Case Name: Milton C. LUGENBUHL, et al. v. Dr. James DOWLING, et al.; Wenonah Lugenbuhl, Wife of/and Milton C. LUGENBUHL, Jr., et al. v. James B. DOWLING, M.D., et al.
Court: Louisiana Court of Appeal
Jurisdiction: Louisiana
Decision Date: 1996-05-15
Citations: 676 So. 2d 602
Docket Number: Nos. 95-CA-1557, 95-CA-1558
Parties: Milton C. LUGENBUHL, et al. v. Dr. James DOWLING, et al. Wenonah Lugenbuhl, Wife of/and Milton C. LUGENBUHL, Jr., et al. v. James B. DOWLING, M.D., et al.
Judges: Before SCHOTT, C.J., and PLOTKIN and WALTZER, JJ.
Reporter: Southern Reporter, Second Series
Volume: 676
Pages: 602–612

Head Matter:
Milton C. LUGENBUHL, et al. v. Dr. James DOWLING, et al. Wenonah Lugenbuhl, Wife of/and Milton C. LUGENBUHL, Jr., et al. v. James B. DOWLING, M.D., et al.
Nos. 95-CA-1557, 95-CA-1558.
Court of Appeal of Louisiana, Fourth Circuit.
May 15, 1996.
J. Wayne Mumphrey, Law Offices of J. Wayne Mumphrey, Chalmette, for Plaintiffs/Appellees.
Stewart E. Niles, Jr., Patricia A. Bethan-court, Jones, Walker, Waechter, Poitevent, Carrere & Denegre, L.L.P., New Orleans, for James Dowling.
Bruce J. Toppin, Jones, Walker, Waechter, Poitevent, Carrere & Denegre, L.L.P., New Orleans, for Louisiana Patients’ Compensation Fund.
Before SCHOTT, C.J., and PLOTKIN and WALTZER, JJ.

Opinion:
hPLOTKIN, Judge.
In this appeal, we consider whether the jury erred in finding a physician liable for damages arising from a patient's subsequent herniation after the physician failed to use the surgical mesh requested by the patient and agreed to by the physician. Finding that the record affords a reasonable basis for the jury's verdict on a theory of informed consent, we affirm the judgment.
Between 1963 and 1974, Mr. Milton C. Lugenbuhl Jr. suffered three failed inguinal hernia repairs until his surgeon, Dr. Vernon Kroll, used mesh in surgery in 1975. Approximately ten years later, Mr. Lugenbuhl developed an incisional hernia as a result of open heart surgery. Dr. James Dowling repaired the incisional hernia after Mr. Lugen-buhl signed a consent form which provided in part (emphasis corresponds to handwritten inserts):
1) I hereby authorize and consent to Dr. Dowling; M.D., and such supervising physicians, surgeons, assistants of his or her choice, to perform upon myself the following surgical, diagnostic, or medical procedure Repair incisional hernia with mesh including any necessary and advisable anesthesia.
|22) I understand the nature and purpose of this procedure to be Repair Incisional Hernia with Mersilene Mesh
Mr. Lugenbuhl subsequently developed further herniation, which was repaired by Dr. Edward Foti. The Lugenbuhls contend that the subsequent herniation was caused by Dr. Dowling's failure to use mesh to repair the hernia in violation of Dr. Dowling's promise to use mesh.
The matter was referred to a medical review panel, which determined that Dr. Dowl-ing did not fail to meet the applicable standard of care in treating Mr. Lugenbuhl. At the conclusion of the case, the trial judge granted Dr. Dowling's motion for a directed verdict on the issues of deviation from the standard of care and causation. This Court granted Mr. Lugenbuhl's application for supervisory writs and ordered that all issues be submitted to the jury. The jury found that Dr. Dowling failed to use reasonable care, that he failed to obtain informed consent, and that his fault was a cause of the injuries. The jury assessed fault at 90% to Dr. Dowl-ing and 10% to Mr. Lugenbuhl, and awarded $300,000 to Mr. Lugenbuhl and $50,000 to Mrs. Lugenbuhl.
Dr. Dowling appeals assigning two errors: (1) that the plaintiffs failed to prove their case under either a theory of medical malpractice or informed consent and (2) that the jury's award is grossly excessive.
At trial, Mr. Lugenbuhl testified that because of his history of unsuccessful hernia repairs he strongly believed that mesh would be necessary. He repeatedly communicated his desire that mesh be used to Dr. Dowling who promised to use mesh. Dr. Dowling never told him that there was a possibility that mesh would not be used in surgery; if he had been told this, he would not have agreed to surgery. After surgery on November 4,1988, he discovered that Dr. Dowl-ing repaired his incisional hernia without mesh. After gallbladder surgery, this _Jjincisional hernia redeveloped and was ultimately repaired with mesh by Dr. Foti. Mr. Lugenbuhl was unable to work for two years during which time he was primarily bedridden and cared for by his wife. Mr. Lugen-buhl's testimony was corroborated by his wife and daughter.
In contrast, Dr. Dowling, who was accepted by the court as an expert in the field of general surgery, testified that he discussed mesh with Mr. Lugenbuhl only as a surgical option; he did not promise to use mesh and Mr. Lugenbuhl understood this. Dr. Dowl-ing explained that the consent form simply authorized that mesh be used if he deemed it necessary in the exercise of medical judgment at the time of surgery. In fact, at the time of surgery he decided that the use of mesh would not be appropriate because of the small size of the hernia and the risk of infection. According to Dr. Dowling, he successfully repaired Mr. Lugenbuhl's incisional hernia, which never redeveloped. Dr. Dowl-ing interpreted Dr. Foti's operative notes to mean that Dr. Foti's hernia repair was unrelated to the hernia that he repaired.
Dr. Foti, who was accepted by the court as an expert in the field of general surgery, testified that he first saw Mr. Lugenbuhl as a patient in May 1988. Mr. Lugenbuhl had developed a hernia which appeared from an examination of the surface to be three or four inches long but was revealed in surgery to be six or seven inches long. He decided to use mesh to repair this hernia in advance of surgery under the circumstances of this case. However, he testified that ordinarily a surgeon would not agree in advance of surgery to repair a hernia with mesh. Therefore, he interpreted the consent form signed by Dr. Dowling and Mr. Lugenbuhl as only authorizing the use of mesh if necessary. When asked whether Dr. Dowling's hernia repair failed, Dr. Foti explained that when he operated on UMr. Lugenbuhl he found that Mr. Lugenbuhl had a large, complex defect in which it was not possible to distinguish the prior hernia repair by Dr. Dowling.
Ms. Pamela Schock R.N., Dr. Dowling's nurse at the time he treated Mr. Lugenbuhl, did not recall the circumstances of the signing of the consent form. She interpreted the form as authorizing the use of mesh if needed.
In his first assignment of error, Dr. Dowling contends that the Lugenbuhls failed to prove their case under either a theory of medical negligence or informed consent. Finding that the record affords a reasonable basis for the jury's verdict on a theory of informed consent, we do not consider whether the Lugenbuhls proved a ease in medical negligence.
An appellate court should not disturb a finding of fact of a jury unless it is clearly wrong. Arceneaux v. Domingue, 365 So.2d 1330, 1333 (La.1978). The reviewing court must give great weight to factual conclusions of the trier of fact; where there is conflict in the testimony, reasonable evaluations of credibility and reasonable inferences of fact should not be disturbed upon review, even though the appellate court may feel that its own evaluations and inferences are as reasonable. Canter v. Koehring Co., 283 So.2d 716, 724 (La.1973). The failure to obtain informed consent is the breach of a duty imposed by law rather than one determined by the medical specialty in which the physician practices. Steele v. St. Paul Fire & Marine Ins. Co., 371 So.2d 843, 848 (La.App. 3d Cir.), unit denied, 374 So.2d 658 (La.1979). Expert testimony is not necessary to establish that a person in the plaintiffs position would attach significance to a particular risk. Smith v. Lincoln General Hosp., 27,133, p. 8-9 (La.App. 2d Cir. 6/21/95), 658 So.2d 256, 263, writ denied, 95-1808 (La. 10/27/95), 662 So.2d 3.
Mr. Lugenbuhl testified that the incisional hernia that was repaired by Dr. Dowling without mesh reopened and was re-repaired by Dr. Foti with mesh. Dr. |sDowling testified that the incisional hernia he repaired without mesh never reopened. Dr. Foti testified that because of the nature and extent of the defect he repaired, it was difficult to tell whether it encompassed Dr. Dowling's repair. Mr. Lugenbuhl and his family testified about their extensive efforts, which were reasonably based on Mr. Lugenbuhl's medical history, to ensure that mesh would be used in surgery by Dr. Dowling. Dr. Dowl-ing denies that he promised to use mesh. Based on this information, the jury could conclude that Dr. Dowling failed to honor a promise to use mesh resulting in subsequent herniation in Mr. Lugenbuhl. Although other interpretations of the evidence may exist, after a review of the record we cannot say that the jury was clearly wrong.
In LaCaze v. Collier, 434 So.2d 1039, 1043 (La.1983) (footnote omitted), the Louisiana Supreme Court commented on the varied nature of the doctrine of informed consent:
The development of the doctrine of informed consent has not been a simple progression evident in the cases. Rather, the doctrine has pulled concepts from various sources and at times indicated various future directions. The two most influential sources of doctrine seem to have been the courts' awareness that the question of consent to medical treatment may be more than a simple question, and the development of an affirmative duty of a physician to disclose information to his patient.
The present case, although unusual, falls within the ambit of the theory of informed consent. In Hondroulis v. Schuhmacher, 553 So.2d 398, 414-14, 417 (La.1988), on rehearing, the Louisiana Supreme Court limited its holding in LaCaze, supra, to ground the informed consent doctrine firmly on the right to self-determination protected by a constitutional right to privacy. In Hondroulis, supra at 412, however, the Louisiana Supreme Court, fearing self-interested testimony and hindsight, retained LaCaze ⅛ objective test:
Generally, courts adopting a patient-based standard of disclosure have also adopted an objective test for determining |6causation. Such a test seeks to determine whether a reasonable person in the patient's position would have consented to the operation if full disclosure had been made. While a subjective test may better protect the patient's right to self-determination, an objective test is consistent with a disclosure requirement based on the informational needs of a reasonable patient and what such a reasonable patient would consider important in making a decision. An objective standard to determine whether the patient, fully informed of the risks, would have undertaken the proposed treatment, is consistent with general tort law and relieves the physician from the dangers of aberrational decisions on the part of the patient.
LaCaze, supra at 1048. Subjective considerations, ' however, can bar recovery: if the patient would have consented regardless of the information given, then he cannot complain that he wasn't sufficiently informed to consent. See, e.g., Bourgeois v. McDonald, 622 So.2d 684, 689 (La.App. 4th Cir.), writ denied, 629 So.2d 1177 (La.1993). Under unusual circumstances, a patient's subjective expectations can also play a significant role in establishing a lack of informed consent. See, e.g., Hartman v. D'Ambrosia, 95-0393, p. 7-8 (La.App. 4th Cir. 11/30/95), 665 So.2d 1206, 1209-10, writ denied, 95-3124 (La. 2/16/96), 667 So.2d 1060.
At first glance, Dr. Dowling's failure to honor his promise to use mesh might appear to sound more in contract or even fraud than tort. In this case, however, what Mr. Lugen-buhl was deprived of was his right to self-determination in his medical treatment. When Mr. Lugenbuhl communicated his strong desire that mesh be used, assuming that desire wasn't wholly irrational, the risk that mesh would not be used became material and Dr. Dowling should have disclosed before surgery that during surgery he might, through the exercise of medical judgment, reevaluate the need for mesh. Mr. Lugen-buhl would then have been free to find another surgeon or to go ahead with the procedure with a better understanding of the risks.
|7In his second assignment of error, Dr. Dowling contends that the jury's award is grossly excessive. The discretion vested in the trier of fact in the award of general damages is so great, even vast, that an appellate court should rarely disturb an award. It is only when the award is, in either direction, beyond that which a reasonable trier of fact could assess under the particular circumstances should an appellate court increase or reduce an award. Youn v. Maritime Overseas Corp., 623 So.2d 1257, 1261 (La.1993), cert. denied, 510 U.S. 1114, 114 S.Ct. 1059, 127 L.Ed.2d 379 (1994). The award appealed is not obviously the result of passion or prejudice. Although many rational triers of fact could have decided that a lower award was appropriate, we cannot conclude from a review of the record that this is one of those exceptional cases where such an award is so gross as to be contrary to right reason. This assignment of error is without merit.
Accordingly, the judgment in favor of the Lugenbuhls is affirmed.
AFFIRMED.
WALTZER, J., concurs with reasons.
SCHOTT, C.J., dissents.