Opinion ID: 2832576
Heading Depth: 5
Heading Rank: 5

Heading: The recognized serious possible risks,

Text: complications, and anticipated benefits involved in the treatment or surgical procedure, and in the recognized possible alternative forms of treatment, including non-treatment, then the standards shall be admissible as evidence of the standard of care required of the health care providers. 24  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  serious possible risks of harm and complications that the physician knew of or should have known[.]” Mroczkowski, 6 Haw. App. at 567, 732 P.2d at 1258; see also Keomaka v. Zakaib, 8 Haw. App. 518, 525, 811 P.2d 478, 483, cert. denied, 72 Haw. 618, 841 P.2d 1075 (1991) (holding that a physician owes a duty to disclose items set forth in HRS § 671-3(b), “including the ‘recognized serious possible risks’ and the ‘recognized possible alternative forms of treatment[]’”). 2. The Patient-Oriented Standard of Disclosure and Expert Testimony Requirements Nishi and HRS § 671-3 left unresolved the question of the standard applicable to the tort of a physician’s negligent failure to obtain informed consent, as well as the role of expert testimony in establishing a prima facie case of negligent failure to obtain informed consent. In Carr, 79 Hawaiʻi 475, 904 P.2d 489, this court addressed these issues. This court first expressly adopted the “patient- oriented standard” to govern whether a physician owes a duty to disclose a particular piece of information to a patient prior to treatment, overruling Nishi to the extent that it required a plaintiff to prove the applicable standard of disclosure of material risks prior to treatment by expert medical testimony. 79 Hawaiʻi at 485, 904 P.2d at 499. Recognizing that (1) Nishi was decided without the benefit of the seminal decision on the 25  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  patient-oriented standard of disclosure, Canterbury v. Spence, 464 F.2d 772 (D.C. Cir.), cert. denied, 409 U.S. 1064 (1972); (2) the informed consent doctrine had been codified; and (3) the growing nationwide trend favored the patient-oriented standard, this court held that the dispositive inquiry regarding a physician’s duty of disclosure in an informed consent case was no longer “what the physician believes his or her patient needs to hear in order for the patient to make an informed and intelligent decision[.]” 79 Hawaiʻi at 486, 904 P.2d at 500. Rather, “the focus should be on what a reasonable person objectively needs to hear from his or her physician to allow the patient to make an informed and intelligent decision regarding proposed medical treatment.” Id. This court therefore held, “a plaintiff is not required to prove the standard of disclosure required for informed consent with medical expert evidence[.]” 79 Hawaiʻi at 487, 904 P.2d at 501. In a footnote, this court differentiated between the standard of care and the standard of disclosure of material risks prior to treatment with respect to the necessity of expert testimony as follows: It is clear that the standard of care for a claim based on allegedly negligent medical treatment must be established by reference to prevailing standards of conduct in the applicable medical community and must be so proved by expert medical 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.” The 26  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  standard of disclosure of material risks prior to treatment, however, as we have discussed above, is capable of determination under the patient-oriented standard without reference to prevailing medical standards or medical judgment, although such evidence may, subject to a Hawaiʻi Rule of Evidence 403 balancing, be relevant and admissible. 79 Hawaiʻi at 485 n.6, 904 P.2d at 499 n.6 (internal citation omitted) (quoting Craft, 78 Hawaiʻi at 298, 893 P.2d at 149). Next, citing to the ICA’s decision in Bernard I, however, this court cautioned “that our adoption of the patientoriented standard does not relieve plaintiffs of their burden to provide expert medical testimony[,]” 79 Hawaiʻi at 486, 904 P.2d at 500 (citing Bernard I, 79 Hawaiʻi at 383, 903 P.2d at 688), “to establish the ‘materiality’ and/or the magnitude of the risk of harm that in fact occurs.” 79 Hawaiʻi at 486 n.7, 904 P.2d at 500 n.7. This court held that “a plaintiff maintains the burden of adducing expert medical testimony to establish ‘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.’” 79 Hawaiʻi at 486, 904 P.2d at 500 (quoting Bernard I, 79 Hawaiʻi at 383, 903 P.2d at 688). See also Barcai, 98 Hawaiʻi at 484, 50 P.3d at 960; Ray, 125 Hawaiʻi at 268, 259 P.3d at 584. In further support of the conclusion in Carr that expert testimony is required in informed consent cases, this 27  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  court cited the United States Court of Appeals for the District of Columbia’s decision in Canterbury, 464 F.2d 772. This seminal decision explained why expert testimony is critical in informed consent cases: Experts are ordinarily indispensable to identify and elucidate for the factfinder the risks of therapy and the consequences of leaving existing maladies untreated. They are normally needed on issues as to the cause of any injury or disability suffered by the patient . . . . Save for relative[ly] infrequent instances where questions of this type are resolvable wholly within the realm of ordinary human knowledge and experience, the need for the expert is clear. 464 F.2d at 791-92, quoted in Carr, 79 Hawaiʻi at 486, 904 P.2d at 500. In Barcai, this court reaffirmed our holdings concerning the “materiality” of the risk in informed consent cases. This court explained that “expert testimony will ordinarily be required” to establish the first aspect of “materiality” -- “the ‘materiality’ of the risks, i.e., ‘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.’”14 98 Hawai‘i at 484, 50 P.3d at 960 (emphasis added) 14 We note that expert testimony is not required in all situations. As stated infra, expert testimony is not required to determine what a reasonable patient needs to hear in order to make an informed decision regarding proposed medical treatment. In addition, expert testimony is ordinarily, but not universally required to rebut a defendant physician’s justification of nondisclosure on the basis of the therapeutic privilege exception. Barcai, 98 Hawaiʻi at 486, 50 P.3d at 962 (“[W]here [a] defendant physician justifies nondisclosure on the basis of the therapeutic privilege (continued . . . ) 28  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  (quoting Carr, 79 Hawaiʻi at 486, 904 P.2d at 500 (citing Bernard I, 79 Hawaiʻi at 383, 903 P.2d at 688)). This court then explained that, “[b]ecause lay jurors do not normally possess such information, it must be made available to them by an expert[,]” so that the jury can make a factual determination regarding the second aspect of “materiality” -- the materiality of the medical information to a patient’s decision, i.e., “whether a reasonable person would have wanted to consider the purportedly withheld information before consenting to the treatment.” Id. (citing 79 Hawai‘i at 486, 904 P.2d at 500). ( . . . continued) exception, expert testimony may be required to refute the contention.”). The therapeutic privilege exception “recognizes that, under some circumstances, disclosure of certain risks would not be in the patient’s best medical interests.” Carr, 79 Hawaiʻi at 480, 904 P.2d at 494. With regard to the necessity of expert testimony to rebut the therapeutic privilege exception, this court has stated: If the jury could evaluate the defendant physician’s testimony without specialized expert knowledge, no such expert testimony is needed and the jury should be instructed on the informed consent issue. . . . It is only when the particular facts associated with the physician’s rationale for withholding disclosure involve “medical facts” that expert testimony will be required to rebut the claim and allow the jury to consider an informed consent claim. 98 Hawaiʻi at 486 n.10, 50 P.3d at 962 n.10. Barcai further stated that “all of the Hawai‘i cases cited since Nishi-- and [] Canterbury, as well-- . . . repeatedly discuss the exception in the context of explicating ‘limits’ to the patient oriented standard, thereby suggesting that Hawai‘i appellate courts have intended this exception to remain applicable.” 98 Hawai‘i at 485 n.9, 961 n.9 (citations omitted). We discuss the exception as illustrative of the necessity of expert testimony in informed consent cases. We do not address the continued viability of the therapeutic privilege exception under the current iteration of HRS § 671- 3(b), as that issue is not before us. 29  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  The second aspect of materiality does not require expert testimony, although, as recognized by footnote 6 from Carr quoted above, expert testimony can also be helpful. Following Barcai, HRS § 671-3 was amended in 2003 (effective January 1, 2004) to integrate advances to legal and medical standards regarding the materiality of the risk of harm. See 2003 Haw. Sess. Laws Act 114, § 2 at 221-222; see also S. Stand. Comm. Rep. No. 1228, in 2003 Senate Journal, at 1547. HRS § 671-3 (Supp. 2003)15 mandated disclosure of specific 15 HRS § 671-3 (Supp. 2003) provided, in relevant part: (a) The board of medical examiners may establish standards for health care providers to follow in giving information to a patient, or to a patient’s guardian or legal surrogate if the patient lacks the capacity to give an informed consent, to ensure that the patient’s consent to treatment is an informed consent. The standards shall be consistent with subsection (b) and may include: (1) The substantive content of the information to be given; (2) The manner in which the information is to be given by the health care provider; and (3) The manner in which consent is to be given by the patient or the patient’s guardian or legal surrogate. (b) The following information shall be supplied to the patient or the patient’s guardian or legal surrogate prior to obtaining consent to a proposed medical or surgical treatment or a diagnostic or therapeutic procedure: (1) The condition to be treated; (2) A description of the proposed treatment or procedure; (3) The intended and anticipated results of the proposed treatment or procedure; (continued . . . ) 30  FOR PUBLICATION IN WEST’S HAWAII REPORTS AND PACIFIC REPORTER  information, in particular, “recognized material risks of serious complications or mortality[,]” as opposed to general standards of medical practice established by the board, and maintained the patient-oriented standard from Carr. See S. Stand. Comm. Rep. No. 1228, in 2003 Senate Journal, at 1547; see also H.B. 651, H.D. 2, 22d Leg., Reg. Sess. (2003) (prior version of bill that became the 2003 act amending HRS § 671-3(b) contemplated switching to a physician-oriented standard). In Ray, this court “interpreted HRS § 671-3(b) as supplying the standard for a physician’s duty to disclose information to the patient.” 125 Hawaiʻi at 266, 259 P.3d at 582. Under HRS § 671-3(b) (Supp. 2008), a physician’s duty to inform encompasses four separate duties: (1) the general duty to supply information about a proposed medical treatment or procedure embodied by HRS § 671-3(b)(1)-(3); (2) the duty to ( . . . continued) (4) The recognized alternative treatments or procedures, including the option of not providing these treatments or procedures; and (5) The recognized material risks of serious complications or mortality associated with: (A) The proposed treatment or procedure (B) The recognized alternative treatments or procedures; and (C) Not undergoing any treatment or procedure; and