Opinion ID: 1842488
Heading Depth: 1
Heading Rank: 5

Heading: Legal errors:

Text: We begin our discussion of the court of appeal's decision with an explanation of the legal error the majority fell into in determining the validity of Mr. Thibodeaux's consent to the hysterectomy. The majority found the husband was not authorized to consent to the hysterectomy by this state's statutory provisions. Louisiana Revised Statutes 40:1299.53 provides that a patient's spouse not judicially separated is authorized and empowered to consent, either orally or otherwise, to any surgical or medical treatment or procedures including autopsy not prohibited by law which may be suggested, recommended, prescribed or directed by a duly licensed physician. [12] However, LSA-R.S. 40:1299.51 provides that the Louisiana Medical Consent Law, which includes LSA-R.S. 40:1299.53, shall not apply in any manner whatsoever to the subjects of abortion and sterilization, which subjects shall continue to be governed by existing law independently of the terms and provisions of the Louisiana Medical Consent Law. The majority stated the existing law concerning sterilization is sparse, but that a review of all pertinent legislation led the court to believe the legislature intended to guarantee an individual patient, alone, the right to make the decision to submit to medical treatment that would effectively end his or her ability to procreate unless an emergency prevents the patient from having that opportunity. Thibodeaux, 03-1298 at 4, 879 So.2d at 914. The majority cited Beck v. Lovell, 361 So.2d 245, 250 (La.App. 1 Cir.), writ denied, 362 So.2d 802 (1978), as authority for the proposition that  absent an emergency, the relationship of husband and wife does not confer authority for one spouse to grant permission for surgery on another. (Emphasis supplied.) The majority's reliance on Beck is misplaced because it is based on the court's conclusion that the issue of consent is still governed by the law enunciated in Beck  in 1978. Thibodeaux, 03-1298 at 5, 879 So.2d at 914. The court acknowledges that LSA-R.S. 40:1299.53 now governs a third party's authority to consent to surgeries and medical treatments, but concludes that statute is inapplicable to a procedure involving sterilization. Id. The majority recognizes that Dr. Jurgelsky's purpose in performing the operation was not solely to render Mrs. Thibodeaux sterile. However, the court states the doctor's purpose in performing the operation is relevant only if she was faced with an emergency situation. As the dissent in the instant case points out, LSA-R.S. 40:1299.53(A) does not require that an emergency be present for a spouse to consent, only that the surgery be suggested, recommended, prescribed, or directed by a duly licensed physician. Thibodeaux , dissent, 03-1298 at 3, 879 So.2d at 918. Further, LSA-R.S. 40:1299.40(A) provides that the consent form be signed by a person who has legal authority to consent on behalf of a patient if the patient for any reason lacks legal capacity to consent. (Emphasis supplied.) This statutory provision is broad enough to authorize consent by a husband if his wife is under anesthesia. Pretermitting the issue of whether there was an emergency situation, we find the doctor's purpose quite relevant in determining whether the exclusion in LSA-R.S. 40:1299.51 applies in this factual situation. Dr. Jurgelsky informed Mr. Thibodeaux that she and his wife had discussed the patient's problematic periods, her wishes not to have more children, and her knowledge that he did not want to have a vasectomy. However, the record is clear that these facts were not the medical purpose of the hysterectomy. Dr. Jurgelsky testified extensively regarding her decision that a hysterectomy was warranted, not for the purpose of sterilization, but due to the potential for hemorrhage and serious future complications. Dr. Dorta testified hysterectomy was preferable to a hysterotomy in order to avoid the risks of infection, bleeding, disseminated intra vascular coagulation, postoperative complications with peritonitis, sepsis, and life-threatening fevers. Significantly, when cross-examined by plaintiffs' counsel about why she did not schedule a hysterectomy instead of a D & C at the time the demise of the fetus was discovered, knowing Mrs. Thibodeaux's wishes not to have more children and her intent to have a tubal ligation at the time of what would have been her fourth delivery, Dr. Jurgelsky stated, You just don't do a hysterectomy on somebody when something milder can be done that's safe.... You don't want to ever have to do a hysterectomy on somebody that is pregnant. Mr. Thibodeaux told the doctor to do what she thought was best (apparently without expressing his desire for more children) and signed a consent form for a hysterectomy which listed injury to the ureter and leakage of urine through the vagina as possible risks. We agree with the two dissenting judges that the purpose of the hysterectomy in this case was not as a sterilization procedure. We conclude the majority committed legal error in finding LSA-R.S. 40:1299.51 vitiated Mr. Thibodeaux's otherwise valid consent to the performance of a hysterectomy and the enumerated risks. The second legal error occurred in the court of appeal's determination that Mrs. Thibodeaux's signature on the consent form did not trigger a presumption of valid consent pursuant to LSA-R.S. 40:1229.40(A)(1). The majority distinguished between risk and choice, the latter being intentional and pro-active. The court stated a physician may not make a choice absent informed consent unless faced with an emergency. [13] Mrs. Thibodeaux signed a consent form for the D & C procedure which warned her of certain risks, including hemorrhage with possible hysterectomy, perforation of the uterus, and sterility. Perforation of the uterus was a risk that materialized during the D & C procedure, but hemorrhage did not although, when she spoke to Mr. Thibodeaux, Dr. Jurgelsky was concerned that his wife was hemorrhaging. However, after the doctor opened her patient's abdomen to repair the uterus, the doctor saw there was no hemorrhaging. The majority found a hysterectomy was not warranted due to that circumstance. Thibodeaux, 03-1298 at 3, 879 So.2d at 913. Further, while the consent form informed Mrs. Thibodeaux that sterility was a possible risk of the D & C procedure, according to the majority sterility did not result from the D & C, but from the unauthorized hysterectomy. In other words, it was a choice, among other available options, which Dr. Jurgelsky made ... absent an emergency. Id. The language of the majority opinion distinguishing between risk and choice and stating that the latter is intentional and pro-active is a thinly disguised reversion to the days of the battery principle in medical malpractice cases  a principle rejected by the legislature and the courts. The Medical Malpractice Act provides that malpractice is any unintentional tort or any breach of contract based on health care or professional services rendered, or which should have been rendered, by a health care provider, to a patient. (Emphasis supplied.) LSA-R.S. 40:1299.41(A)(8). As previously noted, LSA-R.S. 40:1229.40(E)(2)(a) provides that the only theory on which recovery may be obtained is that of negligence in a lack of informed consent case. In Lugenbuhl, 96-1575 at 9, 701 So.2d at 453, this court rejected battery-based liability, even in cases where no consent is alleged, in favor of liability based on the doctor's duty to provide the patient with material information concerning the medical procedure. Thus, the majority's opinion that the hysterectomy was an intentional act by Dr. Jurgelsky absent her patient's consent ignores clear statutory language and controlling jurisprudence, which constitutes legal error on the part of the court of appeal. Further, the majority's decision that the hysterectomy was not a risk led the court of appeal to omit an essential element of the analytical formula in a lack of consent case: the determination of materiality of the disclosure the plaintiffs urge the physician failed to make. This court has explained: The determination of materiality is a two-step process. The first step is to define the existence and nature of the risk and the likelihood of its occurrence. Some expert testimony is necessary to establish this aspect of materiality because only a physician or other qualified expert is capable of judging what risk exists and the likelihood of occurrence. The second prong of the materiality test is for the trier of fact to decide whether the probability of that type harm is a risk which a reasonable patient would consider in deciding on treatment. The focus is on whether a reasonable person in the patient's position probably would attach significance to the specific risk. This determination of materiality does not require expert testimony. Hondroulis v. Schuhmacher, on reh'g, 553 So.2d 398, 412 (La.1989). To determine whether the non-disclosure was a material risk we must look to the testimony of the expert witnesses. Dr. Dorta stated that the husband's consent was inconsequential. Dr. Nolan testified that Dr. Jurgelsky had authority to perform the hysterectomy without consulting the husband, thus indicating that in this factual situation a more specific listing of hysterectomy was unnecessary and not material. Dr. Jurgelsky testified the adhesion of the necrotic tissue to the uterus was the worst she had ever encountered, obviously a rare occurrence. However, the plaintiffs' expert, Dr. Winfield, testified he advises patients who are going to have a D & C that there is a risk of the need for a hysterectomy. He stated further that performance of a hysterectomy is within the applicable standard of care although it is the final option that should be considered. The doctors who testified for the defense merely implied that hysterectomy was not a material risk in this case. However, since Dr. Winfield's testimony directly addressed the issue of disclosure, we can conclude that the first prong of the materiality test, i.e., the existence and nature of the risk and likelihood of occurrence, was proved by plaintiffs. Next, considering the risks that were disclosed on the consent form that Mrs. Thibodeaux signed  hemorrhage with possible hysterectomy, perforation of the uterus, sterility, and abdominal incision/operation to correct injury  along with the doctors' testimony, we can infer that listing hysterectomy caused by something other than hemorrhage was not material to a reasonable person in the patient's position. In other words, Mrs. Thibodeaux accepted the risks of: losing her uterus, although as a result of a specific happening; sterility; and abdominal incision. To say that a reasonable person, or Mrs. Thibodeaux herself, would have considered a more specific listing of hysterectomy [14] important in making her decision of whether to have or not to have the D & C is a strained interpretation of the evidence. We conclude plaintiffs failed to prove the second prong of materiality. Thus, the majority's conclusion that neither Mrs. Thibodeaux's signature nor that of her husband on the respective consent forms created a presumption of valid consent for the hysterectomy was flawed with legal error. After deciding that the presumptions of validity were not available to the defense, the majority then proceeded to consider the other elements of a lack of informed consent action: 1) causal relationship, and 2) the reasonable patient test. The court noted causal relationship was easily met, because the hysterectomy caused the patient to be sterile and ultimately to endure the nephrectomy. Thibodeaux, 03-1298 at 6, 879 So.2d at 915. The next legal error occurred in the court of appeal's misapplication of the reasonable patient test  whether a reasonable patient in the plaintiff's position would have consented to the procedure had the material information and risks been disclosed. The majority decided a reasonable person would have chosen the least intrusive means of all available alternatives to the hysterectomy. Id. This statement by the appellate court misstates the proper test. The test is: 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. 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. [Citations omitted; emphasis supplied.] Lugenbuhl, 96-1575 at 12, 701 So.2d at 454. After our review of the evidence, we are convinced that had the court of appeal correctly stated the causation test, the only logical conclusion was that a reasonable person, and even Mrs. Thibodeaux herself, would not have withheld her consent to the D & C in light of the patient's medical condition and personal history in this particular case. There is no indication in the record by any of the experts that the D & C was not urgently necessary. The final, but not the least significant, legal error was the court of appeal's departure from the manifest error standard of review. The opinion makes no mention of any standard of review. The majority concluded Mrs. Thibodeaux proved the elements of her lack of informed consent claim and Dr. Jurgelsky was liable for all damages associated with the unauthorized hysterectomy, including the nephrectomy. Thibodeaux, 03-1298 at 6, 879 So.2d at 915. [15] This conclusion is the antithesis of the trial court's factual findings that Dr. Jurgelsky complied with the requirements of LSA-R.S. 40:1229.40 and went above and beyond the call of duty by getting Mr. Thibodeaux's consent to the hysterectomy. After reviewing the record, we conclude the court of appeal improperly substituted its own factual findings for that of the district court, thereby misapplying the manifest error standard of review. The court of appeal's failure to abide by the manifest error standard of review was contrary to the established jurisprudence of the third circuit and this court. In Capel, 98-1517 at 6-9, 734 So.2d at 840-841, the third circuit correctly performed a manifest error analysis of the record in a lack of informed consent case. In Lugenbuhl, 96-1575 at 11, 701 So.2d at 453, another informed consent case, we stated: An appellate court, in reviewing a jury's determination that a doctor failed to obtain the patient's informed consent, should focus on the duty of the doctor to provide material information to the patient under the circumstances of the particular case. Noting that the jury apparently accepted the plaintiff's testimony, corroborated by that of his wife and daughter, and not the conflicting testimony of the doctor, we stated the evidence must be viewed in the light most favorable to the party who prevailed before the trier-of-fact. Likewise, in Martin v. East Jefferson General Hospital, 582 So.2d 1272, 1276-1277 (La.1991), we stated that deciding whether the plaintiff established by a preponderance of the evidence that the doctor's actions fell below the ordinary standard of care expected of physicians in his medical specialty and whether a causal relationship existed between the alleged breach of that standard and the injury sustained are determinations of fact which should not be reversed on appeal absent manifest error. Further, [I]f the trial court or jury's findings are reasonable in light of the record reviewed in its entirety, the court of appeal may not reverse, even though convinced that had it been sitting as the trier of fact, it would have weighed the evidence differently. We have instructed the appellate courts that where there are two permissible views of the evidence, the factfinder's choice between them cannot be manifestly erroneous or clearly wrong. .... [E]xpert witnesses who are members of the medical profession are necessary sources of proof in medical malpractice actions.... The determination of an expert's credibility is also a factual question subject to the manifestly erroneous/clearly wrong standard of review. [Citations omitted; emphasis supplied.] Martin, 582 So.2d at 1277. In the instant case, the trial court found for a fact that when Dr. Jurgelsky began the D & C in an effort to remove the deceased fetus, she encountered difficulty which resulted in a uterine perforation. The trial court evaluated the conflicting evidence as follows: Plaintiff's contention is to the effect that Dr. Jurgelsky's treatment of Mrs. Thibodeaux was below the standard of care which one would have expected to receive from her specialist in OB/GYN. Plaintiff's position[ ] is based pretty much entirely upon the testimony of Dr. Felton Winfield, Jr. Dr. Winfield is an OB/GYN and served as one of the members of the Medical Review Panel. While the Medical Review Panel found no fault on the part of Dr. Jurgelsky, Dr. Winfield did not vote with the majority and in effect dissented indicating that Dr. Jurgelsky did deviate from the standard of care because there were other options short of hysterectomy that should have been considered in this patient. In response to that position it is the defendants' [sic] contention that she did consider other possible options but rejected them concluding that hysterectomy was the answer. The defendants' [sic] position is supported by the Medical Review Panel, and upon the trial of the issue the defendant's expert witnesses addressed the options alluded to by Dr. Winfield. At the time of the trial the testimony of the defendants' [sic] experts specifically explained why the options suggested by Dr. Winfield were not appropriate and the action taken by Dr. Jurgelsky was reasonable under the circumstances. .... [T]he Court is of the opinion that Dr. Jurgelsky did in fact comply with the requirements of Louisiana's Consent to Medical Treatment Act  as a matter of fact the Court's opinion is that she went above and beyond the call of duty by getting the consent from the husband when she came out of surgery to discuss the situation. Accordingly, [lack of informed consent] will not form the basis for recovery herein. Our review of the record convinces us the testimony at trial overwhelmingly supports the trial court's findings and accentuates the legal flaws in the court of appeal's majority opinion. Reversal of the trial court's judgment in defendant's favor was erroneous, if for no other reason than failure to adhere to the manifest error standard of review.