Opinion ID: 2090215
Heading Depth: 1
Heading Rank: 4

Heading: Sorting Out Causes of Action

Text: Ms. Belin urges that there is a proper cause of action for breach of contract when a physician promises to fulfill a particular surgical function but fails to do so, resulting in harm, and that that action is independent of any negligence on anyone's part. Her point is that Dr. Magnuson made a mistake in cutting and clipping the common bile duct which, even if not negligent, might not have been made had the cutting and clipping been done by Dr. Dingle, a more experienced surgeon. Dr. Dingle contends that Maryland should not recognize, under any theory, a claim for `ghost surgery' against a physician arising out of an alleged agreement regarding the role a resident is to play during a surgical procedure. At the very least, he contends, such a claim should not be permitted as part of an action for lack of informed consent or breach of contract. Creating a duty to disclose a resident's precise role, he warns, would permit patients to choreograph how an operation is to be performed negating all possibility of informed medical judgment occurring during the operation. The courts, in proper cases, have recognized a number of different causes of action that might lie against a health care provider when a medical procedure or course of therapy produces unintended and harmful results or fails to produce the positive results reasonably anticipated by the patient. These actions, often bearing the common appellation of malpractice, differ in their underlying theory, in some of the elements that must be proved, and in the kind of damages that may be recovered. Most are tort-based, sounding either in battery or in negligence of one kind or another, and, occasionally, in misrepresentation or fraud; some are contractbased. When they are pursued either alternatively or in combination, care must be taken to keep the actions separate and not to allow the theories, elements, and recoverable damages to become improperly intertwined. We have long recognized, as have most courts, that, except in those unusual circumstances when a doctor acts gratuitously or in an emergency situation, recovery for malpractice is allowed only where there is a relationship of doctor and patient as a result of a contract, express or implied, that the doctor will treat the patient with proper professional skill and the patient will pay for such treatment, and there has been a breach of professional duty to the patient. Hoover v. Williamson, 236 Md. 250, 253, 203 A.2d 861, 862 (1964). The relationship that spawns the malpractice claim is thus ordinarily a contractual one. Largely because of the greater facility offered by tort-based actions for recovering damages for non-economic losspredominantly pain, suffering, and disfigurementmalpractice actions have traditionally been tort-based, the tort arising from the underlying contractual relationship. See Schaefer v. Miller, 322 Md. 297, 587 A.2d 491 (1991). [1] The traditional action has been for negligence in the performance (or nonperformance) of a course of therapy or a medical procedure. [2] The negligence consists of the breach of the duty that a physician has to use that degree of care and skill which is expected of a reasonably competent practitioner in the same class to which [the physician] belongs, acting in the same or similar circumstances. Shilkret v. Annapolis Emergency Hosp., 276 Md. 187, 200, 349 A.2d 245, 252 (1975). To recover in such an action, the plaintiff must show that the doctor's conductthe care given or withheld by the doctorwas not in accordance with the standards of practice among members of the same health care profession with similar training and experience situated in the same or similar communities at the time of the act (or omission) giving rise to the cause of action. See Maryland Code, § 3-2A-02(c) of the Courts and Judicial Proceedings Article. That action necessarily focuses on the manner in which the physician diagnosed and treated the patient's medical problem and, except as it may bear on other issues, such as contributory negligence, causation, or damages, not so much on what was told to the patient or what the patient's expectations may have been. In Sard v. Hardy, 281 Md. 432, 379 A.2d 1014 (1977), we recognized, as a separate negligence-based (rather than batterybased) cause of action, the performance of a medical procedure by a physician without the informed consent of the patient. In the course of her third pregnancy, the plaintiff, Ms. Sard, informed her gynecologist, Dr. Hardy, that, in light of her two previous pregnancies, which resulted in Caesarean section deliveries, she did not wish to become pregnant again and requested that she be sterilized. In an attempt to achieve that result, the doctor performed a bilateral tubal ligation in the course of delivering the third child by means of a Caesarean section. That procedure proved ineffective, however, and Ms. Sard became pregnant for the fourth time. She sued Dr. Hardy for failing to inform her that (1) the tubal ligation might not succeed in preventing future pregnancies, (2) other sterilization procedures were available, (3) there were methods of performing a tubal ligation other than the one Dr. Hardy used, that had a lesser risk of failure, and (4) the procedure he used had a lesser risk of failure if not performed contemporaneously with a Caesarean section. The case raised, for the first time in Maryland, the nature of an action based on a lack of informed consent. The underlying premises of an action for conducting a medical procedure without obtaining the patient's informed consent are that (1) the decision to undergo an elective medical procedure rests with the patient, who, if competent, retains the right to exercise control over his or her body, (2) a physician therefore has no right to subject a competent patient to a medical procedure without the patient's consent, (3) the patient will ordinarily be unable to make an intelligent decision whether to proceed without a clear and adequate explanation by the physician of the nature, benefits, and risks of, and alternatives to, the contemplated procedure, and (4) the physician therefore has a duty, before proceeding, to provide that explanation and obtain the patient's informed consent. We stated in Sard: Simply stated, the doctrine of informed consent imposes on a physician, before he subjects his patient to medical treatment, the duty to explain the procedure to the patient and to warn him of any material risks or dangers inherent in or collateral to the therapy, so as to enable the patient to make an intelligent and informed choice about whether or not to undergo such treatment. Id. at 439, 379 A.2d at 1020. See also Wright v. Johns Hopkins Health, 353 Md. 568, 728 A.2d 166 (1999); Faya v. Almaraz, 329 Md. 435, 450 n. 6, 620 A.2d 327, 334 n. 6 (1993). Unlike the traditional action of negligence, a claim for lack of informed consent focuses not on the level of skill exercised in the performance of the procedure itself but on the adequacy of the explanation given by the physician in obtaining the patient's consent. In Sard, we adopted a general, rather than a professional standard in that regard and, quoting from Cobbs v. Grant, 8 Cal.3d 229, 104 Cal.Rptr. 505, 502 P.2d 1, 10 (1972), we determined that the explanation must be measured by the patient's need, and that need is whatever is material to the decision. Thus, we continued, the test for determining whether a potential peril must be divulged is its materiality to the patient's decision. Sard, at 443-44, 379 A.2d at 1022. Although, as in Sard v. Hardy , claims based on lack of informed consent usually involve allegations that the physician failed to make adequate disclosure of a material risk or collateral effect of the contemplated procedure or of an available alternative not carrying that risk or effect, the duty is not so limited. Risks, benefits, collateral effects, and alternatives normally must be disclosed routinely, but other considerations, at least if raised by the patient, may also need to be discussed and resolved. See Aaron D. Twerski & Neil B. Cohen, The Second Revolution in Informed Consent: Comparing Physicians to Each Other, 94 NW. U.L.REV. 1 (1999); Johnson v. Kokemoor, 199 Wis.2d 615, 545 N.W.2d 495 (1996). One of those considerations, in an expanding era of more complex medical procedures, group practices, and collaborative efforts among health care providers, may be who, precisely, will be conducting or superintending the procedure or therapy. This may be especially important with respect to surgical procedures, which usually involve collaboration between the chosen surgeon and other medical professionals who may be unknown to the patient. The physician, as Dr. Dingle indicated was the case here, may be unwilling to accept limitations on the actual performance of the surgery, but, if the identity of the persons who will be performing aspects of the surgery is important to the patient, the matter must be discussed and resolved. Despite Dr. Dingle's protestation to the contrary, a physician who agrees to a specific allocation of responsibility or a specific limitation on his or her discretion in order to obtain the consent of the patient to the procedure and then, absent some emergency or other good cause, proceeds in contravention of that allocation or limitation has not obtained the informed consent of the patient. We do not see this result as having the pernicious effects suggested by Dr. Dingle, of permitting patients to choreograph surgery and unduly restrict the flexibility that the surgeon must retain. Precisely as Dr. Dingle stated was the case here, the surgeon does not have to agree to any such limitations, and, presumably, few, if any, of them will so agree. The issue is raised only when there is a claim that such an agreement was made and, without good cause, violated. Notwithstanding the existence of these tort-based actions, courts have universally recognized that, except in emergency or gratuitous situations, the relationship between doctor and patient is a contractual one, either expressly or by implication, and, from that premise, many have held that, as an alternative to tort-based actions, a separate action for breach of the contract may lie when the doctor acts in contravention of a contractual undertaking, at least in some settings. Those actions are often founded either on a breach of warranty theory, alleging a warranty by the physician of a particular result, or on a promise independent of a medical procedure. For an example of the latter, see Chew v. Meyer, 72 Md.App. 132, 527 A.2d 828 (1987) (failure of doctor to perform agreement to complete and submit patient's medical insurance forms). In Sard v. Hardy, supra, 281 Md. 432, 451-52, 379 A.2d 1014, 1026-27, a breach of warranty claim was made, based on an alleged assurance by Dr. Hardy, following the surgery, that Ms. Sard was absolutely sterile and could not again become pregnant. We concluded that a patient may recover for breach of an express warranty or assurance of that kind under two circumstances: if the assurance was made before the medical procedure or, if made after the procedure, it was supported by separate consideration. Id. Ms. Sard was unable to recover because the assurance was made after the surgery and was not supported by any separate consideration. Other States have allowed such actions. See, for example, Robins v. Finestone, 308 N.Y. 543, 127 N.E.2d 330 (1955), where an action ex contractu to recover the costs of remedial therapy and loss of income was allowed on a complaint that the defendant physician, employed to remove a growth by means of fulguration, expressly promised that he would perform the procedure in a good and workmanlike manner, that the plaintiff would be cured in one or two days, and that the plaintiff could resume work immediately thereafter. The New York court noted that, although it may be unusual for a physician to enter into an agreement to cure, rather than merely undertake to render his or her best skill, a doctor and his patient are at liberty to contract for a particular result and, if that result be not attained, a cause of action for breach of contract results which is entirely separate from one for malpractice although both may arise from the same transaction. Id. at 331-32. Quoting from Colvin v. Smith, 276 A.D. 9, 92 N.Y.S.2d 794, 795 (1949), the court carefully distinguished between the two kinds of actions: The two causes of action are dissimilar as to theory, proof and damages recoverable. Malpractice is predicated upon the failure to exercise requisite medical skill and is tortious in nature. The action in contract is based upon a failure to perform a special agreement. Negligence, the basis of the one, is foreign to the other. The damages recoverable in malpractice are for personal injuries, including the pain and suffering which naturally flow from the tortious act. In the contract action they are restricted to the payments made and to the expenditures for nurses and medicines or other damages that flow from the breach thereof. Robins, supra, 127 N.E.2d at 332. See also Stewart v. Rudner, 349 Mich. 459, 84 N.W.2d 816, 822-23 (1957); Zostautas v. St. Anthony De Padua Hospital, 23 Ill.2d 326, 178 N.E.2d 303 (1961); Scarzella v. Saxon, 436 A.2d 358 (D.C.App.1981) and cases cited at 361; Jack W. Shaw, Jr., Annotation, Recovery Against Physician on Basis of Breach of Contract to Achieve Particular Result or Cure, 43 A.L.R.3d 1221 (1972). Actions for breach of contract have been founded on a variety of alleged promises and commitments. Most have alleged a promise to cure, or to cure within a certain period of time, or of some other particular result. See Robins v. Finestone, supra, 308 N.Y. 543, 127 N.E.2d 330; Giambozi v. Peters, 127 Conn. 380, 16 A.2d 833 (1940); Guilmet v. Campbell, 385 Mich. 57, 188 N.W.2d 601 (1971); Hawkins v. McGee, 84 N.H. 114, 146 A. 641 (1929); Noel v. Proud, 189 Kan. 6, 367 P.2d 61 (1961); Bailey v. Harmon, 74 Colo. 390, 222 P. 393 (1924); Sullivan v. O'Connor, 363 Mass. 579, 296 N.E.2d 183 (1973). Others, such as Stewart v. Rudner, supra, 349 Mich. 459, 84 N.W.2d 816, have been based on a commitment to do a certain procedure, to deliver a child by means of a Caesarean section. See, in general, 4 FRED LANE, MEDICAL LITIGATION GUIDE, § 40.07. We are unaware of any case precisely like this one, where the dispute is over an alleged allocation of specific functions between or among surgeons, all of whom were expressly authorized to participate and perform some role in the procedure. There have, however, been a number of cases in which a patient was informed that Dr. A would do the procedure, consented to Dr. A's performing the procedure, and later learned that the procedure was performed entirely or predominantly by Dr. B, with little or no participation by Dr. A. Liability has been found in those situations, but on different theories. In Perna v. Pirozzi, supra, 92 N.J. 446, 457 A.2d 431the case relied upon by the Court of Special Appealsthe plaintiff gave a proper, informed consent for Dr. Pirozzi to operate upon him in order to remove kidney stones. Dr. Pirozzi was in a group practice with two other urologists. The surgery was performed entirely by the other two doctors; Dr. Pirozzi was not even present. All three doctors were sued, and, among other claims of negligence and battery, the plaintiff asserted the lack of informed consentthat the consent given was conditioned on Dr. Pirozzi performing the surgery. The claims against the two other doctors were treated as batteriesa non-consensual touching. With respect to the claim against Dr. Pirozzi, the court noted that a patient has the right to choose the surgeon who will operate and to refuse to accept a substitute, and that, [c]orrelative to that right is the duty of the doctor to provide his or her personal services in accordance with the agreement with the patient. Id., 92 N.J. 446, 457 A.2d at at 440. The failure to perform that duty, the court held, constitutes a deviation from standard medical care, for which the patient has an action for malpractice. It then addressed the proper form of action: Although an alternative cause of action could be framed as a breach of the contract between the surgeon and the patient, generally the more appropriate characterization of the cause will be for breach of the duty of care owed by the doctor to the patient. The absence of damages may render any action deficient, but the doctor who, without the consent of the patient, permits another surgeon to operate violates not only a fundamental tenet of the medical profession, but also a legal obligation. [3] Id., 92 N.J. 446, 457 A.2d at 441. Perna v. Pirozzi , in other words, while recognizing a cause of action in that circumstance, treated the action against the doctor actually engaged to perform the surgery as preferably one of negligence, rather than as a breach of contract. Indeed, as Dr. Dingle points out, Dr. Pirozzi was not sued on a breach of contract theory. In Grabowski v. Quigley, 454 Pa.Super. 27, 684 A.2d 610 (1996), appeal granted, 548 Pa. 670, 698 A.2d 594, appeal dismissed, 553 Pa. 75, 717 A.2d 1024 (1998), the patient, in need of back surgery, consented to the operation being performed by Dr. Quigley and reported to the hospital at the appointed time, prepared to be operated on by Dr. Quigley. He later learned that Quigley was not present at 8:15 a.m., when the anesthesia was administered and the operation was due to commence, that another surgeon, Dr. Bailes, was eventually summoned, that Dr. Bailes began the surgery at 10:20, and that Dr. Quigley showed up at 11:25 and participated to some extent thereafter until the operation ended at 12:30. The patient sued Dr. Bailes for battery and for negligence in the performance of the surgery, and he sued Dr. Quigley for negligence in the surgery, negligence in not being present, and breach of contract to perform the surgery in its entirety. Reversing summary judgments entered for the doctors, the court concluded that there was sufficient evidence presented to show that the alleged contract existed and that it was breached. The court rejected the argument that a breach of contract action would lie only on a special or express contract that Quigley alone would perform the surgery. Quoting from Perna v. Pirozzi, supra , the court held that a basic tenet of the contract between doctor and patient is that the physician with whom the patient has contracted is obligated to perform the services. Grabowski, at 617. See also Taylor v. Albert Einstein Medical Center, 723 A.2d 1027 (Pa.Super.1998). A breach of contract action was allowed in Alexandridis v. Jewett, 388 F.2d 829 (1st Cir.1968). The plaintiff engaged Drs. Jewett and Driscoll, who were partners, to treat her during her pregnancy and deliver the child. The doctors were aware that the plaintiff had a very soft cervix, which indicated a rapid delivery after the onset of labor. The evidence showed that, at 2:45 a.m., the plaintiff's husband called Dr. Jewett and informed him that the plaintiff was in labor. Jewett allegedly advised him to take the plaintiff immediately to the hospital and said that Dr. Driscoll, who was on duty that night, would meet them there. Jewett apparently informed the hospital, however, not to summon Dr. Driscoll until medication was necessary. The plaintiff arrived at 3:45 and was met by a first-year resident. Dr. Driscoll did not appear until after 5:00. In the meanwhile, the resident diagnosed fetal distress and delivered the baby. As part of the procedure, he performed an episiotomy and, in doing so, cut into the anal sphincter, leading ultimately to the patient suffering from chronic rectal incontinence. Reversing defendants' judgments, the appellate court, applying Massachusetts law, concluded that there was sufficient evidence of both negligence on the part of Jewett and Driscoll in not assuring Driscoll's presence earlier and of breach of contract. The trial court had instructed the jury that, if Jewett and Driscoll, through a lack of diligence, abandoned the plaintiff by failing to meet the standard of their contract, they would be responsible for any negligence on the part of the resident. The jury found no negligence on the part of the resident, however. On appeal, the plaintiff urged that liability for breach of contract did not depend on any third party's negligence, and the appellate court agreed, pointing out that, to condition contract liability on the negligence of the resident would deprive her of what she bargained for. She contracted for the delivery of her baby by one of two highly skilled and experienced doctors, i.e., for specialized care, but what she received was nothing more than an undertaking that the care provided would meet the ordinary standards of the community. The court continued: If either Dr. Jewett or Dr. Driscoll had performed the operation, the standard of care would have been `the care and skill commonly possessed and exercised by similar specialists in like circumstances.' [citations omitted] We cannot understand why a specialist should be subjected to a less onerous burden when he abandons an undertaking than when he attempts to fulfill it. We think the jury should have been instructed, as appellant requested, that if it found that the added skill possessed by Dr. Jewett and Dr. Driscoll would have avoided the injury, contract liability would result. Id. at 833; see also Forlano v. Hughes, 393 Mass. 502, 471 N.E.2d 1315 (1984). We draw a number of conclusions from this judicial landscape. Because the doctor-patient relationship is normally a contractual one, it is permissible for the parties, if they choose to do so, to define with some precision the role that the doctor is to play. The parties may well have conflicting interests in that regardthe doctor wanting as much flexibility and discretion as possible and the patient, if choosing the physician because of some special confidence in that physician's particular abilities, desiring that the selected physician oversee and personally perform the most difficult part of the procedure. As noted in footnote 3 above, the medical community itself recognizes the interest that the patient has in the matter and the need for disclosure and agreement if there is likely to be a significant participation by other persons. The lack of a clear understanding prior to the procedure may well engender a later finding that informed consent was not obtained. A violation of an understanding so reached may constitute the lack of informed consent, negligent delegation, and a breach of the contract, not to mention the risk of a claim of misrepresentation or fraud. It would be prudent, of course, for the written consent form presented to the patient either to set forth any special understanding in this regard or note affirmatively that there is no such understanding. The scenarios in which these claims can arise are too varied to attempt any complete analysis of how they all may relate, one to another. In the context of this case, it will suffice to say that a doctor who partially abandons his or her patient by improperly delegating to others professional tasks that the doctor was engaged personally to do and agreed personally to do may be liable for traditional professional negligence, lack of informed consent, and breach of contract, depending in part on the nature of the consequences that flow from that abandonment. The problem for Ms. Belin in this case is that the one issue, common and central to both her claim of lack of informed consent and her claim for breach of contract was, in fact, submitted to the jury, which necessarily found against her. There was no question as to how the surgery proceededwhat Dr. Dingle did and what Dr. Magnuson did; nor was there any claim by Ms. Belin that Dr. Dingle failed to advise her of material risks, of collateral consequences, or of alternative therapies. [4] The only issue, as to both the informed consent and breach of contract claims, was whether Dr. Dingle ever agreed to the allocation of functions claimed by Ms. Belin. As noted, plaintiff's counsel made clear to the jury, in the context of the informed consent claim, that, to render a defendants' verdict, the jury would have to disbelieve Ms. Belin's version of her conversation with Dr. Dingle. It obviously did so. The breach of contract claim asserted by Ms. Belin could not survive in the face of that finding. JUDGMENT OF COURT OF SPECIAL APPEALS VACATING JUDGMENT OF CIRCUIT COURT ON BREACH OF CONTRACT CLAIM REVERSED; CASE REMANDED TO COURT OF SPECIAL APPEALS WITH INSTRUCTIONS TO AFFIRM JUDGMENT OF CIRCUIT COURT; COSTS IN THIS COURT AND IN COURT OF SPECIAL APPEALS TO BE PAID BY RESPONDENT.