Opinion ID: 1856826
Heading Depth: 1
Heading Rank: 3

Heading: Causation of Damages

Text: The plaintiff in a lack of informed consent case must prove not only that the physician failed to disclose all material information, but also that there was a causal relationship between the doctor's failure and the damages claimed by the patient. LaCaze, 434 So.2d at 1048. Otherwise, the doctor's conduct, however wrongful, is legally inconsequential. Id. There are two aspects to the proof of causation in a lack of informed consent case. First, the plaintiff must prove, as in any other tort action, that the defendant's breach of duty was a cause-in-fact of the claimed damages or, viewed conversely, that the defendant's proper performance of his or her duty would have prevented the damages. Second, the plaintiff must further prove that a reasonable patient in the plaintiff's position would not have consented to the treatment or procedure, had the material information and risks been disclosed. LaCaze, 434 So.2d at 1048; Hondroulis, 553 So.2d at 412; Canterbury v. Spence, 464 F.2d 772, 790 (D.C.Cir. 1972). Causation is established only if adequate disclosure reasonably would be expected to have caused a reasonable person to decline treatment because of the disclosure of the risk or danger that resulted in the injury. Canterbury, 464 F.2d at 791. Although the patient has the absolute right, for whatever reason, to prevent unauthorized intrusions and treatments, he or she can only recover damages for those intrusions in which consent would have been reasonably withheld if the patient had been adequately informed. LaCaze, 434 So.2d at 1049. As to the principal claim for damages in the present case (the subsequent massive herniation in 1988), we need not discuss whether a reasonable person in plaintiff's position would have consented to the cardiac incisional hernia repair if the person had been informed that mesh might not be indicated or used. Based on the complete record, plaintiff has failed to satisfy the threshold element of causation-in-fact. There is no medical evidence from which a rational juror could conclude that Dr. Dowling's failure to use mesh in the cardiac incisional hernia repair caused the plaintiff's subsequent massive herniation. Dr. Foti, the expert called by plaintiff, testified that Dr. Dowling's failure to use mesh in the cardiac incisional hernia repair had nothing to do with plaintiff's subsequent medical conditions. Dr. Foti stated that the hernia he repaired was a very large and complex defect which extended into the area of the cardiac incisional hernia, but that the two areas could not be distinguished from each other. From an etiological standpoint, however, he believed that the major hernia he repaired stemmed from a separation of the abdominal wall after the unrelated gallbladder surgery. [7] Dr. Foti further testified that he believed there was nothing Dr. Dowling failed to do which caused the herniation for which he operated on the plaintiff. Inasmuch as plaintiff failed to prove that the use of mesh in the cardiac incisional hernia repair would have prevented any of his subsequent problems, we conclude that Dr. Dowling's failure to use mesh in accordance with plaintiff's request was not a cause-in-fact of the subsequent massive herniation suffered by plaintiff. Nevertheless, the doctor's breach of duty cannot fairly be said to have resulted in no injury whatsoever. Although we do not base the doctor's liability on a theory of battery, the damages sustained by plaintiff in this case appear to be the type of damages contemplated by the majority of this court in remanding the Pizzalotto case to the court of appeal to fix damages based on a battery. [8] While we have herein rejected battery as the basis for analyzing liability in lack of informed consent cases, some of the damages generally awarded in battery cases are applicable in our discussion of damages in this case. This case is different from the usual lack of informed consent cases where the doctor failed to inform the patient of a material risk and the risk materialized to cause physical damages. Here, the doctor's failure to inform the patient adequately did not cause the patient to undergo a risk that materialized and caused physical damages. [9] Rather, the doctor's breach of duty caused plaintiff to undergo a medical procedure to which the patient expressly objected and for which the doctor failed to provide adequate information in response to the patient's request, thereby causing damages to plaintiff's dignity, privacy and emotional well-being. The doctor, rather than explaining the advantages and disadvantages of the patient's express request, patronized his patient and mentally reserved the right to decide to disregard the patient's expressed wishes. Even the dissenting judge in the court of appeal noted that plaintiff is entitled to an award of damages for being deprived the opportunity of self-determination in regard to subjecting himself to an unwanted procedure. The difficult question is the type of damages to be awarded. While plaintiff failed to prove physical damages or pecuniary loss, he is still entitled to an award of general compensatory damages caused by the doctor's breach of duty. In this type of case, damages for deprivation of self-determination, insult to personal integrity, invasion of privacy, anxiety, worry and mental distress are actual and compensatory. See 2 Dan B. Dobbs, Law of Remedies, §§ 7.1-7.3 (1993) (discussing damages for dignitary torts [10] where the law seeks to protect the plaintiff's intangible interest in personal integrity and privacy, as well as mental tranquility). See also Fontenot v. Magnolia Petroleum Co., 227 La. 866, 80 So.2d 845 (1955); (two plaintiffs awarded $250 each, in addition to property damage awards, where defendants were absolutely liable for use of explosives in seismological exploration); Ard v. Samedan Oil Corp., 483 So.2d 925 (La.1986) (two plaintiffs awarded $10,000 and $7,500 respectively, plus property damage award, for trespass by seismology team who trampled fences on plaintiffs' cattle lands); Guy v. ABC Ins. Co., 629 So.2d 1350 (La.App. 4th Cir.1993) (three plaintiffs awarded $3,500, $3,500 and $5,000 respectively where police conducted warrantless search of home but caused no property damage); Karl J. Pizzalotto, M.D., Ltd. v. Wilson, 444 So.2d 143 (La.App. 1st Cir.1983) (on remand) (damages based on battery theory of lack of consent). This is not a case of mental distress caused by harm to plaintiff's property, for which an award of damages has caused much debate. Rather, the injury was to plaintiff's personal dignity and right of privacy, an injury for which an award of damages generally is considered appropriate. The primary concern in this injury to the personality is vindication of valuable, although intangible, right, the mere invasion of which constitutes harm for which damages are recoverable. Dobbs, supra, at § 7.1(1). On remand in Pizzalotto, the court of appeal awarded $10,000 based on the patient's shock at learning that she had undergone a procedure she had not expected, as well as the added pain and recovery time she experienced due to the more extensive operation that she underwent. Pizzalotto, 444 So.2d at 144. In this case, plaintiff experienced similar shock and mental distress when he learned that his express desire for a repair with mesh had been disregarded. Unlike the plaintiff in Pizzalotto, however, plaintiff in this case did not undergo a more extensive procedure than the one he expected. Accordingly, we fix his compensatory damages at $5,000, proportionate to the damages awarded in Pizzalotto on remand. In summary, we reduce the jury's total award of damages, which included the damages attributable to the massive herniation that was not proved to have been caused by the doctor's failure to provide material information and to obtain adequate informed consent, from $300,000 to $5,000. We also reverse the unsupported jury finding that plaintiff was ten percent at fault.