Opinion ID: 1800402
Heading Depth: 1
Heading Rank: 3

Heading: The Liability of the Treating Physicians

Text: We deal first with the claims against Doctors Jacks and Doe for allowing Corley to leave the institution on pass. It is alleged that Jacks is chief of the medical staff, which would indicate that he has supervisory duties, but for present purposes we shall assume that he was active in the care and treatment of Corley. The claim is that Corley was a dangerous person with severe mental illness, that he should have been confined continuously in an institution, that the defendants Jacks and Doe were grossly negligent in allowing him to leave on pass, and that his presence in the world at large was dangerous to members of the public including the plaintiff's decedent. We gather from the petition that the fatal attack did not occur until several weeks after Corley was due to return from his pass, but shall assume that the issuance of the pass was an event in the direct chain of causation. The question, then, is whether the treating physicians owed such a duty to the general public in deciding which involuntary patients should be released on pass, as to give rise to a civil action by a member of the general public for negligent exercise of judgment. The plaintiff gains nothing by branding the negligence gross. In a line of cases beginning with McPheeters v. Hannibal and St. Jos. R.R. Co., 45 Mo. 22 (1869) and reiterated in Warner v. Southwestern Bell Tel. Co., 428 S.W.2d 596 (Mo.1968), this Court has held that there are no degrees of negligence. The case must be decided on ordinary negligence principles. We conclude that a claim of the kind just described should not be recognized. Physicians at state institutions are called upon to exercise judgment as to the detention and temporary or permanent release of patients. The statutes in effect at the time of Corley's release, and at the time of the killing, explicate the judgment and discretion reposed in the institutional authorities. Section 202.070, RSMo 1969, authorized the conditional or unconditional discharge of a patient whenever in the judgment of the superintendent and his staff such discharge is proper, and went on to provide [t]he decision of the superintendent and his staff on the matter is final. Section 202.830, RSMo 1969 authorized the head of the facility to release a patient on convalescent status whenever he believes that such release is in the best interests of the patient. Matters of detention and full or partial release, then, require judgment calls. The statutory provisions just cited were repealed and replaced by a comprehensive statutory plan effective January 2, 1979. Although we are not called upon to interpret or to apply the new statutes, we observe that they also emphasize the need for the exercise of discretion and judgment by the medical staff. See §§ 632.175, 632.365, 632.385, 632.390, RSMo Cum.Supp.1982. Corley was an involuntary patient, but he was not a convict. The law provides for involuntary confinement of persons in mental hospitals if it can be judicially established that they are dangerous to themselves or to the public, but the authority for confinement is hedged about by severe restrictions. [3] The patients are required to be held in the least restrictive environment compatible with their safety and that of the public, [4] and are entitled to treatment. [5] The treating physicians, in their evaluation of the case, well might believe that Corley could be allowed to leave the institution for a prescribed period and that his release on pass might contribute to his treatment and recovery. We do not believe that they should have to function under the threat of civil liability to members of the general public when making decisions about passes and releases. The plaintiff could undoubtedly find qualified psychiatrists who would testify that the treating physicians exercised negligent judgment, especially when they are fortified by hindsight. The effect would be fairly predictable. The treating physicians would indulge every presumption in favor of further restraint, out of fear of being sued. Such a climate is not in the public interest. Analogies abound. Judges are immune from civil liability for damages. [6] It would be cynical to say that they are favored only because the rules have been made by fellow judges. The reason, rather, is one of policy. Every obstacle to a judicial officer's detached and unencumbered judgment must be removed. There must be protection not only against what might be proved but against what might be claimed. Decisions about temporary or permanent release of involuntary detainees should be likewise unencumbered and unfettered, at least as against negligence claims. In Jackson v. Wilson, 581 S.W.2d 39 (Mo. App.1979), the plaintiff sought to hold the state park director liable for negligently maintaining park facilities so that the plaintiff thought he could dive safely into a pool which turned out to be too shallow. The court discussed the distinction between discretionary and ministerial duties, which it found to be somewhat artificial, but went on to hold that decisions about park layout and design are discretionary and that there is no civil liability for negligent performance of discretionary duties. The opinion emphasized the need for relieving public servants of the threat of burdensome civil litigation and suggested that courts should not construe the term discretionary too narrowly. The opinion is well buttressed by citation of earlier Missouri cases and we believe it accurately expounds Missouri law. The case of Cairl v. State, 323 N.W.2d 20 (Minn.1982), is very close to this one factually. There a mentally retarded and potentially dangerous youth was allowed to leave a state training center for holiday home leave. Suit was filed by victims of a fire he had set. The court held that the state, which had consented to be sued in tort, was not liable on account of a decision involving the exercise of judgment and discretion. The court cited its earlier decision in Papenhausen v. Schoen, 268 N.W.2d 565 (Minn. 1978), holding that the individuals in charge of an institution were not liable for errors of judgment in transferring a patient who then escaped and caused injury. Jarrett v. Wills, 235 Or. 51, 383 P.2d 995 (1963), held that the superintendent of a mental institution was not liable for injuries caused by an allegedly dangerous mental patient who was released. The court pointed to statutes similar to ours and emphasized the element of judgment which is present in any decision about release. Jones v. Czapkay, 182 Cal.App.2d 192, 6 Cal.Rptr. 182 (1960) held that a health commissioner was not liable for failing to quarantine a person suffering from tuberculosis, who allegedly transmitted the disease to the plaintiff, when it was clear from the applicable statutes that the decision to quarantine was a discretionary one. These cases are supportive of our conclusion. Also in line is Dalehite v. United States, 346 U.S. 15, 73 S.Ct. 956, 97 L.Ed. 1427 (1953), holding that the United States was not liable under the Federal Tort Claims Act for the wrongful death of a person killed in the massive Texas City explosion in 1947. It was charged that the United States was negligent by reason of its having accumulated ammonium nitrate fertilizer for shipment abroad in quantities known to be critical and dangerous. The court held that the fertilizer program was a discretionary action which was expressly excluded from the coverage of the Act. Thus there was no liability, even for negligence. Dalehite differs from the case before us in that the discretionary act exception was statutory, and the suit was against the government rather than against individuals. Even with these differences, the principles involved are very similar. The statutory exception in Dalehite is similar to the conclusion of Jackson v. Wilson under the common law. If the government is excused in a case in which it has otherwise consented to be sued because the matter is discretionary, it would be anomalous to hold the individual who exercised the discretion liable. Any such holding will inhibit objective and fearless action and discourage responsible men from taking public employment. 2 F. Harper and F. James, The Law of Torts § 29.9 (1956). See also 3 K. Davis, Administrative Law Treatise § 26.01 (1958); Restatement (Second) of Torts § 895D(3)(a) (1977). The plaintiff cites McIntosh v. Milano, 168 N.J.Super. 466, 403 A.2d 500 (1979). There the plaintiff charged that a private psychiatrist in the course of treating a patient had learned facts which indicated that a patient posed particular danger to the plaintiff's daughter. The psychiatrist did not warn the daughter of the danger, and the patient killed her. The plaintiff sued for the wrongful death and the court denied a motion for summary judgment, holding that facts asserted, if proved, demonstrated a duty on the part of the psychiatrist to warn the potential victim. The court placed strong reliance on the well-known and much discussed case of Tarasoff v. Regents of the University of California, 17 Cal.3d 425, 131 Cal.Rptr. 14, 551 P.2d 334 (1976), involving essentially similar facts, in which the Supreme Court of California found that there was a duty to warn the threatened person. The cases are distinguishable from this one, and we do not have to decide whether we would follow them. [7] The danger alleged in both was to a particular individual, and the claimed breach of duty was the failure to warn that individual. The present petition contains no allegation that the defendant physicians were aware that Corley posed a particular danger to the plaintiff's decedent. In the later case of Thompson v. County of Alameda, 27 Cal.3d 741, 167 Cal.Rptr. 70, 614 P.2d 728 (1980), the Supreme Court of California recognized the distinction between a mental patient who is known to pose a threat to a foreseeable or readily identifiable target and one who is alleged to be dangerous to the public generally. It distinguished Tarasoff in finding that Thompson did not involve a danger to any particular individual, and held that the defendants were not liable for negligent exercise of discretion. This case is similar to Thompson . The plaintiff also relies on Austin W. Jones & Co. v. State, 122 Me. 214, 119 A. 577 (1923), in which the state, which had consented to being sued in tort, was held liable for property damage caused by a fire set by an inmate released from a mental institution on parole. The opinion did not discuss the elements of discretion and judgment which inhere in any decision about the total or partial release of a mental patient, and we believe that cases such as Cairl v. State, supra , and Jarrett v. Wills, supra , are better reasoned. Mathes v. Ireland, 419 N.E.2d 782 (Ind. App.1981), and Semler v. Psychiatric Institute of Washington, D.C., 538 F.2d 121 (4th Cir.1976), rely on Section 319 of the Restatement (Second) of Torts, which has to do with the assumption of care and control of one known to be dangerous, and find liability with regard to the failure to restrain or the release of allegedly dangerous mental patients. The cases are distinguishable because Corley was involuntarily committed to the St. Joseph Hospital. Section 319 does not apply to the case before us. We likewise have little enthusiasm for the case of Grimm v. Arizona Bd. of Pardons and Paroles, 115 Ariz. 260, 564 P.2d 1227 (1977), in which the court held that the plaintiff was entitled to go to trial on the claim that the members of the parole board were reckless and grossly negligent in releasing a prisoner on parole, when the prisoner then killed the plaintiff's decedent during the course of a robbery. The dissenting opinion of Judge Hays seems more in line with the Missouri authorities and with principles which we consider sound. The approach in Martinez v. California, 444 U.S. 277, 100 S.Ct. 553, 62 L.Ed.2d 481 (1980), dealing with a similar question under 42 U.S.C. § 1983, also seems sounder to us. The Court relied primarily on the fact that the public official did not directly cause the damage, but expressed concern about the inhibitory effect of a finding of liability. [8] The Court of Appeals in the case before us recognized the rule of non-liability of public officials and employees for discretionary acts. It was willing to apply the rules to those in supervisory positions, but did not go far enough with the principle. Discretion relates not so much to the exercise of naked and unrestrained power as to the exercise of judgment. Although the statutes purport to make the superintendent responsible for determining the degree of detention or restriction to be imposed on involuntary patients, the treating physicians act on behalf of the superintendent in making decisions about particular patients. [9] There is little virtue in a rule which would immunize the persons on higher levels while holding the doctors who actually see the patients to civil liability to persons who are not their patients. We do not deal with the subject that was addressed in State ex rel. Eli Lilly & Co. v. Gaertner, supra . The major premise of that holding was that treating physicians at state hospitals should be liable to their patients for malpractice, just as private physicians are. We have no occasion to challenge this proposition, because we do not deal with the duty owed by a physician to a patient. Our holding has to do with the duty of the defendant physicians to the general public, as more fully explained in Part II(b) of this opinion. The Attorney General asks us to find that the acts of Corley, rather than the alleged negligence of the defendant physicians, were the proximate cause of the plaintiff's son's death. We are not willing to rest our decision on this ground. We assume, as alleged in the plaintiff's petition, that the jury could find that Corley was a dangerous person with severe mental illness, and could also find that danger to members of the public, including the plaintiff, could be reasonably anticipated if he were released. Cf. Virginia D. v. Madesco Hotel Co., 648 S.W.2d 881 (Mo. banc 1983). We nevertheless conclude that the defendant physicians should not be held liable for even foreseeable civil damages simply because they might be found to have exercised negligent professional judgment in permitting him to leave the premises. The decision to hold a person against his will is a very serious one, especially when the detainee has not been convicted of a crime. We believe that an actual holding of liability would have worse consequences than the possibility of actual mistake. 2 Fleming & James, supra, Sec. 29.10. Our conclusion seems consistent with the weight of modern authority.