Title: Ruiz v. Tenet Hialeah Healthsystem, Inc.
Citation: N/A
Docket Number: SC17-1562
State: Florida
Issuer: Florida Supreme Court
Date: December 20, 2018

Supreme Court of Florida 
 
 
____________ 
 
No. SC17-1562 
____________ 
 
ROLANDO P. RUIZ, etc., 
Petitioner, 
 
vs. 
 
TENET HIALEAH HEALTHSYSTEM, INC., et al., 
Respondents. 
 
December 20, 2018 
 
LABARGA, J. 
 
Petitioner Rolando P. Ruiz seeks review of a decision of the Third District 
Court of Appeal which affirmed the entry of a directed verdict in favor of 
Respondent Arturo Lorenzo, M.D.  Ruiz v. Tenet Hialeah Healthsys., 224 So. 3d 
828 (Fla. 3d DCA 2017).1  Because we hold the Third District erred in that 
decision by equating the proximate cause of an injury with the primary cause of an 
injury, we quash the decision below and remand the case to the Third District. 
 
                                          
 
 
1.  We have jurisdiction.  See art. V, § 3(b)(3), Fla. Const. 
 
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Facts 
 
In 2009, Ruiz’s late wife, Maria Elena Espinosa, noticed a large mass had 
developed on the back of her head.  Espinosa sought the advice of her primary care 
physician, who diagnosed the mass as a tumor and referred Espinosa to a 
neurosurgeon.  The neurosurgeon did not order a biopsy of the tumor, but believed 
it to be an osteosarcoma.  Imaging studies of the tumor showed it had invaded 
Espinosa’s skull and could soon begin to press upon her brain.  The neurosurgeon 
recommended immediate surgery to remove some of the tumor’s mass—a process 
known as “debulking” the tumor—and render it more susceptible to other forms of 
treatment, such as radiation or chemotherapy. 
 
Espinosa agreed to the surgery, which the neurosurgeon would personally 
perform with assistance from a colleague.  The neurosurgeon asked Espinosa’s 
primary care physician to order a battery of laboratory tests to ensure Espinosa was 
medically fit to undergo surgery.  These tests included an electrocardiogram 
(EKG) and a urinalysis.  The results of these tests were included in Espinosa’s 
chart.  The EKG readout in Espinosa’s chart was a copy of a copy, and the image 
quality was correspondingly poor.  It did, however, include an automated 
interpretation by the EKG machine itself which flagged the test result as abnormal, 
indicating Espinosa’s heart may have been enlarged and that she may also have 
suffered two myocardial infarctions.  Espinosa’s urinalysis results occupied two 
 
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pages of her chart.  On the second page, the urinalysis indicated the abnormal 
presence of protein in Espinosa’s urine, a condition known as proteinuria.  Despite 
these abnormal test results, Espinosa’s primary care physician cleared her for 
surgery, which was scheduled to be performed at 8:00 a.m. on May 13, 2009, at 
Hialeah Hospital. 
 
That morning, Espinosa and Ruiz arrived at Hialeah Hospital around 
6:00 a.m.  Espinosa was taken to a separate room to be prepared for surgery while 
Ruiz remained in the waiting area.  Dr. Lorenzo, an anesthesiologist, was also 
present at Hialeah Hospital that morning to assist with a different patient’s 
procedure and was not assigned to Espinosa.  Around 8:00 a.m., however, he 
learned Espinosa’s assigned anesthesiologist, Dr. Guillermo Velasquez, was 
running late and that Espinosa’s pre-anesthesia evaluation had not yet been 
performed.  To maintain the pre-operation schedule and put Espinosa at her ease, 
Dr. Lorenzo decided to perform Espinosa’s pre-anesthesia evaluation himself. 
 
Dr. Lorenzo introduced himself to Espinosa and told her, “I am not going to 
be your anesthesiologist.”  He then asked Espinosa a series of questions about her 
medical history and present condition, recording the information she gave him on a 
“pre-anesthesia form/moderate sedation evaluation form” in Espinosa’s chart.  
Dr. Lorenzo also reviewed some—but not all—of the test results in Espinosa’s 
chart.  He reviewed the EKG and, although the readout was blurry, Dr. Lorenzo 
 
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later testified he was able to interpret the EKG with sufficient clarity to conclude 
Espinosa’s heart was functioning normally.  Dr. Lorenzo believed the abnormal 
result was caused by a malfunction of the EKG machine and not by any problem 
with Espinosa’s heart.  He also reviewed the first page of Espinosa’s urinalysis 
results, but did not look at the second page of those results, where the abnormal 
proteinuria reading was displayed.  During trial, Dr. Lorenzo admitted the 
proteinuria reading was something he “would want to know,” but also stated it 
would not have affected his determination of whether it was safe for Espinosa to 
undergo anesthesia. 
 
After Dr. Lorenzo had completed approximately half of the pre-anesthesia 
form, Dr. Velasquez arrived and took over from Dr. Lorenzo.  Dr. Lorenzo then 
signed the pre-anesthesia form, introduced Dr. Velasquez to Espinosa, and told 
Dr. Velasquez, “There is nothing, no major medical problems whatsoever.  You 
may want to look at the EKG.”  Dr. Lorenzo then left the room.  Overall, he 
estimated he saw Espinosa for between three and five minutes, but stated he 
“wasn’t looking at the clock.”  Dr. Lorenzo did not inform Espinosa’s surgeons 
about the abnormal EKG, which he had reviewed, or about the urinalysis results 
reflecting abnormal proteinuria, which he had not.  Dr. Velasquez later testified 
that after taking over from Dr. Lorenzo he began the pre-anesthesia evaluation over 
again from the beginning.  Dr. Velasquez reviewed the EKG and the urinalysis 
 
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results, including the proteinuria reading, but also did not inform Espinosa’s 
surgeons of these abnormal test results.  He also signed the pre-anesthesia form, 
and cleared Espinosa for surgery. 
 
During the surgery, Espinosa lost a large amount of blood and suffered a 
precipitous drop in blood pressure, which her physicians were unable to reverse.  A 
little over an hour into the surgery, she went into cardiac arrest and could not be 
resuscitated.  An autopsy was performed, and a pathology test of the tumor tissue 
revealed that, rather than being an osteosarcoma, Espinosa’s tumor was caused by 
a type of plasma cell cancer known as multiple myeloma. 
 
Ruiz filed a medical malpractice action against each physician involved in 
Espinosa’s treatment, including Dr. Lorenzo.  In part, Ruiz alleged Espinosa’s 
death was caused by the failure to correctly diagnose her condition as multiple 
myeloma.  Ruiz argued multiple myeloma should only be treated through radiation 
or chemotherapy, and that surgery was not appropriate in Espinosa’s case.  Had 
Espinosa been correctly diagnosed at any point, Ruiz claimed, the surgery would 
have been canceled, and Espinosa would have survived.  With regard to 
Dr. Lorenzo, Ruiz alleged he breached the standard of care by (1) not reviewing all 
the available data in Espinosa’s chart, (2) not ordering a second EKG to reconcile 
the abnormal results of the first EKG, and (3) not reporting the abnormal lab 
results—some of which he did not review—to Espinosa’s surgeons.  Ruiz 
 
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contended that, had Dr. Lorenzo adhered to the standard of care, either Dr. Lorenzo 
or the surgeons would have realized Espinosa was suffering from multiple 
myeloma and the surgery would have been canceled. 
 
The trial court granted a directed verdict in favor of Dr. Lorenzo, holding 
that, even assuming Dr. Lorenzo was negligent in his care of Espinosa, he did 
nothing more than place her in a position to be injured by the independent actions 
of third parties—namely, the surgeons.2  The trial court analogized Dr. Lorenzo to 
“the cab driver who drove [Espinosa] to the hospital.”  Ruiz appealed, and the 
district court affirmed the trial court’s ruling, concluding that no competent, 
substantial evidence in the record would allow a reasonable factfinder to conclude 
Dr. Lorenzo was the “primary cause” of Espinosa’s death.  Id. at 830.  This review 
follows. 
Analysis 
A directed verdict can only be affirmed “where no proper view of the 
evidence could sustain a verdict in favor of the nonmoving party.”  Friedrich v. 
                                          
 
 
2.  We note that the trial court granted Dr. Lorenzo’s motion for directed 
verdict on proximate cause grounds and assumed, for the limited purpose of ruling 
on that motion, that Dr. Lorenzo breached the standard of care.  The issue before 
the Court is whether, even if the other elements of Ruiz’s claim were satisfied, 
Ruiz failed to present competent, substantial evidence that Dr. Lorenzo 
proximately caused Espinosa’s death.  Accordingly, any issue regarding the scope 
of Dr. Lorenzo’s duty to Espinosa is beyond the scope of our review, and we 
express no opinion with regard to that issue. 
 
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Fetterman & Assocs., P.A., 137 So. 3d 362, 365 (Fla. 2013) (quoting Owens v. 
Publix Supermkts., Inc., 802 So. 2d 315, 315 (Fla. 2001)); see also Cox v. St. 
Joseph’s Hosp., 71 So. 3d 795, 801 (Fla. 2011) (explaining “a directed verdict is 
appropriate in cases where the plaintiff has failed to provide evidence that the 
negligent act more likely than not caused the injury”).  “The elements of a medical 
malpractice action are: (1) a duty by the physician, (2) a breach of that duty, and 
(3) causation.”  Saunders v. Dickens, 151 So. 3d 434, 441 (Fla. 2014).  “Florida 
follows the ‘more likely than not’ standard in proving causation, i.e., that the 
negligence ‘probably caused’ the plaintiff’s injury.”  Cox, 71 So. 3d at 799 
(quoting St. Joseph’s Hosp. v. Cox, 14 So. 3d 1124, 1127 (Fla. 2d DCA 2009)).  
For the limited purposes of Dr. Lorenzo’s motion for directed verdict, the trial 
court assumed Dr. Lorenzo owed Espinosa a duty of care and that he breached that 
duty.  The issue, then, is whether there was competent, substantial evidence in the 
record which would permit a reasonable factfinder to conclude that Dr. Lorenzo, 
more likely than not, proximately caused Espinosa’s death.  This case presents a 
pure question of law, which we review de novo.  Keck v. Eminisor, 104 So. 3d 359, 
363 (Fla. 2012). 
In determining whether a defendant’s conduct proximately caused a 
plaintiff’s injury, courts analyze “whether said injury, given actual causation, was a 
foreseeable consequence of the danger created by the defendant’s negligent act or 
 
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omission.”  Stahl v. Metro. Dade Cty., 438 So. 2d 14, 21 (Fla. 3d DCA 1983).  
Merely furnishing the occasion for a person to be injured by the supervening 
negligence of a third party is ordinarily not sufficient to establish proximate cause.  
Matthews v. Williford, 318 So. 2d 480, 481 (Fla. 2d DCA 1975).  Instead, the 
injured party must show that the alleged tortfeasor “substantially caused the 
specific injury that actually occurred.”  McCain v. Fla. Power Corp., 593 So. 2d 
500, 502 (Fla. 1992).  A “harm is ‘proximate’ in a legal sense if prudent human 
foresight would lead one to expect that similar harm is likely to be substantially 
caused by the specific act or omission in question.”  Id. at 503.  In the absence of 
“a freakish and improbable chain of events” leading to injury, “the question of 
foreseeability as it relates to proximate causation generally must be left to the fact-
finder to resolve.”  Id. at 503-04; see also Gooding v. Univ. Hosp. Bldg., 445 So. 
2d 1015, 1018 (Fla. 1984) (explaining that the defendant’s conduct must be “a 
substantial factor in bringing about” the plaintiff’s injury) (quoting Prosser, Law of 
Torts § 41 (4th ed. 1971)). 
As evidenced by the above, the law does not require an act to be the 
exclusive or even the primary cause of an injury in order for that act to be 
considered the proximate cause of the injury: rather, it need only be a substantial 
cause of the injury.  For example, in Sardell v. Malanio, 202 So. 2d 746, 746-47 
(Fla. 1967), this Court held that a young boy who threw a football to his friend 
 
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could be held to have proximately caused the injuries sustained by a passerby with 
whom his friend collided as he tried to catch the ball.  The district court in Sardell 
had reasoned that Malanio, who threw the ball, “had no ‘physical control over the 
pass catcher’ and had no reason to expect the collision with the plaintiff,” and 
therefore “held that the alleged negligence of the catcher effectively isolated the 
initial alleged negligence of the passer” such that Malanio’s act of throwing the 
football could not be the proximate cause of the plaintiff’s injuries.  Id. at 747 
(quoting Sardell v. Malanio, 189 So. 2d 393, 394 (Fla. 3d DCA 1966)).  On that 
basis, the district court affirmed the trial court’s dismissal of the complaint against 
Malanio.  Id. 
This Court quashed that decision, explaining that “[t]o preclude liability of 
the initial negligent actor, the alleged intervening cause must be efficient in the 
sense that it is independent of and not set in motion by the initial wrong.”  Id.  The 
Court reasoned that the act which injured the plaintiff—that is, the attempt to catch 
the ball—“was merely a direct, natural and continuous sequel to the initial act of 
the passer Malanio.”  Id.  Indeed, the catcher “would not have acted at all had it not 
been for the initial act of Malanio, who threw the ball and thereby initiated the 
series of events which in natural sequence allegedly produced the ultimate injury.”  
Id.  Thus, although the primary cause of the plaintiff’s injury was the collision with 
 
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the catcher, Malanio substantially contributed to causing the plaintiff’s injury by 
throwing the football without due care. 
The case now before us presents an analogous circumstance: Ruiz argues 
that Dr. Lorenzo’s alleged failure to act with due care allowed Espinosa’s surgery 
to occur.  Had Dr. Lorenzo read and reported the abnormal results of Espinosa’s 
pre-operative lab tests, Ruiz alleges, Espinosa’s surgery would not have occurred 
and she would not have died during that surgery.  Cf. Gooding, 445 So. 2d at 1019 
(holding that, in a wrongful death case arising out of alleged medical malpractice, 
the plaintiff must show the decedent would probably have survived had the care 
not been negligent).  Dr. Lorenzo’s conduct was not the primary cause of 
Espinosa’s death, but he may nonetheless be liable for his part in it if his failure to 
read and report the abnormal test results substantially contributed to causing it. 
Our medical malpractice jurisprudence makes clear that a physician may be 
the proximate cause of a patient’s injury even if that physician is not the primary 
cause of that injury.  In Saunders, we held that a treating physician “cannot 
insulate himself or herself from liability for negligence by presenting a subsequent 
treating physician who testifies that adequate care by the defendant physician 
would not have altered the subsequent care.”  151 So. 3d at 442.  Therefore, we 
explained, “the issue of whether a treating physician acted in a reasonably prudent 
manner must be determined for each individual physician who is a defendant in a 
 
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medical malpractice action.”  Id.  This is inconsistent with the notion that only 
physicians who are the primary cause of a patient’s injury may be the proximate 
cause of that injury.  Indeed, our holding in Saunders is predicated on the principle 
that a physician who is not the primary cause of a patient’s injury may nonetheless 
be liable for that injury: otherwise, there would be no reason to analyze the 
behavior of each physician individually. 
By concluding that Dr. Lorenzo was entitled to a directed verdict on 
causation because he was not the primary cause of Espinosa’s death, the Third 
District entered into conflict with our precedent.  The record does not reflect that 
Espinosa’s abnormal lab results caused her death.  See Ruiz, 224 So. 3d at 830 
(noting “the record is devoid of competent, substantial evidence upon which to 
conclude that the blurry EKG or the abnormal protein level results caused 
Espinosa’s death”).  The record does reflect that “the primary cause of Espinosa’s 
death was exsanguination.”  Id.  The district court erred, however, when it held that 
in light of these facts, “[t]he trial court thus correctly granted Dr. Lorenzo’s motion 
for directed verdict.”  Id.  Our precedent makes clear that Dr. Lorenzo cannot 
prevent Ruiz from establishing proximate cause merely by showing his actions or 
omissions were not the primary cause of Espinosa’s death.  Instead, to foreclose 
liability on the grounds of causation, Dr. Lorenzo’s acts or omissions must not 
have substantially contributed to Espinosa’s death as part of a natural and 
 
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continuous sequence of events which brought about that result.  See McCain, 593 
So. 2d at 502-03; Gooding, 445 So. 2d at 1018.  To obtain a directed verdict on this 
basis, Dr. Lorenzo must show there is no competent, substantial evidence in the 
record which would permit a reasonable factfinder to reach such a conclusion at 
all.  See Friedrich, 137 So. 3d at 365; Cox, 71 So. 3d at 801. 
Accordingly, because the decision below is inconsistent with our precedent 
regarding the proximate causation standard, we quash Ruiz and remand to the 
Third District for further proceedings consistent with this opinion. 
 
It is so ordered. 
PARIENTE, LEWIS, and QUINCE, JJ., concur. 
POLSTON, J., dissents with an opinion, in which CANADY, C.J., and LAWSON, 
J., concur. 
 
ANY MOTION FOR REHEARING OR CLARIFICATION MUST BE FILED 
ON OR BEFORE DECEMBER 27, 2018.  A RESPONSE TO THE MOTION 
FOR REHEARING/CLARIFICATION MAY BE FILED ON OR BEFORE 
JANUARY 2, 2019.  NOT FINAL UNTIL THIS TIME PERIOD EXPIRES TO 
FILE A REHEARING/CLARIFICATION MOTION AND, IF FILED, 
DETERMINED. 
 
POLSTON, J., dissenting. 
 
Because the Third District’s decision in Ruiz v. Tenet Hialeah Healthsystem, 
Inc., 224 So. 3d 828 (Fla. 3d DCA 2017), does not expressly and directly conflict 
with the decisions alleged by the Petitioner during jurisdictional briefing, this 
Court does not have the constitutional authority to review this case.  Accordingly, I 
respectfully dissent. 
 
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For example, Ruiz does not conflict with Cox v. St. Josephs Hospital, 71 So. 
3d 795 (Fla. 2011), or Friedrich v. Fetterman & Assocs., P.A., 137 So. 3d 362 (Fla. 
2013).  In Cox, this Court concluded “that the district court impermissibly 
reweighed the evidence and substituted its own evaluation of the evidence in place 
of the jury.”  71 So. 3d at 800.  At trial, conflicting evidence was presented, and 
the jury entered a verdict in favor of Cox, which was reversed on appeal by the 
Second District.  Id. at 801.  When quashing the Second District, this Court in Cox 
explained that “the jury was presented with conflicting testimony[,] . . . which is a 
matter for the jury, not a matter for the appellate court to resolve as a matter of 
law.”  Id.  Similarly, in Friedrich, this Court held that the Fourth District 
impermissibly reweighed conflicting expert testimony and “substituted its own 
evaluation of the evidence in place of that of the jury.”  137 So. 3d at 366.  In 
contrast, in Ruiz the Third District explained that “[n]one of the expert witnesses 
testified that Dr. Lorenzo’s evaluation of Espinosa fell below the standard of care 
such that any breach more likely than not caused Espinosa’s death.”  224 So. 3d at 
830.  “In addition, the record is devoid of competent, substantial evidence upon 
which to conclude that the blurry EKG or the abnormal protein level results caused 
Espinosa’s death.”  Id.  In other words, there was no evidence in support of Ruiz’s 
argument.  Therefore, because in Ruiz (unlike in Cox and Friedrich), there was no 
evidence to reweigh, there is no conflict.   
 
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Moreover, there is no conflict with Saunders v. Dickens, 151 So. 3d 434 
(Fla. 2014).  In Saunders, this Court addressed statements made by Dr. Dickens’ 
counsel that “because [the subsequent physician] would not have done anything 
differently had Dr. Dickens ordered a cervical MRI, any purported negligence by 
Dr. Dickens could not be the cause of Saunders’s injuries.”  Id. at 442.  This Court 
held that the statements were improper and that “testimony that a subsequent 
treating physician would not have treated the patient plaintiff differently had the 
defendant physician acted within the applicable standard of care is irrelevant and 
inadmissible and will not insulate a defendant physician from liability for his or her 
own negligence.”  Id. at 443.  However, in Ruiz, the Third District did not address 
an argument that subsequent physicians would not have done anything differently.  
Therefore, because the legal issues are different, there is no conflict between Ruiz 
and Saunders.   
 
There is also no conflict with Owens v. Publix Supermarkets, Inc., 802 So. 
2d 315 (Fla. 2001).  In Owens, this Court reviewed the entry of a directed verdict 
in a slip and fall case and whether the appearance of the hazardous condition, when 
there was no evidence as to how long the hazard had been on the floor, was enough 
to constitute constructive knowledge.  802 So. 2d at 329.  This Court held that “the 
condition of the banana raised a basis for establishing the store’s constructive 
knowledge,” precluding a directed verdict.  Id. at 332.  In Ruiz, the issue was 
 
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whether there was competent, substantial evidence for a jury to find that Dr. 
Lorenzo’s alleged negligence caused Espinosa’s death.  224 So. 3d at 830.  
Therefore, because Ruiz (unlike Owens) did not address the issue of constructive 
knowledge in slip and fall cases, there is no conflict.   
 
Additionally, there is no conflict with Gooding v. University Hospital 
Building, Inc. 445 So. 2d 1015 (Fla. 1984).  In Gooding, this Court set forth the 
following “more likely than not standard:”    
The plaintiff must show that the injury more likely than not resulted 
from the defendant’s negligence in order to establish a jury question 
on proximate cause.  In other words, the plaintiff must show that what 
was done or failed to be done probably would have affected the 
outcome. 
445 So. 2d at 1020.  Because the plaintiff in Gooding failed to satisfy this test, this 
Court held that the hospital’s motion for a directed verdict should have been 
granted.  Id.  More specifically, this Court in Gooding concluded that “the 
testimony established a no better than even chance for Mr. Gooding to survive, 
even had there been an immediate diagnosis of the aneurysm and emergency 
surgery[; t]herefore, a jury could not reasonably find that but for the negligent 
failure to properly diagnose and treat Mr. Gooding he would not have died.”  Id. at 
1018.  Similar to Gooding, the Third District in Ruiz applied the “more likely than 
not standard” and concluded “[t]here is no competent, substantial evidence at trial 
from which a jury could reasonably conclude that Dr. Lorenzo’s behavior fell 
 
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below the standard of care, or that any breach of the standard of care more likely 
than not caused Espinosa’s death.”  Ruiz, 224 So. 3d at 830.  Therefore, because 
both Gooding and Ruiz applied the “more likely than not standard” and reached 
similar results, there is no conflict between the two cases.   
 
Accordingly, because the cases alleged by the Petitioner do not conflict with 
Ruiz, this Court lacks jurisdiction to review this case.  I respectfully dissent.  
CANADY, C.J., and LAWSON, J., concur. 
 
Application for Review of the Decision of the District Court of Appeal – Direct 
Conflict of Decisions  
 
 
Third District - Case No. 3D15-2474 
 
 
(Miami-Dade County) 
 
Jorge P. Gutierrez, Jr., of The Gutierrez Firm, Coral Gables, Florida; and Philip D. 
Parrish of Philip D. Parrish, P.A., Miami, Florida, 
 
 
for Petitioner 
 
Mark Hicks, Dinah Stein, Amanda Forti, and Erik P. Bartenhagen of Hicks, Porter, 
Ebenfeld & Stein, P.A., Miami, Florida; and Jonathon P. Lynn of Chimpoulis, 
Hunter & Lynn, P.A., Plantation, Florida, 
 
 
for Respondents 
 
Daniel B. Rogers of Shook, Hardy & Bacon, LLP, Miami, Florida, 
 
for Amici Curiae American Medical Association and Florida Medical 
Association