Title: Roberson v. Counselman
Citation: 235 Kan. 1006, 686 P.2d 149
Docket Number: 56,325
State: Kansas
Issuer: Kansas Supreme Court
Date: July 13, 1984

235 Kan. 1006 (1984)
686 P.2d 149
CHRISTINE ROBERSON, Appellant,
v.
G. ED COUNSELMAN, Appellee.
No. 56,325

Supreme Court of Kansas.
Opinion filed July 13, 1984.
Janet Jo Smith, of Law Offices of Jerry K. Levy, P.A., of Topeka, argued the cause and was on the brief for appellant.
Thomas E. Wright, of Fisher, Ochs, Heck and Wright, P.A., of Topeka, argued the cause and was on the brief for appellee.
The opinion of the court was delivered by
McFARLAND, J.:
Plaintiff Christine Roberson, the widow and heir-at-law of Richard C. Roberson, deceased, brings this professional malpractice action against G. Ed Counselman, a chiropractor. Plaintiff contends defendant was professionally negligent in failing to recognize his patient (the deceased) was experiencing symptoms consistent with those of acute heart disease and in failing to refer the patient for appropriate medical treatment. Plaintiff contends this negligence substantially reduced deceased's chance of surviving the heart attack which took his life within hours after he had received chiropractic treatment. The district court held plaintiff had failed to meet her burden of proof to show it was more likely than not defendant's conduct was a substantial factor in the causation of the injury and sustained defendant's pretrial motion for summary judgment. Plaintiff appeals therefrom.
*1007 The applicable rules relative to summary judgment were reiterated in McAlister v. Atlantic Richfield Co., 233 Kan. 252, 662 P.2d 1203 (1983), as follows:
A summary of the facts, in the light most favorable to the plaintiff, is as follows. Richard C. Roberson was initially seen by defendant Counselman in December 1972. At that time he complained of and was treated for a back sprain. Approximately a week later Mr. Roberson became ill. Plaintiff then contacted defendant and advised him she believed her husband had a heart problem and requested that defendant urge her husband to see a heart specialist. Defendant made arrangements for Mr. Roberson to be seen by Dr. Robert Roeder, a Topeka cardiologist where he was diagnosed as having suffered a heart attack and was hospitalized.
Under Dr. Roeder's supervision, a continuing course of treatment, including medication, was undertaken and Mr. Roberson was ultimately released from the hospital. On January 12, 1973, Mr. Roberson was rehospitalized complaining of chest discomfort. Three years later, in May 1976, Mr. Roberson was again admitted to the hospital with similar complaints. During the 1976 hospitalization Mr. Roberson underwent diagnostic coronary arteriograms to determine the state of his cardiac circulation in relation to his coronary arteries. The tests revealed the right coronary was totally blocked while there was a seventy percent narrowing in the left anterior descending to a forty percent narrowing in the circumflex. Also during the 1976 hospitalization, x-rays of Mr. Roberson's back revealed he had a mild degenerative arthritic change of the lumbar and cervical regions of the spine. All these findings were presented to Mr. Roberson. *1008 The last time Dr. Roeder saw Mr. Roberson was on January 24, 1980, where he exhibited stable angina pain.
On July 28, 1980, Mr. Roberson appeared at defendant's office complaining of "pain in the left shoulder area and left side causing hard breathing and chest ache." Defendant, with knowledge of the decedent's prior heart history, diagnosed Mr. Roberson as suffering from a neuromuscular difficulty and gave two chiropractice adjustments which were described as an anterior move for his upper back and an intersegmental traction. At no time during the July 28th consultation did the defendant advise Mr. Roberson he should consult a medical physician about his heart. Throughout the evening of July 28, Mr. Roberson's condition deteriorated and plaintiff became very concerned about her husband's health. Plaintiff urged her husband to seek immediate medical treatment. In her deposition, plaintiff testified the following exchange occurred between her husband and herself:
"A. He would not.
"A. He would not."
Plaintiff and her husband argued over his medical condition. Later in the evening, the following conversation occurred:
"Q. What did he say?
A few hours later Mr. Roberson died of a heart attack in his home, without medical attention. He was 51 years of age at the time of his death.
*1009 Plaintiff presented three expert witnesses whose depositions were taken during discovery. Their testimony, as pertinent to the issue before us, may be summarized as follows:
1. Dr. Malcolm W. Haber (chiropractor) stated that Dr. Counselman had a duty to refer a patient with Mr. Roberson's symptoms to a medical specialist and the failure to do so constituted a breach of that duty.
2. Dr. Richard Roeder (cardiologist) stated with in-hospital treatment for his heart attack, Mr. Roberson had a nineteen percent chance of dying. Without such treatment the mortality rate is twenty-five percent. Therefore, the failure to receive proper medical treatment cost Mr. Roberson a six percent chance of survival.
3. Dr. Lillian Rodriquez-Tocker (cardiologist) stated with proper medical treatment Mr. Roberson had a forty percent chance of survival and that without such treatment his chance of survival was zero percent.
The district court in sustaining defendant's motion for summary judgment reasoned:
....
....
The sole issue on appeal is whether the district court erred in concluding the evidence on causation was insufficient to constitute a submissible jury question.
*1010 Durflinger v. Artiles, 234 Kan. 484, 673 P.2d 86 (1983), contains a general review of the Kansas law relative to medical malpractice. A physician has the duty to exercise reasonable and ordinary care and diligence. The particular decision and acts required of the physician in fulfilling the duty will vary with the circumstances of the patient's situation and the medical specialty of the physician. 234 Kan. at 490. The rules of law pertaining to medical malpractice are applicable to chiropractors. See Hinthorn v. Garrison, 108 Kan. 510, 196 Pac. 439 (1921); Case v. Vearrindy, 339 Mich. 579, 64 N.W.2d 670 (1954). Like physicians (see Annot., Malpractice: Physician's Failure to Advise Patient to Consult Specialist or One Qualified in a Method of Treatment which Physician is not Qualified to Give, 35 A.L.R.3d 349), a chiropractor may be liable for failing to refer a patient to a medical practitioner. Annot., Chiropractor's Liability for Failure to Refer Patient to Medical Practitioner, 58 A.L.R.3d 590; 24 Am. Jur. Proof of Facts, Chiropractic Malpractice § 21, p. 467; 61 Am.Jur.2d, Physicians, Surgeons, Etc. § 233; Mostrom v. Pettibon, 25 Wash. App. 158, 607 P.2d 864 (1980); Tschirhart v. Pethtel, 61 Mich. App. 581, 233 N.W.2d 93, appeal denied 395 Mich. 774 (1975); Salazar v. Ehmann, 505 P.2d 387 (Colo. App. 1972), 58 A.L.R.3d 585; Ison v. McFall, 55 Tenn. App. 326, 400 S.W.2d 243 (1964); Ritter v. Sivils, 206 Or. 410, 293 P.2d 211 (1956).
It should be emphasized that the summary judgment herein was not granted on the basis plaintiff's evidence was insufficient to establish the duty owed or the breach thereof. Indeed, the deposition of Dr. Haber was sufficient to establish the duty and the breach thereof for purposes of withstanding a summary judgment motion. Rather, the district court concluded there was insufficient evidence that the alleged breach of Dr. Counselman's duty to Mr. Roberson caused the man's death. Therefore, the issue before us relates wholly to causation  not whether Dr. Counselman was negligent in his treatment of Mr. Roberson.
In granting the summary judgment herein the district court cited Restatement (Second) of Torts § 433B, comments a and b (1965).
Comment b declares:
Comment b concludes by providing a hypothetical drowned child scenario which appears analytically applicable in the instant action.
Dean Prosser, also cited by the district court, is consistent with the Restatement (Second) of Torts in holding causation must be established by the so-called "substantial factor" test. Prosser, Law of Torts § 41, pp. 240-41 (4th ed. 1971). Prosser is critical of the "but for" test of causation. Prosser, pp. 238-40. Like the Restatement (Second) of Torts, Prosser argues whether the defendant's conduct was a substantial factor in bringing about the plaintiff's injury "is for the jury to determine, unless the issue is so clear that reasonable men could not differ." Prosser, p. 240.
57 Am.Jur.2d, Negligence § 147, at pp. 503-04, states:
As the preceding passage from Am.Jur.2d reveals, the Restatement (Second) of Torts discusses and defines "substantial factor" as it relates to causation in negligence actions. Initially, Restatement (Second) of Torts § 430 (1965) provides in order that a negligent actor shall be liable for another's harm, it is necessary not only that the actor's conduct be negligent toward the other, but also the negligence of the actor be the legal cause of the other's harm. Restatement (Second) of Torts § 431 (1965) defines "legal cause";
Comment a, following § 431, proclaims in order to be a legal cause of another's harm it is not enough the harm would not have occurred had the actor not been negligent  a rejection of the "but for" test. Rather, the negligence must also be a substantial factor in bringing about the plaintiff's harm.
In State Highway Comm. v. Empire Oil &amp; Ref. Co., 141 Kan. 161, 40 P.2d 355 (1935), the court defined legal cause as the invasion of some legally protected interest of another for which the actor is held responsible in law for the harm. Further, "the act or omission must be a substantial factor in bringing about the harm (see § 431)." 141 Kan. at 165. (Emphasis supplied.)
In Adams v. Casebolt, 145 Kan. 3, 63 P.2d 927 (1937), at p. 7, *1013 this court, relying upon Restatement of Torts § 431, comment b (1934), said:
Cole v. Shell Petroleum Corp., 149 Kan. 25, 86 P.2d 740 (1939), at p. 37, saw this court, in relying upon authority, noting "[c]ausation is a matter of fact."
As is evident from the preceding discussion, causation is easier stated than explained. The legal treatises on causation are voluminous. A few good examples are: Delgado, Beyond Sindell: Relaxation of Cause-In-Fact Rules for Indeterminate Plaintiffs, 70 Calif. L. Rev. 881 (1982); King, Causation, Valuation, and Chance in Personal Injury Torts Involving Preexisting Conditions and Future Consequences, 90 Yale L.J. 1353 (1981); Danner &amp; Sagall, Medicolegal Causation: A Source of Professional Misunderstanding, 3 Am. J.L. &amp; Med. 303 (1977); Note, Expert Testimony on Causation in a Wrongful Death Case: Should "Reasonable Medical Certainty" be Necessary to Make a Submissible Case? 36 Mo. L. Rev. 127 (1971); 3 Am. Jur. Proof of Facts, Causation  Medical Opinion, p. 161; Annot., Proximate Cause in Malpractice Cases, 13 A.L.R.2d 11.
To iterate, in the case before us, for purposes of withstanding the summary judgment motion, negligence on the part of Dr. Counselman was adequately established. In essence, the district court held that, to establish a submissible jury issue of causation, plaintiff must show that, but for defendant's negligence, deceased would have had a better than even chance of surviving the heart attack. The plaintiff's evidence in its most favorable light showed only a forty percent chance of survival. This, the district court concluded, was insufficient.
Plaintiff's claim centers on defendant's negligence having reduced or obliterated her husband's chance of survival. While such action frequently arises within the context of a wrongful death case, the complainant is really seeking redress not for the death but for the deprivation of the chance to survive. Delgado, 70 Calif. L. Rev. at 889. It should be noted that there is no issue before us relative to by what legal capacity the action is brought and such is not germane to the issue to be decided. The case does appear, however, to be the first deprivation-of-the-chance-to-survive *1014 action before a Kansas appellate court. This type of action has been before a number of appellate courts in other jurisdictions.
In Hernandez v. Clinica Pasteur, Inc., 293 So. 2d 747 (Fla. Dist. Ct. App. 1974), Mr. Hernandez visited defendant clinic with symptoms which should have resulted in an electrocardiogram being administered, but which was not done. He was diagnosed as suffering from gastric distress. The patient was told he had no serious health problems and should exercise more. The patient exercised that evening and was dead by morning from a myocardial infarction. At trial a cardiologist testified Mr. Hernandez would "probably and possibly" have had a better chance of survival if he had received proper treatment at the defendant clinic. A directed verdict was entered for defendants at trial. The Florida Appellate Court reversed the directed verdict holding:
Continuing:
Concluding:
Hernandez arose in the District Court of Appeal of Florida, Third District.
A different result was reached in the First District of the same appellate court. In University Hosp. Bldg., Inc. v. Gooding, 419 So. 2d 1111 (Fla. Dist. Ct. App. 1982), the patient had a condition when brought to the hospital which, with proper medical treatment, he had a fifty percent chance to survive. The treatment was *1015 not given and the patient died. A verdict was rendered against the hospital. In reversing, the appellate court said:
Perhaps the most liberal view is expressed in Hicks v. United States, 368 F.2d 626 (4th Cir.1966), which involves Virginia law. In Hicks a diabetic patient was taken to a navy hospital with intense abdominal pain and vomiting. Proper testing would have revealed a high obstruction. Instead the patient was diagnosed as having a minor problem and sent home, where she died. There was expert testimony the patient would have survived if given proper treatment. The district court dismissed the action. In reversing the district court the Court of Appeals stated:
Hicks has been followed by the Maryland Court of Appeals (Maryland's highest court) in Thomas v. Corso, 265 Md. 84, 101-02, 288 A.2d 379 (1972).
In Kallenberg v. Beth Israel Hosp., 45 App. Div.2d 177, 357 *1016 N.Y.S.2d 508 (1974), aff'd 37 N.Y.2d 719, 374 N.Y.S.2d 615, 337 N.E.2d 128 (1975), the decedent was admitted to the Beth Israel Hospital for surgery. The decedent had a cerebral aneurysm. Upon admission her physician ordered she receive a specific medication to reduce her blood pressure. It was critical her blood pressure be reduced as a condition for performing surgery. The decedent never received the medication. Her blood pressure remained high and, consequently, surgery could not be performed. Ultimately the patient died when the cerebral aneurysm hemorrhaged. The evidence revealed the decedent did not reach the point where nothing could be done for her until six days after admission. Expert testimony established had the decedent been promptly, properly, energetically and adequately treated, she would have had at least a twenty percent survival chance, but no more than forty percent. 45 App. Div.2d at 179. If the decedent had received medication, but had not undergone surgery, she would have had a two percent chance of survival. 45 App. Div.2d at 180. Even with this less than evenly balanced survival chance, the New York appellate court, in affirming a jury verdict for the plaintiffs, said:
In Jones v. Montefiore Hospital, 494 Pa. 410, 431 A.2d 920 (1981), plaintiff alleged the misdiagnoses and delay in treating her for breast cancer resulted in her life being impaired and shortened, and caused financial loss. The trial court, in charging the jury on causation, said proximate cause is that cause which in direct and continuous sequence uninterrupted by any intervening cause produces the result and without which it would not occur. 494 Pa. at 415. The jury returned a verdict in favor of the defendants. On appeal the Pennsylvania Supreme Court reversed, holding the lower court had erred in charging the jury on causation.
In Jones the Pennsylvania court applied liability under Restatement (Second) of Torts § 323 (1965), which provides:
The Pennsylvania court specifically relied upon subsection (a). According to the Pennsylvania court, once a plaintiff demonstrated defendant's acts or omissions, in a situation to which § 323(a) applied, increased the risk of harm to another, such evidence would furnish a basis for a factfinder to go further and find that such increased risk was in turn a substantial factor in bringing about the resultant harm. To the Jones court the necessary proximate cause would have been made out if the jury saw fit to find causation in fact. According to the Pennsylvania court, "... medical opinion need only demonstrate, with a reasonable degree of medical certainty, that a defendant's conduct increased the risk of the harm actually sustained, and the jury then must decide whether that conduct was a substantial factor in bringing about the harm." 494 Pa. at 417. Recently, in Circle Land &amp; Cattle Corp. v. Amoco Oil Co., 232 Kan. 482, 490, 657 P.2d 532 (1983), this Court adopted Restatement (Second) of Torts § 323 (1965).
Clark v. United States, 402 F.2d 950 (4th Cir.1968), applying Virginia law, involved allegations the physicians had been negligent in delaying use of proper and standard diagnostic procedures to identify the patient's illness and the delay was the cause of the loss of a kidney. The trial court entered judgment for plaintiff and the United States Government appealed, contending lack of causation. The Fourth Circuit Court of Appeals, in affirming the lower court, commented:
Perhaps the most rigid position is expressed in Cooper v. Sisters, 27 Ohio St.2d 242, 56 Ohio Op.2d 146, 272 N.E.2d 97 (1971). In Cooper, plaintiff's minor son was involved in a bicycle-truck collision. Improper emergency room procedures failed to disclose a major head injury. The child was released and died the following morning. One expert testified death had been almost certain without proper treatment but declined to speculate on the percentage of chance of survival with proper treatment. Another expert placed survival chances with proper treatment "around" fifty percent. The trial court entered judgment for the defendants. In affirming, the Ohio Supreme Court stated:
In Daniels v. Hadley Memorial Hospital, 566 F.2d 749 (D.C. Cir.1977), a Mr. Horace Miller went to a hospital emergency room for treatment for abrasions he received following a fall from his bicycle. During treatment Mr. Miller received a penicillin shot and fifteen to twenty minutes later was allowed to leave. About ten minutes after being discharged, he was found in the hospital parking lot suffering from an anaphylactic reaction to the penicillin. Thirty-four minutes after he had been rushed back into the emergency room, Mr. Miller was dead. In a wrongful death action against the hospital the plaintiff alleged when the hospital staff was treating the decedent for the anaphylactic reaction it had a duty to provide both oxygen and adrenalin as quickly as possible (for proper ventilation) and the staff's failure to do so effectively eliminated whatever chance Mr. Miller had of surviving. 566 F.2d  at 753. Plaintiff's expert testimony established while Mr. Miller had been in a grave condition when he was rushed back into the emergency room, he still had a significant chance of recovery if properly treated. His condition was capable of being medically corrected. Death was possible, but not inevitable. According to one expert there was an appreciable chance of survival in anaphylactic reaction to penicillin cases although fifteen to twenty-five percent of the victims ultimately die. As each moment passed the chances of survival diminished. The plaintiff's expert witness testified the hospital staff's failure to supply proper ventilation "significantly diminished" Mr. Miller's chances of survival. 566 F.2d  at 758. The trial court found the hospital staff had been negligent in its emergency treatment of the decedent, but such treatment had not been the proximate cause of his death. 566 F.2d  at 751. The plaintiff appealed and the United States Court of Appeals, District of Columbia Circuit, reversed and remanded the case.
In reversing the lower court the federal appellate court wrote:
The question of causation in cases involving negligent treatment of a potentially fatal condition (including failure to refer the patient to an appropriate specialist) is generally a matter to be determined by the finder of fact where the evidence has established the patient had an appreciable chance to survive if given proper treatment. In making the determination, the finder of fact should take into account both the patient's chances of survival if properly treated and the extent to which the patient's chances of survival have been reduced by the claimed negligence.
In the case before us one of plaintiff's experts testified the failure to obtain proper treatment increased Mr. Roberson's *1021 chances of dying from the heart attack from nineteen percent mortality rate to twenty-five percent mortality rate (an increase of over thirty percent). The other expert testified the patient had a forty percent chance of surviving with treatment and zero percent chance without treatment. In addition to the failure to refer aspect of this case, we have the added factor of assuring the patient his heart was not causing his suffering and that his pain was to be expected from the muscular problem. We believe under the totality of the circumstances herein, the district court's entry of summary judgment in favor of defendant predicated upon insufficient evidence of causation was erroneous, and, in so doing, the district court usurped the function of the jury as the finder of fact. Whether the negligence of defendant was a substantial factor in Mr. Roberson's death is a matter for determination by a jury upon due consideration of all related factors.
We conclude that under the totality of the circumstances sufficient evidence was before the district court to have precluded summary judgment being granted on causation.
There are sound reasons of public policy involved in reaching this result. The reasoning of the district court herein (which is similar to the extreme position taken in Cooper v. Sisters, 27 Ohio St.2d 242), in essence, declares open season on critically ill or injured persons as care providers would be free of liability for even the grossest malpractice if the patient had only a fifty-fifty chance of surviving the disease or injury even with proper treatment. Under such rationale a segment of society often least able to exercise independent judgment would be at the mercy of those professionals on whom it must rely for life-saving health care.
The judgment is reversed and the case is remanded for trial.
HOLMES, J., not participating.
SCHROEDER, C.J., dissenting.