patient's informed consent to the procedure, evidence is required as to the nature and extent of the risks and of the standard prevailing in the medical community, i.e., whether a reasonable medical practitioner in the community would make such disclosure under the same or similar circumstances. Ditlow v. Kaplan, 181 So.2d 226 (Fla. 3d DCA 1966). Such evidence was available to plaintiff through her expert who presented evidence on the standard of care with respect to the negligence or malpractice issue and who testified that this standard of care was the same wherever the surgery was performed. He was not asked, however, what the standard was with regard to disclosures of risks so that an informed consent could be given.
Mr. Ritz signed a consent specifically authorizing the performance of a bilateral am-ygdalotomy, not just a general consent to do anything thought necessary. The form he signed, among other things, says:
2. The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me. I acknowledge that no guarantee or assurance has been made to me [sic] the results that may be obtained.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO OPERATE, THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND IN APPLICABLE [SIC] PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED.
Both parents had a lifetime of experience with Marcie's problems. They were curious and knowledgeable about her treatment. The parents knew that the surgery involved inserting a probe through the skull to create a brain lesion, i.e., to destroy certain brain tissue which controlled the area of the brain responsible for the behavioral prob lems their daughter had. Mrs. Ritz had been for years closely associated and quite active in an organization of parents with retarded children. Under these circumstances, and considering the minimal problems customarily incurred as was testified to by the experts, how much of the specific risks or possible results should be discussed with the consenting parent in order that his consent be "informed"? Nothing in the record answers that question. The jury should not be permitted to speculate on this question any more than should the trial judge or this court. What are the accepted risks, what are foreseeable risks, what are remote and speculative risks require, in our opinion, expert testimony as a basis for determining the extent of disclosures necessary to constitute consent as "informed." The patient here did not die, so any failure to disclose that risk is academic only. The same argument can be made with regard to "paralysis," because the record shows that Marcie suffers from a weakness on the left side, not a complete inability to use that side or a complete absence of motion in it.
It appears that the rule of law in Florida on proof of informed consent is still that expressed in Thomas v. Berrios, 348 So.2d 905 (Fla. 2d DCA 1977), as follows:
The duty of the physician to inform and the extent of the information which may be required varies in each case depending upon the particular circumstances.... The factors involved in making this determination are often complicated and technical, and in any event involve considerations beyond the expertise of the ordinary layman who is uneducated in medicine. Consequently, we have no hesitation in following the lead of our sister court in Ditlow v. Kaplan, 181 So.2d 226 (Fla. 3d DCA 1966), by holding that expert testimony is required in informed consent cases to establish whether a reasonable medical practitioner in the community would make the pertinent disclosures under the same or similar circumstances. Our ruling accords with those of most courts which have considered this issue. Annot., 52 A.L.R.3d 1084 (1973).
Id. at 907. This is still the view in most jurisdictions. Anno. 88 ALR 3d 1008 (1978). The reference in Berrios to the extent of a doctor's duty to advise his patient of the material risks involved, described in ZeBarth v. Swedish Hospital Medical Center, 81 Wash.2d 12, 499 P.2d 1 (1972), is worthy of repetition. It was said there that:
The duty of a medical doctor to inform his patient of the risks of harm reasonably to be expected from a proposed course of treatment does not place upon the physician a duty to elucidate upon all of the possible risks, but only those of a serious nature. Nor does it contemplate that the patient or those in whose charge he may be are completely ignorant of medical matters. A patient is obliged to exercise the intelligence and act on the knowledge which an ordinary person would bring to the doctors' office. The law does not contemplate that a doctor need conduct a short course in anatomy, medicine, surgery, and therapeutics nor that he do anything which in reasonable standards for practice of medicine in the community might be inimical to the patient's best interests. The doctrine of informed consent does not require the doctor to risk frightening the patient out of a course of treatment which sound medical judgment dictates the patient should undertake, nor does the rule assume that the patient possesses less knowledge of medical matters than a person of ordinary understanding could reasonably be expected to have or by law should be charged with having. Nor should the rule declaring a duty to inform be so stated or applied that a physician, in the interest of protecting himself from an overburden of law suits and the attendant costs upon his time and purse, will always follow the most conservative therapy — which, while of doubtful benefit to the patient exposes the patient to no affirmative medical hazards and the doctor to no risks of litigation. Thus, the information required of the doctor by the general rule is that information which a reasonably prudent physician or medical specialist of that medical community should or would know to be essential to enable a patient of ordinary understanding to intelligently decide whether to incur the risk by accepting the proposed treatment or avoid that risk by foregoing it. (emphasis supplied).
Dandashi v. Fine, 397 So.2d 442 (Fla. 3d DCA 1981), is distinguishable. There, on the issue of consent, the record was clear that the patient, with a language barrier, had torn up one consent, and testified that he did not know that the paper he later signed was another consent form. An issue of fact was found on whether the signature had been fraudulently obtained, so that, in law, no consent had been given. No such issue is made here. Similarly, Morganstine v. Rosomoff, 407 So.2d 941 (Fla. 3d DCA 1981), is distinguishable because it was contended there that the consent was fraudulently obtained, thus bringing into play the provision of section 768.46(4)(a), Fla.Stat. (1981). Here, plaintiffs did not allege nor attempt to prove any fraudulent misrepresentations. Cf. Meretsky v. Ellenby, 370 So.2d 1222 (Fla. 3d DCA 1979), [where the evidence revealed no consent at all to operate on the tip of plaintiff's nose, and the court distinguished between issues of no consent and cases where the issue was informed consent].
The consent form signed by Marcella's father, in addition to approving the specific surgery involved, states that the nature and purpose of the operation, possible alternative methods of treatment, the risks involved and the possibility of complications have been fully explained. The consent thus appears to comply with the requirements of section 768.46, Florida Statutes (1981). We find nothing in the statute that changes the rule of law expressed in Ditlow v. Kaplan or Thomas v. Berrios. The statute appears to codify that rule of law. If the plaintiff relies on the absence of informed consent, it is incumbent on plaintiff to provide evidence on the nature of the risks and the reasonable medical standard of disclosure. Without such evidence the jury can only speculate on the existence and extent of possible risks, on alternative methods of treatment and on possible complications.
It is not sufficient to say, with the 20/20 vision of hindsight, that had the consenting person known that a result which does occur could have occurred, no consent would have been given. That is not the test even in those few states which do not require expert testimony on the nature of the risks and the medical standard of disclosure. We would expect no less of a plaintiff alleging malpractice, than to say that if he had known what was going to happen, he would not have consented.
The cases cited by the dissent as support for a rule that requires the physician to prove the community standard for disclosure do not appear to agree on the precise nature of the standard. The Colorado cases cited in the dissent, as exemplified by Hamilton v. Hardy, 37 Colo.App. 375, 549 P.2d 1099 (Ct.App.1976), follow a rule that the plaintiff need only show that he was uninformed as to material risks inherent in the procedure and when he shows that he was uninformed due to a failure of disclosure, the physician must go forward with the evidence establishing that his failure to disclose conformed with community standards. This rule, it seems to us, leaves much to the imagination of the plaintiff and the jury. The opinions seem to imply that the need to disclose applies only to relevant and material risks, yet there is no indication as to how and by whom the evidence is presented.
In Natanson v. Kline, 187 Kan. 186, 354 P.2d 670 (1960), a case relied on by the Colorado courts, the Supreme Court of Kansas held that when facts concerning the actual disclosures to the patient are ascertained, then expert medical testimony of medical witnesses is required to establish whether such disclosures are in accordance with those which a reasonable medical practitioner would make under the same or similar circumstances. Here, too, nothing is said in the opinion about who shoulders the burden, but the opinion emphasizes the rule, correctly we believe, that the burden of proof rests throughout the trial upon the patient who seeks to recover for her injury.
In Miller v. Kennedy, 11 Wash.App. 272, 522 P.2d 852 (Ct.App.1974), the court held that it was the plaintiffs burden to prove, not only the non-disclosure, but the fact that the given risk not disclosed was relevant and material. Thus, it would appear that expert medical testimony is required, except perhaps in those situations where the material risks are so obvious and well known that lay testimony is appropriate. Miller emphasizes that the plaintiff must prove, not that he would not have consented had a material disclosure been made, but that a reasonably prudent person would not have consented to the procedure had the material risks been disclosed.
We believe the better rule to be that expressed in Ditlow and Thomas, and adopted here. Similarly, if plaintiff relies on fraud as the means of obtaining the signed consent, that should be pleaded and put in issue and here too, the plaintiff has the initial burden of demonstrating that fraud or misrepresentation produced the signature. There is neither allegation nor proof of fraud here.
The judgment is AFFIRMED.
COWART, J., concurs.
SHARP, J., dissents in part, concurs in part, with opinion.
. This statute contained the same language in 1977 when Marcella's surgery was performed.
. The doctor was asked, however, if the failure to secure Marcella's consent was a deviation from the recognized standard of care and he made the rather incredible statement that the patient's consent should have been obtained, despite his agreement that she was incompetent, had an I.Q. of about 25, and would not have understood anything she was told about the operation.
. Mrs. Ritz's familiarity with the medical terminology is demonstrated by her testimony, viz:
Q. Then, after Marcie was out of the hospital and went back over to Sunland, you and Mr. Ritz went to his office, Doctor Keller's office on some occasion and had a sit-down discussion about surgery?
A. That was to discuss the brain scan and the tests that were taken of Marcie when she—
Q. Don't imagine you remember what date it was, and he doesn't either, but was it fairly soon after she got out of the May hospitalization?
A. She was in the hospital for the purpose of these tests to determine whether or not surgery — she was a candidate for surgery, and it was shortly after he had these reports and read them that we were directed to come down to his office and discuss it.
Q. Okay.
A. I would say within two weeks after.
Q. All right. So, probably May or June of 1977?
A. Yes, still May, I would say it was still in May.
Q. All right. And you all met in his office and talked about for about forty-five minutes on the—
A. We met at his office and talked for at least a half an hour.
Q. And he told you about the surgery, told you how it's done, told you what it was like, gave you a description of it, and that sort of thing?
A. He told us about the CAT Scan and about the test that Marcie was — had taken, and he discussed the type of surgery, and said that she was a perfect candidate for that type of surgery, that since nothing else had worked for her that that was the answer for her problem.
Q. And you actually discussed amygdaloto-mies?
A. We discussed brain surgery and placing a lesion to alleviate her problem. We were assured that the CAT Scan revealed a perfectly normal brain, and the E.E.G. revealed no problems whatsoever.
Therefore, all he had to do was follow the normal pattern that anyone would take for surgery, and that he anticipated no problems because of the scan showing there was no lesions or nothing.
. It can also be said that any person should know that drilling holes in the skull and inserting a probe for the purpose of destroying brain tissue involves certain dangers, one of which is death.