Opinion ID: 2736095
Heading Depth: 2
Heading Rank: 1

Heading: Depending on how you're defining

Text: symptomatic; yes. Q. How are you defining it. A. When someone has significant hydrocephalus or severe symptoms and exam findings from the cyst. Q. But it doesn't have to be hydrocephalus only; is that correct? 8 There is no evidence in the record that a surgical treatment option, other than placing a shunt, existed. 9 Hydrocephalus is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. National Institute of Neurological Disorders and Stroke, Hydrocephalus Fact Sheet, available at http://www.ninds.nih.gov/disorders/hydrocephalus/detail_hydroceph alus.htm (last visited August 22, 2014). -15- A. Correct. Q. Would you agree with this: When symptoms warrant, the surgical placement of a shunt may be required to decompress the cyst? A. Can you repeat that? [question repeated] A. Yes. Q. Doctor, would you agree that the decision of when it is that the symptoms warrant shunting is a clinical judgment call? A. To a certain extent, yes. Q. And that call, you have never taken it in your life? A. Correct. Q. Doctor, would you agree with the following: Untreated arachnoid cysts may cause permanent severe neurological damage due to the progressive expansion of the cyst or hemorrhage? A. In the appropriate circumstance, yes. Q. Would you agree with the following statement: With treatment, most individuals with symptomatic arachnoid cysts do well? A. Many, yes. Q. Doctor, would you agree with the following: Controversy surrounds the treatment of arachnoid cysts? A. Yes. Q. Some clinicians advocate treating only patients with symptomatic cysts whereas others believe that even [a]symptomatic cyst[s] should be decompressed to avoid future complications? -16- A. I would - my opinion is that doctors that recommend asymptomatic - treatment of asymptomatic cysts are not in the majority, they are probably in the minority. Q. But there are some authorities that state that also? A. In my opinion, those authorities are not reasonable or credible. Q. But those authorities or school of thought exist? A. Yes. Q. And you don't agree with that, but others don't agree with you; is that correct? A. I guess so; yes. Q. Would you agree with the following: The most effective surgical treatment appears to be excision of the outer cyst membrane and cystoperitoneal [sic] shunting? A. In the appropriate circumstance; yes. In addition, Santana-Concepción's responses to interrogatories indicated that she felt [her] eyes were going to fall [sic] of their socket when she saw Dr. Rosado for the first time. It was at the conclusion of that examination that Dr. Rosado recommended surgery to place a shunt and relieve intracranial pressure. On this record, a reasonable jury would be compelled to conclude that legitimate debate existed among medical experts as to which treatment would be appropriate for Santana-Concepción's arachnoid cyst, which, though not causing hydrocephalus, did cause significant pain. Lozada, 16 P.R. Offic. Trans. at 267. Given the -17- testimony of the plaintiffs' own expert, they were unable to generate a genuine issue of material fact as to the application of the error of judgment defense. Hence, the district court was correct to grant summary judgment to the minor plaintiffs on their medical malpractice claims. 2. Informed Consent The remaining claim of the minor plaintiffs is based on the doctrine of informed consent, which imposes on physicians the duty to inform their patients about the nature and risks of the proposed medical treatment in order to place the patients in a position to reach an intelligent and informed decision. LozadaTirado v. Tirado-Flecha, 177 P.R. Dec. 893 (2010). The minor plaintiffs claim that Dr. Rosado performed the shunt placement surgery on Santana-Concepción without obtaining her fully informed consent. The scope of the duty to inform does not reach every remote, hypothetical risk posed by a medical procedure. Indeed, the scope of the duty varies with the nature of the proposed treatment. Sepúlveda de Arrieta v. Barreto, No. RE-90-41, 1994 WL 908876 (P.R. Dec. 23, 1994). 'If [the medical intervention] is to save a life, the surgeon should, above all, create a favorable atmosphere. If the intervention is simply useful, he must then be more precise in his disclosure.' Id. (emphasis omitted) (quoting J. Ataz López, Los médicos y la responsabilidad civil 74 (1985)). -18- In order to prevail on a claim for lack of informed consent, a plaintiff must prove that the complained-of injury resulted from the failure of the physician to fully inform the patient (i.e., causation). Sepulveda de Arrieta, No. RE-90-41, 1994 WL 908876. One might expect that such causation can be proved by showing that the plaintiff would not have consented to the medical treatment at issue if fully informed of the risks. The debate in most U.S. jurisdictions is generally over whether that fact must be shown subjectively (i.e., from the perspective of the specific patient) or objectively (i.e., from the perspective of the reasonable patient). Id. Contrary to the United States model -- that focuses on the decision-making process of the injured party, whether objective or subjective -- civil law tradition focuses on the alleged aggravating circumstance. Id. Hence, in Puerto Rico, the question of proximate causation is viewed from the perspective of the physician. In other words, the analysis does not turn on whether the patient would have declined to consent if provided with the allegedly absent information. See id. ([I]t is not necessary to determine if she, as a patient -- subjectively or objectively -- would or would have not consented to the proposed medical treatment.). Instead, the pertinent question is whether in the normal course of events [the physician] had to foresee that the lack of pertinent information would lead [the] patient . . . to -19- take a different decision than the one she would have taken if she had been suitably informed. Id. The district court held that it would not have been foreseeable that any further disclosure would have changed Santana-Concepción's decision to undergo surgery. The court granted summary judgment on that basis. Here, the minor plaintiffs claim that Santana-Concepción was never fully informed of the risks of surgery and was never told that foregoing surgery was a viable option. The record includes an informed consent form signed by Santana-Concepción, the authenticity of which is not dispute. The minor plaintiffs nonetheless argue that Santana-Concepción was not fully informed because four terms on the form (arachnoid cyst, drainage, fenestration, and shunt) were in English rather than Spanish (which was the language of the rest of the document). They also argue that Dr. Rosado did not tell Santana-Concepción that her condition was manageable without surgery, instead implying that the shunt surgery was a life-saving necessity. Both of these arguments focus on the wrong perspective, however. As explained above, we must examine the question of foreseeability from Dr. Rosado's perspective, not SantanaConcepción's. The district court was correct in explaining that to create a genuine issue of fact under the applicable foreseeability standard, plaintiffs needed to direct the Court to facts Dr. Rosado could have relied upon to foresee that -20- Santana–Concepción was likely to behave different than most people under the circumstances. [However,] [p]laintiffs have provided no evidence whatsoever in this regard. Dr. Rosado was confronted with a patient who had a cyst on her brain that was causing her debilitating pain. He understood it to be a possible life-or-death situation and communicated that to her. Santana-Concepción indicated a willingness to entertain any treatment option that would take away her pain. Doing nothing was simply not an acceptable option, even if Dr. Rosado had suggested it. Dr. Rosado ultimately suggested a surgical procedure to relieve some of the pressure. However, before performing the surgery, Dr. Rosado informed Santana-Concepción and her family of the major risks of surgery and obtained written consent. As the district court put it, [t]he conclusion that Dr. Rosado could have foreseen a decision to forego surgery by SantanaConcepción is inconceivable under these circumstances. In other words, the minor plaintiffs failed to generate a genuine issue of material fact on the proposition that Dr. Rosado could have foreseen that providing Spanish translations for the four English terms, or further discussing some of the possible side effects of surgery as reasons for not undergoing it, would have changed Sanatana-Concepción's decision to consent to surgery. Accordingly, -21- the district court was correct to grant summary judgment to the defendants on the informed consent claims of the minor plaintiffs.10 Affirmed. 10 Because, as explained supra, the hospital and related entities were sued on the basis of vicarious liability for Dr. Rosado's actions, all claims against those corporate defendants fail with the claims against him. -22-