Opinion ID: 1707689
Heading Depth: 5
Heading Rank: 3

Heading: failure to present a triable issue of fact regarding absence of informed consent

Text: Palmer also claims that Wooten failed to inform Patricia or her family of the risks involved in the surgery. The trial judge determined  though without explanation  the claim was not sufficiently substantiated to defeat the motion for summary judgment on this issue. The doctrine of informed consent represents the application to medical practice of principles of tort law. Thus, when a lack of informed consent is claimed, the plaintiff has the burden to prove by a preponderance each element of the prima facie case: duty, breach of duty, proximate causation, and injury. Hull, 516 So.2d at 492 (providing a detailed discussion on historical aspects of the informed consent doctrine and its development in Mississippi); see also P. APPELBAUM, C. LIDZ & A. MEISEL, INFORMED CONSENT: LEGAL THEORY AND CLINICAL PRACTICE 123 (1979). When a physician-patient relationship exists, the physician owes the patient a duty to inform and obtain consent with regard to the proposed treatment. APPELBAUM, LIDZ & MEISEL, supra, at 123-24. Proving breach of duty requires more than mere allegation that the physician did not obtain informed consent. For example, if the plaintiff's allegation ( i.e., that her consent was not informed consent) is based on a failure to understand the information provided by the physician prior to being administered treatment, then she may need to show the information was too complex or too vague. Basically, this is a question of adequacy of the information provided. In a recent case, this Court delineated a disclosure checklist which should be useful in scrutinizing adequacy of information. Hull, 516 So.2d at 493. Pursuant to this list, a medical practitioner should disclose to a patient (or to the patient's guardian or representative): (1) a diagnosis, (2) nature and purpose of the treatment, (3) risks and consequences, (4) probable success of the treatment, (5) alternatives, and (6) prognosis if the treatment is not administered. Applicability of each item may shift from case to case, depending upon the particular facts. See 11B P. LASKY, HOSPITAL LAW MANUAL: CONSENT TO MEDICAL AND SURGICAL PROCEDURES 38-39, cited in Hull, 516 So.2d at 493. Evidence that the physician complied with the checklist (or some variation) may be sufficient to defeat a claim of informational vagueness; however, a question may still remain with regard to informational complexity. The California Supreme Court aptly noted that the patient's interest is not in a lengthy polysyllabic discourse, but in provision of relevant information in lay terms. Cobbs v. Grant, 8 Cal.3d 229, 104 Cal. Rptr. 505, 502 P.2d 1 (1972); see also Gray v. Grunnagle, 423 Pa. 144, 223 A.2d 663 (1966) (Supreme Court held that consent was invalid because terminology used to obtain consent was too complex for patient to understand). If the allegation of lack of informed consent is based on incompetency, the plaintiff may need to show, for example, that she was under the influence of an anesthetic when infomation was provided and consent obtained. See, e.g., Demers v. Gerety, 85 N.M. 641, 515 P.2d 645 (Ct.App. 1973) (consent invalid because obtained after awakening patient in middle of the night; patient had been administered sleeping pills earlier and was groggy when awakened); see Cahal & Cody, Consent and the Groggy Patient, 40 GENERAL PRACTITIONER 195 (1969). If lack of informed consent is based on involuntariness, the plaintiff may need to show, for example, that she was pressured into signing a consent form or was under duress when consent was obtained. APPELBAUM, LIDZ & MEISEL, supra, at 179. Recovery under the informed consent doctrine is circumscribed by numerous affirmative defenses. For example, the physician may not be required to inform the patient of unexpected [20] or immaterial [21] risks. Obtaining informed consent may not be necessary under circumstances involving an emergency ( e.g., life or death situation), [22] incapacity ( e.g., unconscious patient), [23] waiver ( e.g., patient waived right to receive information), [24] and therapeutic privilege ( e.g., disclosure would be harmful to patient). [25] Once proof of duty and breach of that duty is provided, the plaintiff is required to produce evidence of two subelements of causation. First, the plaintiff must show that a reasonable patient would have withheld consent had she been properly informed of the risks, alternatives, and so forth. Hull, 516 So.2d at 493 (reaffirming Mississippi's adoption of the objective test); APPELBAUM, LIDZ & MEISEL, supra, at 121. And second, the plaintiff must show that the treatment was the proximate cause of the worsened condition ( i.e., injury). That is, the plaintiff must show that she would not have been injured had the appropriate standard of care been exercised. Generally, proof of the latter sub-element requires expert testimony that the defendant's conduct  not the patient's original illness or injury  led to the worsened condition. In the case sub judice, Palmer claimed lack of informed consent, but failed to produce any evidence of the doctrine's four elements. Conversely, the record contains two documents entitled: Authorization for Medical and/or Surgical Treatment. Palmer's signature is affixed to both documents, which expressly authorized Wooten to make an impression of Patricia's teeth and to repair her fractured jaw. These documents also include a declaration by Palmer, who considers herself to be a medical expert, that she fully understand[s] ... the reasons why [Patricia's] surgery is considered necessary, its advantages and possible complications, if any, as well as possible alternative modes of treatment, which were explained to me by Dr. James Wooten. Admittedly, the documents do not reveal the specific information disclosed and whether the information was adequate; however, the documents constitute some evidence supporting Wooten's claim that informed consent was indeed obtained. In another medical malpractice case before this Court, such evidence may have defeated a plaintiff's claim that her physician failed to obtain informed consent prior to negligently performing tubal ligation. In Phillips v. Hull , the physician successfully moved for summary judgment on the issues of surgical negligence and failure to obtain informed consent. On appeal, this Court reversed in part on the issue of informed consent because [n]o form in the record indicates the patient's consent was in fact an informed consent. 516 So.2d at 494 (emphasis added). [I]n the absence of any documentary evidence substantiating [the physician's] claim of having obtained [his patient's] `informed' consent for the operation, this Court [can]not find that `the strength of [the movant's] showing is such that [she] is entitled to summary judgment as a matter of law.' Id. (emphasis added and citation omitted). In the case sub judice, Wooten clearly met his burden of persuasion by introducing documentary evidence indicating informed consent was obtained from Palmer, a self-proclaimed expert on oral surgery. Palmer's mere allegation to the contrary is insufficient rebuttal. Assuming, arguendo, that Wooten breached his duty to obtain informed consent, then evidence in the record must reflect a causal connection between breach of that duty and the death of Patricia. Reikes v. Martin, 471 So.2d 385, 392 (Miss. 1985), cited in Hull, 516 So.2d at 493. As discussed in the preceding subsection, Palmer has produced no significant, probative evidence showing a causal connection between the repair of Patricia's fractured jaw and her subsequent cardiac arrest. Thus, without more, this Court cannot conclude that summary judgment on this issue was improperly granted.