Opinion ID: 1856826
Heading Depth: 1
Heading Rank: 2

Heading: Lack of Informed Consent Generally

Text: The requirement of consent to medical treatment was initially based on the idea that a competent person has the right to make decisions regarding his or her own body. As Justice Cardozo stated in Schloendorff v. Society of N.Y. Hosp., 211 N.Y. 125, 105 N.E. 92, 93 (1914), [e]very human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages. After the early cases struggled with the concept of consent that may be implied from the circumstances, including the patient's silence, there was a gradual development of a duty imposed on doctors to disclose information to the patient in order to afford the patient the opportunity of making an informed choice about proposed medical procedures. Significant litigation ensued concerning the scope of the doctor's duty to provide informed consent. In 1975, the Louisiana Legislature enacted La.Rev.Stat. 40:1299.40 A and B relative to informed consent to medical treatment, and Subsection C was added the following year. La.Rev.Stat. 40:1299.40 A-C now provide: A. (1) Notwithstanding any other law to the contrary, written consent to medical treatment means a consent in writing to any medical or surgical procedure or course of procedures which: sets forth in general terms the nature and purpose of the procedure or procedures, together with the known risks, if any, of death, brain damage, quadriplegia, paraplegia, the loss or loss of function of any organ or limb, of disfiguring scars associated with such procedure or procedures; acknowledges that such disclosure of information has been made and that all questions asked about the procedure or procedures have been answered in a satisfactory manner; and is signed by the patient for whom the procedure is to be performed, or if the patient for any reason lacks legal capacity to consent by a person who has legal authority to consent on behalf of such patient in such circumstances. Such consent shall be presumed to be valid and effective, in the absence of proof that execution of the consent was induced by misrepresentation of material facts. (2) In addition to the information required to be disclosed in Paragraph (1) of this Subsection, where the medical treatment involves the surgical implantation of Norplant contraceptive devices, the explanation to the patient shall include the known and significant or other material risks, the known adverse results, and alternative methods of contraception. B. Except as provided in Subsection A of this Section, no evidence shall be admissible to modify or limit the authorization for performance of the procedure or procedures set forth in such written consent. C. Where consent to medical treatment from a patient, or from a person authorized by law to consent to medical treatment for such patient, is secured other than in accordance with Subsection A above, the explanation to the patient or to the person consenting for such patient shall include the matters set forth in Paragraph (a) of Subsection A above, and an opportunity shall be afforded for asking questions concerning the procedures to be performed which shall be answered in a satisfactory manner. Such consent shall be valid and effective and is subject to proof according to the rules of evidence in ordinary cases. This court first addressed the informed consent statute in LaCaze v. Collier, 434 So.2d 1039 (La.1983). There, after several years of treatment for severe pelvic inflammatory disease, the patient accepted the doctor's recommendation of a hysterectomy. The patient signed two consent forms. The first was essentially blank, and the second listed only the type of surgery, without listing any risks or acknowledging that disclosures had been made or questions answered. After the surgery, a vesico-vaginal fistula developed, requiring additional surgery. The patient sued on the basis that the doctor made insufficient disclosure of the surgical risks to obtain a valid informed consent. This court held that the consent forms did not satisfy the statutory requirements, but concluded that the lack of informed consent did not give rise to any damages. This court reasoned that the patient failed to prove causation of the claimed damages because a reasonable person in the patient's position would have consented to the surgery even if the doctor had disclosed the risk that materialized. In Karl J. Pizzalotto, M.D., Ltd. v. Wilson, 437 So.2d 859 (La.1983), the doctor, after conservatively treating the patient's lower abdominal pain, prescribed exploratory abdominal surgery (laparotomy) to determine the cause of the pain. The consent form signed by the patient listed (1) Pelvic inflammatory disease, marked (2) endometriosis as the diagnosis and Laparotomy-Lysis of adhesions, Fulguration of endometrioma as the recommended procedure. Although the doctor noted probable salpingo-oophorectomy (the surgical removal of the ovary and its fallopian tube) on the admission chart, he did not inform the patient, who desired to have children, of this probability. During surgery, the doctor removed the patient's severely damaged reproductive organs, believing that the patient was sterile and that further pain would necessitate additional surgery. This court, concluding that the doctor removed the patient's reproductive organs without obtaining her implied or expressed consent to that operation, held that the doctor committed a battery and remanded the case to the court of appeal to determine the damages due for that tort. In Hondroulis v. Schuhmacher, 553 So.2d 398 (La.1988) (on rehearing), the patient consulted the doctor about low back pain that radiated into the hip and leg. After attempting conservative treatment, the doctor recommended a myelogram and a laminectomy. The consent form signed by the patient, essentially tracking the general risks stated in the statute, listed the risks of this procedure as anesthesia; death; brain damage; disfiguring scars; paralysis; the loss of or loss of function of body organs; and the loss or loss of function of any arm or leg. After the surgery, the patient experienced incontinency, constipation and numbness in the leg. She filed suit on the basis that she would not have undergone the surgery if she had been informed of these known material risks. This court first noted that: Where circumstances permit, the patient should be told the nature of the pertinent ailment or condition, the general nature of the proposed treatment or procedure, the risks involved in the proposed treatment or procedure, the prospects of success, the risks of failing to undergo any treatment or procedure at all, and the risks of any alternate methods of treatment. Id. at 411. Explaining further, this court stated: The determination of materiality [of a risk] is a two-step process. The first step is to define the existence and nature of the risk and the likelihood of its occurrence. Some expert testimony is necessary to establish this aspect of materiality because only a physician or other qualified expert is capable of judging that risk exists and the likelihood of occurrence. The second prong of the materiality test is for the trier of fact to decide whether the probability of that type harm is a risk which a reasonable patient would consider in deciding on treatment. The focus is on whether a reasonable person in the patient's position probably would attach significance to the specific risk. Id. at 412. Reversing a summary judgment in favor of the doctor, this court held that the issues of whether the loss of bladder control was a material risk which was not disclosed to the patient and whether a reasonable person in the patient's position would have refused the operation, had she been advised of the risk, were issues triable on the merits. Id. at 421-22. Liability in the Pizzalotto case was based on commission of a battery because the doctor, although obtaining consent to perform a laparotomy and to unbind the adhesions and fulgurate the endometrioma, performed other anticipated procedures for which he did not have consent. We deem it appropriate to clarify now the use of the term battery in the Pizzalotto case. While the early development of liability for failing to obtain informed consent was based on concepts of battery or unconsented touching, the imposition of liability in later cases has been based on breach of a duty imposed on the doctor to disclose material information in obtaining consent. Such a breach of duty by the doctor results in liability based on negligence or other fault. While perhaps the performance of a medical procedure without obtaining any kind of consent, in the absence of an emergency, technically constitutes a battery, [5] liability issues involving inadequate consent are more appropriately analyzed under negligence or other fault concepts. See W. Page Keeton et al, Prosser and Keeton on the Law of Torts 190 (5th ed. 1984) (Beginning around 1960, however, it began to be recognized that the matter was really one of the standard of professional conduct, and so negligence has now generally displaced battery as the basis for liability); 1 Fowler V. Harper et al., The Law of Torts § 3.10 & nn. 36-38 (3d ed. 1997) (The problem of informed consent is essentially one of professional responsibility, not intentional wrongdoing, and can be handled more coherently within the framework of negligence law than as an aspect of battery.); 4 Stuart M. Speiser et al., The American Law of Torts § 15.71 n. 21 (noting that more and more courts have turned to the theory of negligenceprofessional malpracticeas the basis for suits predicated on lack of informed consent); David W. Robertson et al., Cases and Materials on Torts 608 n. 1 (1989) (modern courts analyze the adequacy of consent as a question of negligence, not battery); 3 David W. Louisell & Harold Williams, Medical Malpractice § 22.03[2] (1997); Frank L. Maraist & Thomas C. Galligan, Jr., Louisiana Tort Law § 2-9(a) (1996) (most modern authorities now treat lack of informed consent as a negligence, i.e., malpractice matter); Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093 (1960); Woolley v. Henderson, 418 A.2d 1123 (Me.1980). The Louisiana Legislature has also specified the theory of recovery in lack of informed consent claims as properly based on traditional fault theories, apparently to bring such claims under the Medical Malpractice Act. By La. Acts 1990, No. 1093, the Legislature amended La.Rev.Stat. 40:1299.40 to add Subsection E, which establishes the Louisiana Medical Disclosure Panel to determine the risks and hazards related to medical care and surgical procedures that must be disclosed to the patient. Pertinent to the present discussion, Subsection 1299.40 E(2)(a) provides: In a suit against a physician or other health care provider involving a health care liability or medical malpractice claim which is based on the failure of the physician or other health care provider to disclose or adequately to disclose the risks and hazards involved in the medical care or surgical procedure rendered by the physician or other health care provider, the only theory on which recovery may be obtained is that of negligence in failing to disclose the risks or hazards that could have influenced a reasonable person in making a decision to give or withhold consent. (emphasis added). We therefore reject battery-based liability in lack of informed consent cases (which include no-consent cases) in favor of liability based on breach of the doctor's duty to provide the patient with material information concerning the medical procedure. Lack of Informed Consent in the Present Case In support of his contention that Dr. Dowling is liable for damages based on lack of informed consent, plaintiff testified he repeatedly informed Dr. Dowling prior to his cardiac incisional hernia repair that he wanted the doctor to use mesh to close the wound, believing that three of his four prior inguinal hernia repairs had failed because mesh was not used. According to plaintiff, Dr. Dowling promised he would use mesh in the operation and noted the use of mesh on the consent form, and Dr. Dowling never told plaintiff of any risks involved in using mesh or that a decision whether to use mesh would be reserved until during surgery. Had Dr. Dowling told him the decision whether to use mesh would only be made during surgery, plaintiff asserted he would have sought another doctor. This testimony was corroborated by plaintiff's wife. Dr. Dowling testified that he discussed the use of mesh with plaintiff and that its use was an option during surgery. The doctor stated he never committed to the use of mesh or promised it would be used, and if plaintiff had insisted on such a promise, he would have told plaintiff to find another surgeon. [6] He believed plaintiff understood that mesh was an option and that Dr. Dowling would make the decision whether to use mesh according to the conditions found during the surgery. Dr. Dowling insisted that he included similar language in every consent form for hernia repairs, meaning that he was authorized to use mesh if he determined during the surgery that its use was required. Plaintiff's wife testified that she asked Dr. Dowling immediately after the operation if he had used mesh, and he told her he had not because I don't like it. This testimony was corroborated by her daughter. Plaintiff testified that when he asked Dr. Dowling about the decision not to use mesh, Dr. Dowling stated he had sutured the hernia repair in such a way that the sutures would not fail. Dr. Dowling denied that he said he had used any special sutures or that he said the sutures would not fail. He also denied telling plaintiff's wife that he did not like to use mesh. The jury apparently accepted plaintiff's testimony, corroborated by that of his wife and daughter, that the doctor agreed to plaintiff's steadfast demand for the use of mesh and simply disregarded that agreement during the surgery. The plain language of the written consent form clearly supports the jury's determination. The term incisional hernia repair was sufficient to authorize that surgical repair using normal procedures within the surgeon's judgment; there was no necessity to use the words with mesh except to confirm the patient's request. An appellate court, in reviewing a jury's determination that a doctor failed to obtain the patient's informed consent, should focus on the duty of the doctor to provide material information to the patient under the circumstances of the particular case. Here, the patient, regardless of the validity of his conviction, believed that previous hernia repairs had failed because of the non-use of mesh and conditioned his consent to the surgery upon the use of mesh. Under the evidence viewed in the light most favorable to the party who prevailed before the trier-of-fact, the doctor understood and agreed to the condition, indicating that agreement in plain language on the written form. Under these circumstances, it was incumbent upon the doctor to explain to the patient the advantages and disadvantages in the use of mesh, the attendant risks, and the necessity of reserving the decision on the use of mesh to the surgeon during the course of the operation. The doctor, under the record-supported decision of the jury, failed to discharge that duty in this case. Accordingly, the doctor failed to obtain adequate informed consent to the surgery that he anticipated and performed, and deprived the patient of the opportunity to decide, with appropriate material information, whether he wanted to have the hernia repair only with mesh and to reject a medical procedure that he did not want. Because of the breach of duty, the doctor is liable for the damages caused by that breach of duty.