Opinion ID: 161331
Heading Depth: 2
Heading Rank: 2

Heading: Did Dr. Rodgers' Testimony Rebut the Presumption?

Text: 33 The Ecks next challenge whether the defendants presented evidence to rebut the presumption that had Dr. Rodgers been properly warned, she would have read and heeded the warning. The Ecks also question whether Dr. Rodgers' knowledge about the adverse risks was substantially the same as the risks presented in the proposed warning. If not, they posit, she would be unable to incorporate the adverse risks into her risk/benefit analysis. 34 In rebutting the presumption, the defendants offer Dr. Rodgers' deposition testimony. Dr. Rodgers testified that she discussed with Mr. Eck the list of medications he was taking, but does not recall that Isocet was on the list. She stated that the Ecks assured her Mr. Eck was not taking any medications other than those on the list. See Aplt's App. vol. II, at 573 (depo. of Dr. Rodgers). 35 Dr. Rodgers also indicated that she had discussed Mr. Eck's acetaminophen intake with him. She told him that his intake of up to twelve tablets a day of Tylenol was way too much, id. at 574, and indicated that she feared this intake because [acetaminophen] was hepatotoxic. Id. She testified that Mr. Eck indicated that he understood what hepatotoxic meant. Id. 36 Dr. Rodgers also testified that she was aware of medical literature that suggested Dilantin might be a enzyme inducer that could increase the hepatotoxicity of acetaminophen. She also testified that she was aware of the possibility of an adverse reaction when Dilantin and acetaminophen were taken together. See id. at 574, 740. 37 Dr. Rodgers further testified that she performs a risk/benefit analysis for every medication. Id. at 740. In weighing the risks and benefits, she concluded that she would have prescribed Dilantin even if [Mr. Eck] had been on a drug that had a more frequent hepatotoxicity [than acetaminophen] . . . because the risk of him having a problem due to his seizure was much greater than him taking the Dilantin. Id. at 736. 38 The Ecks argue that the evidence offered by defendants failed to rebut the presumption that Dr. Rodgers would have read and heeded an adequate warning. The Ecks dispute that Dr. Rodgers or any physician discussed with them Mr. Eck's acetaminophen use prior to his liver failure, and point out that Dr. Rodgers' notes do not reflect such a discussion. See id. at 278, 731, 800. However, Mrs. Eck does recall faxing a list of her husband's prescriptions to Dr. Rodgers, and that they discussed the medications he was taking. The Ecks also point to Dr. Rodgers' testimony that she generally does not particularly find Tylenol to be effective and that it has a number of things that make it less than an attractive drug to use, including its potential for hepatotoxicity as evidence that she would have changed her course of treatment. Id. at 577. 39 The Ecks construe Dr. Rodgers' heeding an adequate warning to mean she would have given the warning. However, 'heed' in this context means only that the learned intermediary would have incorporated the 'additional' risk into [her] decisional calculus. Thomas, 949 F.2d at 814. In the risk/benefit analysis of drug prescription, the prescribing physician can choose to use the product and face its risks, or choose not to use the product and lose its potential benefits. Generally, using the product will present the less risky of these two alternatives. Id. at 813; see also Talley v. Danek Med., Inc., 179 F.3d 154, 163 (4th Cir. 1999) (applying Virginia law) (noting that the prescribing physician can take into account the propensities of the drug, as well as the susceptibilities of [her] patient and has the task of weighing the benefits of any medication against its potential dangers). 40 We also disagree with the Ecks' construction of the burden shifting under the learned intermediary doctrine. Dr. Rodgers testified that even if she knew Mr. Eck was taking a drug with a more frequent hepatotoxicity enzyme, she would have still prescribed Dilantin to Mr. Eck. We hold the defendants provided sufficient evidence that Dr. Rodgers would have not changed her course of treatment. See Woulfe, 965 F. Supp. at 1485; Garside, 976 F.2d at 80 (Where the manufacturer fails to provide the physician with an adequate warning, courts have held that the manufacturer may still be shielded from liability if it can show that the prescribing physician would not have heeded an adequate warning.); see also Plummer v. Lederle Labs., 819 F.2d 349, 358-59 (2d Cir. 1987) (applying California law) (granting judgment as a matter of law and noting that the plaintiff failed to prove that a proper warning would have altered the doctor's conduct). 41 C. Did Dr. Rodgers have Substantially the Same Knowledge of Adverse Risks that the Warning Would have Imparted? 42 The Ecks next propose that because Dr. Rodgers' testimony did not imply that she had substantially the same knowledge of the adverse risks as the proposed warning would have reflected, her testimony did not demonstrate unequivocally that s/he knew at the relevant time all the information which would have been included in a warning. Garside, 976 F.2d at 82. Dr. Rodgers testified that she was aware of a scientific hypothesis that the hepatotoxicity of acetaminophen is increased when used in conjunction with Dilantin, but she did not appear certain of the interaction between a therapeutic dose of acetaminophen and Dilantin. Aplt's App. vol. II, at 574, 740. Thus, she was unable to incorporate this knowledge into her risk/benefit analysis of Mr. Eck's course of treatment. 43 The Ecks cite Christopher v. Cutter Labs., 53 F.3d 1184, 1192 (11th Cir. 1995) (applying Florida law) in support of their contention that Dr. Rodgers must have unequivocal knowledge of the effects of the interaction of the drugs. In Christopher, the Eleventh Circuit examined whether the plaintiffs had presented substantial evidence that absence of an adequate warning was a proximate cause of the injury. The defendant manufacturer challenged a jury instruction that required the jury to find that, at the time in question, the prescribing physician had a knowledge of reasonable evidence of the connection between AIDS and blood products. Id. at 1193. The given warning required only a knowledge that the possibility exists that AIDS could be transmitted through blood products. Id. There was no testimony that physicians in general or that the prescribing physician understood that there was reasonable evidence of an association between AIDS and blood products during the relevant timeframe. The Eleventh Circuit held that the district court erred when it required the manufacturer to establish reasonable evidence of the risk, which imposed a higher and erroneous layer of proof on its affirmative defense and that the error required a new trial. Id. at 1193. 44 In the present case, we are faced with a very different set of facts: Dr. Rodgers has testified that she is aware that Dilantin is an enzyme inducer, one that could increase the hepatotoxicity of acetaminophen. She also testified that she was aware of the possibility of an adverse reaction when Dilantin and acetaminophen were taken together. Most importantly, she testified that even if she knew Mr. Eck was taking, or might take, a drug with a more frequent hepatoxicity enzyme than acetaminophen, she still would have prescribed Dilantin, because the risk of him having a problem due to his seizure was much greater than him taking the Dilantin. Aplt's App. vol. II, at 736. See also Thomas, 949 F.2d at 811-15 (holding that a warning stating that seizures had occurred in 9 of 400,000 patients who had ingested the drug Accutane would not have altered physician's behavior where he testified that he was aware at the time he prescribed the drug of the possibility that Accutane may have caused seizures in very rare cases); Plummer, 819 F.2d at 358 (holding that where physician testified he was aware of the risks of contact polio, a warning stating that an unimmunized person should avoid contact with a polio vaccinee for 30 days would not have altered his behavior); Stanback v. Parke, Davis & Co., 657 F.2d 642, 645 (4th Cir. 1981) (applying Virginia law) (holding that a warning stating that there was a risk of acquiring a neurological disorder from ingesting the drug Fluogen would not have altered physician's behavior where his decisions and actions [were] made in full knowledge of [that] information); Windham v. Wyeth Labs., Inc., 786 F. Supp. 607, 612 (S.D. Miss.1992) (applying Mississippi law) (holding that a warning stating that a pregnant patient who uses Phenergan suppositories might suffer adverse consequences would not have altered physician's behavior where he testified that he was aware of such risk and weighed the risk of the drug against the benefit of the drug before prescribing it). Cf. Garside, 976 F.2d at 82 (holding where physician's affidavit stated he was aware of alleged connection between the combined ingestion of phenobarbital and amoxicillin and the risk of toxic epidermal necrolysis did not suggest the physician knew of the causal connection). 45 Mr. Eck's reliance on Tatum v. Schering Corp., 795 F.2d 925, 927 (11th Cir. 1996) (applying Alabama law), is similarly misplaced. There, as in Garside, the prescribing physician was not adequately warned of the degree or extent of serious adverse effects. The Tatum court held that a jury might have concluded the physician, armed with this knowledge, might have reconsidered her decision to prescribe the drug. See id. Here, Dr. Rodgers testified that she still would have prescribed Dilantin, because the risk of seizure was more severe than the risk of hepatotoxicity induction. Thus, Dr. Rodgers was already aware of the medical risk that the warning would have imparted, and having integrated this knowledge into her risk/benefit calculation, determined her decision to prescribe would remain unchanged. See e.g., Garside, 976 F.2d at 80 (collecting cases and stating [w]here the manufacturer fails to provide the physician with an adequate warning, courts have held that the manufacturer may still be shielded from liability if it can show that the prescribing physician would not have heeded an adequate warning . . . [and] have reasoned that the physician's conduct acts as an intervening-superseding cause of the plaintiff's injury which vitiates any liability on the part of the manufacturer); Stanback, 657 F.2d at 645-46 (stating that the manufacturer cannot be said to have caused the injury if the doctor already knew of the medical risk); Wooten v. Johnson & Johnson Prods, Inc., 635 F. Supp. 799, 803 (N.D. Ill.1986) (noting that [c]ourts have held consistently that a drug manufacturer is entitled to summary judgment where the prescribing physician is aware of the risks associated with a drug) (citing Goodson v. Searle Labs., 471 F. Supp. 546 (N.D. Conn. 1978), and Cobb v. Syntax Labs., 444 So. 2d 203 (La. App. 1983)). 46 Oklahoma courts have not considered whether a physician's conduct automatically acts as an intervening cause relieving the manufacturer of liability, but instead shifts the burden back to the plaintiff to allow him to controvert the physician's testimony. See Woulfe, 965 F. Supp. at 1485-86. If the Ecks can produce sufficient evidence to create a triable issue of the question of causation, Garside, 976 F.2d at 81, they will defeat a motion for summary judgment. See Woulfe, 965 F. Supp. at 1485-86 (noting plaintiff was unable to establish that failure to warn was a proximate cause of injuries and granting summary judgment to defendant). 47 D. Material Fact Questions Regarding Causation 48 Finally, the Ecks contend that even if the defendants successfully rebutted the presumption that a proper warning would have been heeded, they satisfied their burden by presenting sufficient evidence to create a material fact as to causation by casting doubt upon the credibility of Dr. Rodgers. Ordinarily, what constitutes the proximate cause of any injury is a question of fact. See Lefthand v. City of Okmulgee, 968 P.2d 1224, 1226 (Okla. 1998). However, the question of proximate cause becomes a question of law when the facts are undisputed and there is no evidence from which a jury could reasonably find a causal connection between the allegedly negligent act and the injury. Id. 49 The Ecks challenge Dr. Rodgers' credibility, and note that she formerly conducted research for several pharmaceutical companies. As the district court observed: 50 These facts standing alone, however, merely offer speculation as to Dr. Rodgers' motives for testifying and they are clearly insufficient to call into question either Dr. Rodgers' credibility or the veracity of her statements. 51 Aplt's App. vol. III, doc. 31, at 8 (Dist. Ct. Order filed Jan. 18, 2000). The speculative nature of this argument is increased by the fact that if anything, Dr. Rodgers' testimony would have enhanced her own exposure to liability. Absent evidence suggesting Dr. Rodgers was otherwise influenced by the defendants, we, like the district court, find no reason to question her credibility or the truth of her testimony. 52 Even viewing the facts most favorably to the Ecks, we cannot disagree with the district court's conclusion that Dr. Rodgers would have prescribed Dilantin no matter how carefully the Ecks proposed or refined the phrasing of the suggested warning. Dr. Rodgers testified about her independent knowledge of the risk of the potential interaction between the two drugs, and indicated that if presented with even a higher risk, she would have prescribed Dilantin. The Ecks have failed to controvert this testimony and have failed to create an issue of fact of whether defendants' failure to warn was the proximate cause of their injuries.