Opinion ID: 499726
Heading Depth: 3
Heading Rank: 1

Heading: The duty of care and its breach

Text: 9 The four principal components of the duty of care element are that 1) there exists a sufficiently close doctor-patient relationship, 2) the information subject to disclosure is known or reasonably should have been known by the doctors, 3) the information is such that the doctors should reasonably recognize that it would be material to the plaintiff's decision whether to forego treatment, and 4) the doctors failed to disclose the material information. Halley v. Birbiglia, 390 Mass. 540, 458 N.E.2d 710, 715 (Mass.1983). 10 We find sufficient evidence for the jury to have found that the doctor-patient relationship was sufficiently close to impose a duty to inform as to both defendants. The fact that Dr. Lofgren was the surgeon in charge of the operation is alone enough to make the relationship sufficiently close. See Harnish, 439 N.E.2d at 244. Dr. Remensnyder also had a similar duty of care because he admitted Kissinger into Mass. General, advised the patient prior to the operation, and assisted Lofgren during surgery. See Halley, 458 N.E.2d at 715. 11 Secondly, expert testimony sufficiently established that the doctors knew or reasonably should have known that chronic pain was one consequence of a severe injury to the infraorbital nerve occurring during the Caldwell-Luc operation. Dr. Gregory F. O'Brien, an otolaryngologist, testified for the plaintiff that the risk of injury to the nerve is known or reasonably should be known by every physician who performs that kind of operation. Dr. Remensnyder himself admitted that such an injury is a known risk of the Caldwell-Luc procedure. Dr. O'Brien also opined that chronic pain is a consequence of a severe injury to the nerve that should be communicated to the patient before surgery. The additional fact that both defendants had prior experience with the Caldwell-Luc procedure lends support to a finding that they knew or reasonably should have known of its risks and consequences. 12 The third component of the duty of care analysis, the materiality of the information, lies at the crux of this case. Dr. Lofgren complains that the evidence was insufficient to go to the jury on this question. Whether the evidence was legally sufficient to sustain the verdict is determined by the meaning of materiality under Massachusetts law. According to the Massachusetts Supreme Judicial Court, information is material when a physician reasonably should recognize it as necessary for his patient to make an informed decision whether to forego proposed treatment. Harnish, 439 N.E.2d at 743. Certain risks inherent in any operation, such as infections, should reasonably be known to every patient and need not be disclosed. Id. Other risks which are possible, but remote or unforeseeable due to their negligible probability of occurrence, are immaterial as a matter of law. See Precourt, 481 N.E.2d at 1148-49. 13 In Precourt, there was an absence of expert testimony as to whether a degenerative bone disorder (aseptic necrosis) was a foreseeable result of a course of treatment with the drug Prednisone. Expert testimony that the risk of contracting aseptic necrosis was high if the medication was taken in high doses, during a long course of therapy, was deemed speculative by the Court. Id. at 1149. Despite evidence to the effect that aseptic necrosis was one of the most prominent musculoskeletal complications of Prednisone, it was inappropriate to submit the materiality issue to the jury in the absence of expert testimony as to the actual likelihood of that risk occurring. Precourt did not consider, however, whether the materiality analysis requires an expert to assess the risk of occurrence in terms of numerical data and we refuse to adopt such a rule. 1 14 In this case the jury had evidence from which to find the likelihood of occurrence of the harm. There was ample evidence that the risk of injury to the nerve was substantial, a known risk, and one that requires warning the patient. 2 It also was uncontroverted that the injury could produce ill effects ranging from numbness to severe pain. In addition there was evidence that the risk of severe pain was not remote, that an otolaryngologist had seen instances of severe injury in his practice, and that it happened often enough that a facial pain expert treated many dozens of patients who were in Kissinger's same shoes. This kind of testimony is much less tenuous than the statement that a long course of treatment, with high dosages, creates a high risk of injury, as in Precourt. In light of the expert testimony that injury to the nerve is not a freak accident of the Caldwell-Luc procedure, it became the jury's responsibility to decide whether that peril was of sufficient magnitude to bring the disclosure duty into play. Canterbury v. Spence, 464 F.2d 772, 794 (D.C.Cir.), cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (1972). 15 Dr. Remensnyder argues that the charge to the jury with regard to the materiality issue was erroneous. The court, tracking the language in Precourt, supra, instructed the jury:The materiality of information about a potential injury is a function not only of the severity of the injury but also of the likelihood that it will occur. Regardless of the severity of a potential injury, if the probability that the injury will occur is so small as to be practically nonexistent, then the possibility of that injury occurring cannot be considered a material factor in a rational assessment of whether to engage in the activity that exposes one to the potential injury. 16 A severe consequence ordinarily of interest to the patient would not require disclosure if the chance of the consequence occurring was so remote as to be negligible. Likewise, no disclosure would be required of a very minor consequence even though the probability of occurrence was high. 17 The obligation to give adequate information does not require the disclosure of all risks of a proposed therapy. The remotely possible risks of a proposed treatment may be also without limit, and a physician is not required to inform a patient of remote risks. 18