Opinion ID: 2336020
Heading Depth: 1
Heading Rank: 4

Heading: Lost Chance of a Better Outcome

Text: ¶ 12 The medical malpractice statute requires the same elements of proof as traditional tort elements of proof: duty, breach, injury, and proximate cause. RCW 7.70.040. Whether there is a cause of action for a lost chance of a better outcome in the medical malpractice context is a question of law, which we review de novo. Berger v. Sonneland, 144 Wash.2d 91, 103, 26 P.3d 257 (2001). The standard formulation for proving proximate causation [4] in tort cases requires, first, a showing that the breach of duty was a cause in fact of the injury, and, second, a showing that as a matter of law liability should attach. Harbeson v. Parke-Davis, Inc., 98 Wash.2d 460, 475-76, 656 P.2d 483 (1983). In a medical malpractice case, for example, a plaintiff would traditionally seek to prove cause in fact by showing that he or she would not have been injured but for the health care provider's failure to use reasonable care. Hill v. Sacred Heart Med. Ctr., 143 Wash.App. 438, 448, 177 P.3d 1152 (2008) (citing McLaughlin v. Cooke, 112 Wash.2d 829, 837, 774 P.2d 1171 (1989)). However, as the plurality noted in Herskovits, [t]he word `cause' has a notoriously elusive meaning (as the writings on legal causation all agree). 99 Wash.2d at 635 n. 1, 664 P.2d 474 (Pearson, J., plurality opinion). For this reason, and in service of underlying tort principles, this court and others have recognized some limited exceptions to the strict tort formula, including recognition of lost chance claims. See, e.g., id. at 619, 664 P.2d 474 (Dore, J., lead opinion), 634-35 (Pearson, J., plurality opinion). ¶ 13 Herskovits involved a survival action following an allegedly negligent failure to diagnose lung cancer. Over the course of a year, Leslie Herskovits repeatedly sought treatment for persistent chest pains and a cough, for which he was prescribed only cough medicine. Id. at 611, 664 P.2d 474 (Dore, J., lead opinion). When he finally sought another medical opinion, Herskovits was diagnosed with lung cancer within three weeks. Id. His diagnosing physician testified that the delay in diagnosis likely diminished Herskovits's chance of long-term survival from 39 percent to 25 percent. Id. at 612, 664 P.2d 474. Less than two years after his diagnosis, then 60 years old, Herskovits died. Id. at 611, 664 P.2d 474. The trial court dismissed the case on summary judgment on the basis that Herskovits's estate, which brought suit, failed to establish a prima facie case of proximate cause: it could not show that but for his doctor's negligence he would have survived because he  probably would have died from lung cancer even if the diagnosis had been made earlier. Id. Though divided by different reasoning, this court reversed the trial court, finding that Herskovits's lost chance was actionable. ¶ 14 The lead opinion, signed by two justices, and the concurring opinion, which garnered a plurality, agreed on the fundamental bases for recognizing a cause of action for the loss of a chance. The lead opinion explained: To decide otherwise would be a blanket release from liability for doctors and hospitals any time there was less than a 50 percent chance of survival, regardless of how flagrant the negligence. Id. at 614, 664 P.2d 474. The plurality similarly noted that traditional all-or-nothing causation in lost chance cases `subverts the deterrence objectives of tort law.' Id. at 634, 664 P.2d 474 (Pearson, J., plurality opinion) (quoting Joseph H. King, Jr., Causation, Valuation, and Chance in Personal Injury Torts Involving Preexisting Conditions and Future Consequences, 90 YALE L.J. 1353, 1377 (1981)). Both opinions found that the loss of a less than even chance is a loss worthy of redress. Id. With emphasis, the lead opinion agreed, stating that `[ n ] o matter how small that chance may have beenand its magnitude cannot be ascertainedno one can say that the chance of prolonging one's life or decreasing suffering is valueless.' Id. at 618, 664 P.2d 474 (Dore, J., lead opinion) (quoting James v. United States, 483 F.Supp. 581, 587 (N.D.Cal.1980)). ¶ 15 The lead and plurality opinions split over how, not whether, to recognize a cause of action. Drawing from other jurisdictions, especially the Pennsylvania Supreme Court's holding in Hamil v. Bashline, 481 Pa. 256, 392 A.2d 1280 (1978), the lead opinion held that the appropriate framework for considering a lost chance claim was with a substantial factor theory of causation. The court summarized that once a plaintiff has demonstrated that the defendant's acts or omissions have increased the risk of harm to another, such evidence furnishes a basis for the jury to make a determination as to whether such increased risk was in turn a substantial factor in bringing about the resultant harm. Herskovits, 99 Wash.2d at 616, 664 P.2d 474 (additionally noting the Hamil court's reliance on the Restatement (Second) of Torts § 323 (1965), which provides that one who renders services to another, necessary for the protection of that person, is liable if his failure to exercise [reasonable] care increases the risk of [physical] harm). [5] The substantial factor test is an exception to the general rule of proving but for causation and requires that a plaintiff prove that the defendant's alleged act or omission was a substantial factor in causing the plaintiff's injury, even if the injury could have occurred anyway. Fabrique v. Choice Hotels Int'l, Inc., 144 Wash.App. 675, 684, 183 P.3d 1118 (2008). ¶ 16 Rather than looking to the causation element, the plurality opinion in Herskovits focused instead on the nature of the injury. Herskovits, 99 Wash.2d at 634, 664 P.2d 474 (Pearson, J., plurality opinion) ([T]he best resolution of the issue before us is to recognize the loss of a less than even chance as an actionable injury.). The plurality noted among its concerns about the all or nothing traditional tort approach to recovery that it creates pressure to manipulate and distort other rules affecting causation and damages in an attempt to mitigate perceived injustices. Id. In part, this characterizes what the Herskovits lead opinion does by prescribing that causation in all lost chance cases is to be examined under the substantial factor doctrine. The plurality found it more analytically sound to conceive of the injury as the lost chance. Id. ¶ 17 Though this court has not reconsidered or clarified the rule of Herskovits in the survival action context or, until now, considered whether the rule extends to medical malpractice cases where the ultimate harm is something short of death, the Herskovits majority's recognition of a cause of action in a survival action has remained intact since its adoption. Washington recognizes loss of chance as a compensable interest. Shellenbarger v. Brigman, 101 Wash.App. 339, 348, 3 P.3d 211 (2000); see Zueger v. Pub. Hosp. Dist. No. 2, 57 Wash.App. 584, 591, 789 P.2d 326 (1990) (finding that the Herskovits plurality represents the law on a loss of the chance of survival); 16 DAVID K. DEWOLF & KELLER W. ALLEN, WASHINGTON PRACTICE: TORT LAW AND PRACTICE § 4. 10, at 155-56, § 15.32, at 488 (3d ed. 2006) (Washington courts recognize the doctrine of `loss of a chance' as an exception to a strict application of the but-for causation test in medical malpractice cases.). In Shellenbarger, the Court of Appeals reversed summary judgment of a medical malpractice claim of negligent failure to diagnose and treat lung disease from asbestos exposure in its early stages. 101 Wash.App. at 342, 3 P.3d 211. Expert witnesses testified that had Shellenbarger received nonnegligent testing and early diagnosis, which would have led to treatment, he would have had a 20 percent chance that the disease's progress would have been slowed and, accordingly, he would have had a longer life expectancy. Id. at 348, 3 P.3d 211. The court concluded, We find no meaningful difference between this and Herskovits' lost chance of survival. Id. at 349, 3 P.3d 211. ¶ 18 Washington courts have, however, generally declined to extend Herskovits to other negligence claims. See, e.g., Daugert v. Pappas, 104 Wash.2d 254, 260-62, 704 P.2d 600 (1985) (declining to apply Herskovits in a legal malpractice claim); Fabrique, 144 Wash.App. at 685, 183 P.3d 1118 (following Daugert and finding no authority supporting the application of the `substantial factor' definition of proximate cause to a negligence or strict liability action involving a contaminated food product); Sorenson v. Raymark Indus., Inc., 51 Wash.App. 954, 957, 756 P.2d 740 (1988) (distinguishing Herskovits from an asbestos exposure claim that the plaintiff's risk of cancer was increased). Such limitation is common: [T]he courts that have accepted lost opportunity as cognizable harm have almost universally limited its recognition to medical-malpractice cases. RESTATEMENT (THIRD) OF TORTS: LIABILITY FOR PHYSICAL AND EMOTIONAL HARM § 26 cmt. n at 356-57 (2010). ¶ 19 Herskovits has been widely cited as an authority by other state courts and in journal articles for recognizing a cause of action in lost chance cases. See, e.g., Matsuyama v. Birnbaum, 452 Mass. 1, 16, 890 N.E.2d 819 (2008); McMackin v. Johnson County Healthcare Ctr., 2003 WY 91, ¶¶ 16-17, 73 P.3d 1094, 1100, adhered to on reh'g, 2004 WY 44, 88 P.3d 491; Tory A. Weigand, Loss of Chance in Medical Malpractice: The Need for Caution, 87 Mass. L.Rev. 3, 9 (2002). Since Herskovits, the majority of states that have considered the lost chance doctrine have adopted it, although with varying rationales. Matsuyama, 452 Mass. at 10 n. 23, 890 N.E.2d 819 (listing 20 states and the District of Columbia that have recognized the lost chance doctrine); see Weigand, supra, at 7-10. Several states have rejected the doctrine. Matsuyama, 452 Mass. at 10 n. 23, 890 N.E.2d 819 (listing 10 states that have declined to adopt the doctrine). And others have not yet reviewed the issue or have declined to reach the question. Id. ¶ 20 The rationales underpinning the lost chance doctrine have generally been applied the same in wrongful death claims and medical malpractice claims where the ultimate harm is something short of death. See, e.g., Shellenbarger, 101 Wash.App. at 349, 3 P.3d 211. In Delaney v. Cade, 255 Kan. 199, 873 P.2d 175 (1994), the Kansas Supreme Court recognized a cause of action for loss of chance of a better outcome. The court observed that many jurisdictions are like Kansas, in that the issue has only come up in a loss of survival case or a loss of a better recovery case. . . . We have found no authority or rational argument which would apply the loss of chance theory solely to survival actions or solely to loss of a better recovery actions and not to both. Id. at 209-10, 873 P.2d 175. But cf. Weymers v. Khera, 454 Mich. 639, 653, 563 N.W.2d 647 (1997) (we reject scrapping causation (the bedrock of our tort law) in negligence cases where the injury alleged by the plaintiff is something less than death). [6] We find no persuasive rationale to distinguish Herskovits from a medical malpractice claim where the facts involve a loss of chance of avoiding or minimizing permanent disability rather than death. To limit Herskovits to cases that result in death is arbitrary; the same underlying principles of deterring negligence and compensating for injury apply when the ultimate harm is permanent disability. ¶ 21 We note that, significantly, nothing in the medical malpractice statute precludes a lost chance cause of action. In relevant part, chapter 7.70 RCW provides that, in order to prove that injury resulted from the failure of the health care provider to follow the accepted standard of care, a plaintiff must establish: (1) The health care provider failed to exercise that degree of care, skill, and learning expected of a reasonably prudent health care provider at that time in the profession or class to which he belongs, in the state of Washington, acting in the same or similar circumstances; (2) Such failure was a proximate cause of the injury complained of. RCW 7.70.040. The chapter does not define proximate cause or injury. RCW 7.70.020. ¶ 22 The principal arguments against recognizing a cause of action for loss of a chance of a better outcome are broad arguments, similar to those raised when Herskovits was decided: concerns of an overwhelming number of lawsuits and their impact on the health care system; distaste for contravening traditional tort law, especially regarding causation; discomfort with the reliance on scientific probabilities and uncertainties to value lost opportunities. See Joseph H. King, Jr.,  Reduction of Likelihood Reformulation and Other Retrofitting of the Loss-of-a-Chance Doctrine, 28 U. MEM. L.REV. 491, 506 (1998); Matsuyama, 452 Mass. at 15, 890 N.E.2d 819 (noting criticisms of the doctrine, namely that it upends the long-standing preponderance of the evidence standard; alters the burden of proof in favor of the plaintiff; undermines the uniformity and predictability central to tort litigation; results in an expansion of liability; and is too complex to administer) However, none of these arguments effectively distinguish the Mohrs' claim from Herskovits and seem instead to agitate for its overruling. Now nearly 30 years since Herskovits was decided, history assures us that Herskovits did not upend the world of torts in Washington, as demonstrated by the few cases relying on Herskovits that have been heard by Washington appellate courts. ¶ 23 We hold that Herskovits applies to lost chance claims where the ultimate harm is some serious injury short of death. We also formally adopt the reasoning of the Herskovits plurality. Under this formulation, a plaintiff bears the burden to prove duty, breach, and that such breach of duty proximately caused a loss of chance of a better outcome. This reasoning of the Herskovits plurality has largely withstood many of the concerns about the doctrine, particularly because it does not prescribe the specific manner of proving causation in lost chance cases. Rather, it relies on established tort theories of causation, without applying a particular causation test to all lost chance cases. Instead, the loss of a chance is the compensable injury. ¶ 24 The significant remaining concern about considering the loss of chance as the compensable injury, applying established tort causation, is whether the harm is too speculative. We do not find this concern to be dissuasive because the nature of tort law involves complex considerations of many experiences that are difficult to calculate or reduce to specific sums; yet juries and courts manage to do so. We agree that [s]uch difficulties are not confined to loss of chance claims. A wide range of medical malpractice cases, as well as numerous other tort actions, are complex and involve actuarial or other probabilistic estimates. Matsuyama, 452 Mass. at 18, 890 N.E.2d 819. Moreover, calculation of a loss of chance for a better outcome is based on expert testimony, which in turn is based on significant practical experience and on data obtained and analyzed scientifically . . . as part of the repertoire of diagnosis and treatment, as applied to the specific facts of the plaintiff's case. Id. at 17, 890 N.E.2d 819. Finally, discounting damages responds, to some degree, to this concern. ¶ 25 In Herskovits, both the lead and concurring opinions discussed limiting damages. 99 Wash.2d at 619, 664 P.2d 474 (Dore, J., lead opinion), 635 (Pearson, J., plurality opinion). This is a common approach in lost chance cases, responsive in part to the criticism of holding individuals or organizations liable on the basis of uncertain probabilities. RESTATEMENT (THIRD) OF TORTS: LIABILITY FOR PHYSICAL AND EMOTIONAL HARM § 26 cmt. n at 356 (Rather than full damages for the adverse outcome, the plaintiff is only compensated for the lost opportunity. The lost opportunity may be thought of as the adverse outcome discounted by the difference between the ex ante probability of the outcome in light of the defendant's negligence and the probability of the outcome absent the defendant's negligence.). Treating the loss of a chance as the cognizable injury permits plaintiffs to recover for the loss of an opportunity for a better outcome, an interest that we agree should be compensable, while providing for the proper valuation of such an interest. Lord v. Lovett, 146 N.H. 232, 236, 770 A.2d 1103 (2001). In particular, the Herskovits plurality adopted a proportional damages approach, holding that, if the loss was a 40 percent chance of survival, the plaintiff could recover only 40 percent of what would be compensable under the ultimate harm of death or disability (i.e., 40 percent of traditional tort recovery), such as lost earnings. Herskovits, 99 Wash.2d at 635, 664 P.2d 474 (Pearson, J., plurality opinion) (citing, King, supra, 90 YALE L.J. at 1382). This percentage of loss is a question of fact for the jury and will relate to the scientific measures available, likely as presented through experts. Where appropriate, it may otherwise be discounted for margins of error to further reflect the uncertainty of outcome even with a nonnegligent standard of care. See King, supra, 28 U. MEM. L.REV. at 554-57 (conjunction principle). ¶ 26 We find that the Herskovits plurality has withstood the broad policy criticisms raised against it and comports with the medical malpractice statute. We find no meaningful basis to distinguish permanent disability from death for the purposes of raising a loss of chance claim. Accordingly, we hold that Herskovits applies to medical malpractice cases that result in harm short of death and formally adopt the rationale of the plurality opinion that the injury is the lost chance. For the reasons discussed next, as it relates to the facts of this case, we reverse the order of summary judgment.