Opinion ID: 2588193
Heading Depth: 2
Heading Rank: 3

Heading: The Trial Court's Refusal to Instruct the Jury on the Tort of Negligent Failure to Obtain Informed Consent

Text: As a result of MMH's dismissal from the case and the dismissal of the false imprisonment and battery claims against Dr. Betwee, trial proceeded with respect to the medical negligence, NIED, and negligent failure to obtain informed consent claims against Dr. Betwee on October 7, 1997. Dr. Cohn testified that the treatment by Dr. Betwee fell below the standard of care because of his failure to diagnose NMS on June 12, 1990 (when Barcai was initially transferred to the medical ward) and again on June 25, 1990 (when Barcai's condition began to deteriorate rapidly) and that Barcai's death was caused by NMS. Dr. Cohn also testified that, on or around June 21, 1990, Dr. Betwee should have consulted again with the neurologist who saw Barcai earlier in the hospitalization. Dr. Cohn did not testify as to the incidence of NMS or as to any issue concerning informed consent. Dr. Betwee testified that NMS was a rare complication that can occur in patients taking antipsychotic medications. He conceded that, if a patient had NMS, the first step would be to stop administering antipsychotic medications. However, Dr. Betwee testified that he did not believe that Barcai suffered from NMS when he was initially admitted to MMH or at any time thereafter. Dr. Betwee began prescribing antipsychotic medications again on June 19, 1997 because Barcai's condition was deteriorating. For example, the evidence indicated, among other things, that Barcai: (1) claimed that the devil was outside of his room, that another patient was the devil, and that he himself was the devil; (2) after being found at 2:00 AM in the shower screaming fuck the devil, would not respond to anyone and subsequently refused to come out, curling up in a fetal position while claiming he was a baby; (3) repeatedly hid in a bathroom stall refusing to leave; (4) called police to complain that the nurses were poisoning him; (5) stretched out like a cross, murmuring Jesus; and (6) had to be placed, with resistance, in a locked seclusion room, whereupon he was found pacing with bedding wrapped over his head. With respect to the issue of informed consent, Dr. Betwee testified that he did not inform patients to whom he prescribed antipsychotic medication about the risk of NMS because it was a rare occurrence, one to three per thousand. Describing the information he typically disclosed to patients, Dr. Betwee testified as follows: [Defense Counsel]: When you are discussing these risks that do happened [sic] with the patient, is there a barrier sometimes because of their condition? [Betwee]: Oh, typically. If you are dealing with someone like any of us are in the courtroom, you can have a calm rationale [sic] discussion about things. If you're dealing with someone who says he's God or who is fearful of the nurses, then it's an entirely different matter. You still have to get some information across. You want people to know something about what's likely to happen with them. But people's ability to understand information is different. It may be different from time to time. So if people are getting neuroleptics, particularly the potent ones, things I will typically tell them are you may get these stiffness reactions that I described [earlier] and may demonstrate them to the patient. I will tell them what to do. If they are getting a low milligram potency drug, like Thorazine I may tell them to be careful and to stand up slowly because their blood pressure could fall and they could get dizzy, and I don't want them falling down. But typically not a lot more than that and [sic] people who are acutely ill in the hospital. The defense also presented the testimony of Gerard Addonizio, M.D. (Dr. Addonizio), the co-author of a book devoted exclusively to NMS. See supra note 1. Dr. Addonizio testified that Dr. Betwee's use of antipsychotic medication was necessary and met an acceptable standard of care. Dr. Addonizio further testified that Barcai's death was not caused by NMS and that he had absolutely no doubt that Barcai did not have NMS during the final days of his life. On the issue of informed consent, Dr. Addonizio testified that he does not advise his own patients of the risk of NMS because, first of all, it would scare them. And it is not a common event. It's a relatively rare event. And also patients who are getting neuroleptics where you're initiating neuroleptics are often very psychotic, and it would not be in their best interest to just further scare them and deter them from accepting needed medication. According to Dr. Addonizio, the accepted figure for the incidence of NMS among patients taking neuroleptics at the time of Barcai's hospitalization was between 0.1 to 0.8 percent. Like Dr. Addonizio, Richard Markhoff, M.D. (Dr. Markhoff), a psychiatrist and medical school professor, testified that he did not believe that Barcai died from NMS. Dr. Markhoff further testified that psychiatrists generally do not tell their patients about the risk of NMS because it is a rare event. At the conference to settle jury instructions, the defense objected to Plaintiffs' proposed instructions concerning negligent failure to obtain informed consent, essentially arguing that, because Plaintiffs did not present any testimony that Dr. Betwee had breached a standard of care in failing to disclose the risk of NMS, there was no evidence to support an informed consent claim and that the jury should not be allowed to consider it. Relying on Carr v. Strode, 79 Hawai`i 475, 904 P.2d 489 (1995), discussed infra, the trial court initially determined that sufficient evidence had been presented to allow the jury to decide whether a reasonable person would have wanted to be informed of the risk of NMS. However, the court subsequently accepted the defense's argument that Dr. Betwee had justified his nondisclosure of the risk of NMS on the basis of the therapeutic privilege exception, discussed infra, i.e., that it would have been harmful to Barcai to disclose the risk of NMS. Relying on Bernard v. Char, 79 Hawai`i 371, 383, 903 P.2d 676, 688 (App.1995) [hereinafter, Bernard I ], the trial court ruled that expert testimony was required to rebut Dr. Betwee's therapeutic privilege justification, and, because Plaintiffs had presented no such testimony, there was insufficient evidence to send the issue of informed consent to the jury. Consequently, over the objection of Plaintiffs, the trial court refused their proposed jury instructions on informed consent.
When jury instructions, or the omission thereof, are at issue on appeal, the standard of review is whether, when read together and considered as a whole, the instructions given are prejudicially insufficient, erroneous, inconsistent or misleading. Craft v. Peebles, 78 Hawai`i 287, 302, 893 P.2d 138, 153 (1995) (citations omitted).
Plaintiffs contend that the trial court erred in refusing to instruct the jury concerning the tort of negligent failure to provide informed consent. Specifically, Plaintiffs claim that Dr. Betwee never properly established at trial the therapeutic privilege exception to the requirement that informed consent be obtained before starting Barcai on antipsychotic medication. We agree. Physicians have an obligation to obtain the informed consent of their patients before administering diagnostic and treatment procedures. See Carr v. Strode, 79 Hawai`i 475, 479, 904 P.2d 489, 493 (1995). The elements of informed consent commonly consist of ensuring that the patient consents to the prescribed procedure only after being made aware of the: (1) condition being treated; (2) nature and character of the proposed treatment or surgical procedure; (3) anticipated results; (4) recognized possible alternative forms of treatment; and (5) recognized serious possible risks, complications, and anticipated benefits involved in the treatment or surgical procedure, as well as the recognized possible alternative forms of treatment, including non-treatment. See HRS § 671-3 (1993). In addition, the law requires that written informed consent be obtained from psychiatric patients before providing non-emergency psychiatric treatment. See HRS § 334E-1 (1993). The rendering of professional medical services without informed consent is a tort. HRS § 671-1(2) (1993). Claims for negligent failure to obtain informed consent typically arise when a plaintiff patient alleges that the defendant physician failed to warn the patient of a particular risk associated with the procedure and the particular risk ultimately occurred. To establish a claim of negligent failure to obtain informed consent under Hawai`i law, the plaintiff must demonstrate that: (1) the physician owed a duty to disclose the risk of one or more of the collateral injuries that the patient suffered; (2) the physician breached that duty; (3) the patient suffered injury; (4) the physician's breach of duty was a cause of the patient's injury in that (a) the physician's treatment was a substantial factor in bringing about the patient's injury and (b) a reasonable person in the plaintiff patient's position would not have consented to the treatment that led to the injuries had the plaintiff patient been properly informed; and (5) no other cause is a superseding cause of the patient's injury. Bernard v. Char, 79 Hawai`i 362, 365, 371, 903 P.2d 667, 670, 676 (1995) [hereinafter, Bernard II ]. In order to determine whether a physician owes a duty to disclose a particular piece of information to the patient, this court, relying upon the seminal case of Canterbury v. Spence, 464 F.2d 772, reh'g denied, 464 F.2d 772 (D.C.Cir.1972), cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (1972), has adopted the patient oriented standard. See Carr v. Strode, 79 Hawai`i 475, 480, 485, 904 P.2d 489, 494, 499 (1995); accord Bernard II, 79 Hawai`i at 365, 903 P.2d at 670. The patient oriented standard requires a physician to disclose what a reasonable patient needs to hear from his or her physician in order to make an informed and intelligent decision regarding treatment.... Carr, 79 Hawai`i at 484, 904 P.2d at 498. Under the patient standard, expert testimony is not critical to demonstrate the amount of information a patient needs in order to intelligently decide between two treatment options. The decision as to what procedure to undergo is ultimately the patient's; to impose a standard of disclosure dictated by experts would be to undermine the decision-making power of patients in similar situations. Therefore, in proving the element of duty for informed consent purposes, a patient is not required to produce any expert medical testimony regarding what other reasonable [physicians] would have disclosed under the same or similar circumstances. Id. (citing Bernard I, 79 Hawai`i at 382, 903 P.2d at 687) (underscored emphasis in original) (bold emphasis added). [7] However, typically, expert testimony is necessary in informed consent cases. In particular, expert testimony will ordinarily be required to establish the materiality of the risks, i.e., the nature of risks inherent in a particular treatment, the probabilities of therapeutic success, the frequency of the occurrence of particular risks, and the nature of available alternatives to treatment. Carr, 79 Hawai`i at 486, 904 P.2d at 500 (citing Bernard I, 79 Hawai`i at 383, 903 P.2d at 688). Because lay jurors do not normally possess such information, it must be made available to them by an expert in order that they can determine the factual question whether a reasonable person would have wanted to consider the purportedly withheld information before consenting to the treatment. See Carr, 79 Hawai`i at 486, 904 P.2d at 500. The plaintiff, however, need not necessarily provide such expert testimony; the requisite foundation can be established by the defendant's expert testimony. See id. at 487, 904 P.2d at 501. As discussed infra, expert testimony may, depending on the circumstances, also be required to refute the existence of the therapeutic privilege exception to the duty to disclose relevant information. This exception to the duty to completely inform a patient of all of the risks attendant to a particular treatment was first articulated in Nishi v. Hartwell, 52 Haw. 188, 473 P.2d 116, reh'g denied, 52 Haw. 296, 473 P.2d 116 (1970). [8] In Nishi, the plaintiff was paralyzed from the waist down by the injection of a contrast dye used to obtain an x-ray of his thoracic aorta. See id. at 190, 473 P.2d at 118. One of the treating physicians testified that the plaintiff was never informed that paralysis was a potential side effect because, inter alia, it would have been a terrible mistake due to the fact that he was in pain, frightened and apprehensive about his condition, had serious heart disease and hypertension, and the physician felt that disclosure of a side effect with such a minimal risk would make matters worse. See id. at 193, 473 P.2d at 120. The plaintiff did not present any evidence to refute this contention, and the trial court directed a verdict at the close of the plaintiff's case. See id. at 195-96, 473 P.2d at 121. This court affirmed the trial court, holding that the uncontradicted evidence brought defendants' omission to disclose clearly within the exception to the duty of full disclosure which excuses the withholding of information for therapeutic reasons. Id. at 195, 473 P.2d at 121. In Canterbury, the United States Court of Appeals for the District of Colombia, citing Nishi, among others, described the therapeutic privilege exception as follows: The [therapeutic privilege] exception obtains when risk-disclosure poses such a threat of detriment to the patient as to become unfeasible or contraindicated from a medical point of view. It is recognized that patients occasionally become so ill or emotionally distraught on disclosure as to foreclose a rational decision, or complicate or hinder the treatment, or perhaps even pose psychological damage to the patient. Where that is so, the cases have generally held that the physician is armed with a privilege to keep the information from the patient, and we think it clear that portents of that type may justify the physician in action he deems medically warranted. The critical inquiry is whether the physician responded to a sound medical judgment that communication of the risk information would present a threat to the patient's well-being. Canterbury, 464 F.2d at 789 (footnotes omitted). Similarly, the ICA has stated: Clearly it will not in every case be in the patient's own best interest to be told all the bad results that might possibly attend a course of treatment. Some patients are so likely to exaggerate their fears out of all proportion to reality that their power of free choice will be destroyed rather than informed; some are likely to be unreasonably deterred from treatment they desperately need. Bernard I, 79 Hawai`i at 383, 903 P.2d at 688; see also Leyson v. Steuermann, 5 Haw.App. 504, 513-514, 705 P.2d 37, 45 (relying upon Prosser and Keeton, The Law of Torts, § 32 at 192 (5th ed.1984), to identify, inter alia, a therapeutic privilege exception to the duty to obtain informed consent), [9] overruled on other grounds by Bernard II, 79 Hawai`i at 371, 903 P.2d at 676. Our cases have suggested that expert testimony is ordinarily required to rebut a defendant physician's claim asserting the therapeutic privilege exception. See Bernard I, 79 Hawai`i at 383, 903 P.2d at 688 (expert testimony as to the proper medical standards of disclosure will be required where a physician justifies his or her nondisclosure of risks to a patient on the basis of the therapeutic privilege exception); cf. Carr, 79 Hawai`i at 485, 904 P.2d at 499 (noting that, barring situations where the therapeutic privilege exception to the physician's duty to disclose is applicable, expert testimony is not needed to resolve the question of what an individual patient reasonably needs to hear in order to make an informed choice regarding the proposed medical treatment). Requiring expert testimony to rebut a claim of therapeutic privilege is nothing more than a specific application of the well-established rule that [t]he standard of care to which a doctor has failed to adhere [in ordinary medical negligence actions] must be established by expert testimony because a jury generally lacks the requisite special knowledge, technical training, and background to be able to determine the applicable standard without the assistance of an expert. Craft, 78 Hawai`i at 298, 893 P.2d at 149 (citing Rosenberg v. Cahill, 99 N.J. 318, 492 A.2d 371, 374 (1985)) (citations and internal quotation marks omitted). [10] Furthermore, as the ICA has stated: Although [exceptions to the duty to obtain informed consent] are not defenses and are a part of the definition of the duty [to obtain informed consent], the defendant-physician has the initial burden of going forward with evidence pertaining to them. If and when the physician meets that burden, however, the plaintiff-patient has the ultimate burden of proving their nonexistence. Leyson, 5 Haw.App. at 516, 705 P.2d at 45 (citing Canterbury, 464 F.2d at 791). Thus, where the defendant physician justifies nondisclosure on the basis of the therapeutic privilege exception, expert testimony may be required to refute the contention. In this case, the testimony generally placed the risk of developing NMS at one to eight per thousand for any given individual who takes antipsychotic medication. [11] Therefore, as an initial matter, we believe that, under Carr, the trial court was correct in its initial determination that the question whether Dr. Betwee owed a duty to disclose the risk of developing NMS was one properly for the jury. [12] However, the trial court ruled that Dr. Betwee had established the therapeutic privilege exception to justify his nondisclosure of the risk of developing NMS to Barcai. Because there was no competing expert testimony upon which the jury could evaluate Dr. Betwee's claim of therapeutic privilege, the court refused to allow an informed consent instruction inasmuch as it believed that the uncontradicted expert testimony established that it would have been harmful to Barcai to hear the information. Plaintiffs, however, contend that, at trial, Dr. Betwee never properly established the therapeutic privilege exception. Plaintiffs submit that Dr. Betwee's generic statement that he never tells any of his patients about the risk of developing NMS is insufficient to assert this privilege because the therapeutic privilege exception is a factual issue specific to a particular patient. Plaintiffs point out that none of the expert witnesses testified specifically that it would have been harmful to Barcai to receive this information. Plaintiffs also correctly point out that requiring expert testimony to rebut a generic assertion of therapeutic privilege would allow the exception to swallow the general rule that expert testimony is not necessary for a jury to decide whether a reasonable person would have wanted to be informed of a particular risk. If, for example, all a physician had to do to assert the privilege was to claim that he or she never told patients of a particular risk because the risk would scare them, it would eviscerate the patient oriented disclosure standard because expert testimony would always be required to rebut such a general claim. Moreover, in discussing the therapeutic privilege exception, the court in Canterbury noted: The physician's privilege to withhold information for therapeutic reasons must be carefully circumscribed, however, for otherwise it might devour the disclosure rule itself. The privilege does not accept the paternalistic notion that the physician may remain silent simply because divulgence might prompt the patient to forego therapy the physician feels the patient really needs. That attitude presumes instability or perversity for even the normal patient, and runs counter to the foundation principle that the patient should and ordinarily can make the choice for himself. Canterbury, 464 F.2d at 789. Thus, in order to assure that the use of the therapeutic privilege exception is carefully circumscribed, the trial court should ensure that the defendant physician who claims the privilege expressly testifies that his or her decision to withhold information was based on specific considerations in the individual patient's case and identify those considerations. In this case, the defense maintains that the evidence established the therapeutic privilege because: (1) Dr. Betwee testified that acutely ill patients often are unable to adequately understand detailed information; and (2) Barcai's paranoia and fear of the nursing staff supports the conclusion that it would have been harmful to disclose information about NMS to Barcai. Indeed, Dr. Betwee, in relating his general disclosure practice, discussed as a hypothetical patient someone who says he's God or who is fearful of the nurses.... See supra at ___, 50 P.3d at 958. Although describing his practice generally, Dr. Betwee's testimony arguably could be interpreted as indicating that he believed Barcai, who exhibited behaviors similar to the hypothetical patient, was unable to adequately understand detailed information about NMS and that, therefore, disclosure of such information to him might be harmful. Certainly, Dr. Betwee's testimony is not inconsistent with this claim. However, as discussed above, given the need to carefully circumscribe the therapeutic privilege exception, we conclude that Dr. Betwee's testimony fell short of establishing the privilege in Barcai's case where Dr. Betwee did not expressly testify that his decision to withhold information was based on specific considerations in Barcai's case and did not identify those considerations. Moreover, although we recognize that the claim of privilege is not an affirmative defense and that the burden of rebutting such a claim remains with the Plaintiffs, we believe it would be unfair to penalize Plaintiffs for not having expert testimony available to rebut this claim when it is raised for the first time during trial. See, e.g., Rules of the Circuit Courts of the State of Hawai`i (RCCH) Rule 12(b)(3) (2000) [13] and Rule 12(h) (2000) (requiring defendants to file a responsive pretrial statement that includes all defenses advanced ... and the type of evidence expected to be offered in support thereof); RCCH Rule 12.1(b)(2)(iv) (2000) (requiring defendants to set forth, in their settlement conference statement, their defenses to each theory of liability). Throughout Dr. Betwee's answers to interrogatories and in his deposition testimony, as well as in the defense's trial statement, settlement conference statements, and memorandum in opposition to Plaintiffs' proposed jury instructions, no mention is made of this claim. Accordingly, we hold that the trial court erred in finding that Dr. Betwee had established the therapeutic privilege exception and, as a result, also erred in refusing the informed consent instruction. [14]