Opinion ID: 1417789
Heading Depth: 1
Heading Rank: 8

Heading: Battery v. Malpractice

Text: Because of the shambles that this case has left in the New Mexico law of malpractice and physician-battery, we are compelled to analyze and define the nomenclature and the components of various issues arising in these cases. In the past twenty years, since the decision in Salgo v. Leland Stanford, Jr. Univ. Bd. of Trustees, 154 Cal. App.2d 560, 317 P.2d 170 (1957), which first introduced the theory of informed consent in medical malpractice suits, few legal issues have generated as great confusion and as great a volume of cases and law review articles. The cases, which deal with a vast number of conflicting theories, demonstrate rapid and radical changes in this field of law. E.g., the list of authorities in the concurring opinion of Sutin, J., in Demers, supra, 85 N.M. at 649, 515 P.2d at 653; Woods v. Brumlop, 71 N.M. 221, 377 P.2d 520 (1962); Canterbury v. Spence, 150 U.S.App.D.C. 263, 464 F.2d 772 (1972), cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (1972); Shetter v. Rochelle, 2 Ariz. App. 358, 409 P.2d 74 (1965) modified on rehearing, 2 Ariz. App. 607, 411 P.2d 45 (1966); Cobbs v. Grant, 8 Cal.3d 229, 104 Cal. Rptr. 505, 502 P.2d 1 (1972); Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093 (1960); Bang v. Charles T. Miller Hospital, 251 Minn. 427, 88 N.W.2d 186 (1958); Aiken v. Clary, 396 S.W.2d 668 (Mo. 1965); Mitchell v. Robinson, 334 S.W.2d 11 (Mo. 1960), aff'd after remand, 360 S.W.2d 673 (Mo. 1962); Corn v. French, 71 Nev. 280, 289 P.2d 173 (1955), aff'd after remand, 74 Nev. 329, 331 P.2d 850 (1958); Gray v. Grunnagle, 423 Pa. 144, 223 A.2d 663 (1966); Plant, The Decline of Informed Consent, 35 Wash. & Lee L.Rev. 91 (1978); Riga, Informed Consent, 10 Lincoln L.Rev. 159 (1977). A favorite starting place for literature on informed consent is the statement of Justice Cardozo in Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 105 N.E. 92, 93 (1914) that: Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages. The right of self-determination by an informed patient has developed as the most important ingredient in the law on this subject. At the outset it must be emphasized that one of the greatest causes of confusion is the failure to distinguish between causes of action founded on battery and those based on negligence. Cobbs, supra ; Plante, An Analysis of Informed Consent, 36 Fordham L.Rev. 639, 650 (1968). Under the legal rubric of battery, courts have jealously guarded a patient's right to know and to agree to what a physician or surgeon intends to do to him. An intentional touching to which a patient has given no consent is considered a battery. W. Prosser, Handbook of the Law of Torts, § 18, at 102-6 (4th ed. 1971). Katz, Informed Consent  A Fairy Tale? Law's Vision, 39 U.Pitt.L.Rev. 137, at 144 (1977). To defeat a battery claim, however, the information which must be disclosed is quite narrow in scope. A physician only has to inform the patient of the nature of the procedure; that is, what the doctor proposes to do to him. Failure to advise the patient of this minimal basic information admits of no excuse, except when an emergency requires intervention without delay. Katz, supra, citing Cobbs, supra ; Schloendorff, supra ; and, McCoid, A Reappraisal for Liability for Unauthorized Medical Treatment, 41 Minn.L.Rev. 381 (1957). The only question that is asked in a battery case is did the patient know and agree to what was going to be done to him. If not, the law does not require the patient to be physically damaged by the intervention. Even if his health is significantly improved, the doctor is still liable. Informed consent is not a key issue. There need be no proof that the patient may have gone ahead with the operation had the doctor fulfilled his duty to disclose the nature of the procedure. Generally included in the battery cases are those instances where the patient consented to the performance of one kind of operation and the physician performed a substantially different one for which consent was not obtained, as is alleged by Demers in this case. These are considered to be clear cases of battery, as opposed to malpractice, which is based on negligence. Cobbs, supra ; Bang, supra, (plaintiff consented to a prostrate resection when uninformed that this procedure involved tying off his sperm ducts); Corn, supra, (patient consented to an exploratory surgery but the doctor performed a mastectomy). The importance of distinguishing between the two types of action becomes apparent when it is considered that in most medical malpractice suits expert medical testimony must be adduced to establish a standard of care, to assess the doctor's performance in light of the standard, and to prove causation. In battery cases it has generally been held that expert medical testimony is not required to establish a standard of care or to show causation. Cobbs, supra . This makes the case much easier for the plaintiff to prove. The factual issue is whether the patient did or did not consent to the specific operation performed by the physician. It is not a question of what the doctor should have told his patient about the nature of the operation but whether he did tell him what was going to transpire. In other areas of litigation jurors have the daily responsibility of assessing conflicting testimony and determining what was said and what agreements were reached by litigants. There is nothing unique about the doctor-patient relationship that warrants a rule that in all cases expert medical testimony is required to establish what was agreed to by the parties. Shetter, supra ; Cobbs, supra . As to causation in a battery action, the tort of battery is the wrongful touching of the patient's body which by itself gives the patient a claim for substantial damages. Shetter, supra . In Cobbs, supra, the court held: The battery theory should be reserved for those circumstances when a doctor performs an operation to which the patient has not consented. When the patient gives permission to perform one type of treatment and the doctor performs another, the requisite element of deliberate intent to deviate from the consent given is present. However, when the patient consents to certain treatment and the doctor performs that treatment but an undisclosed inherent complication with a low probability occurs, no intentional deviation from the consent given appears; rather, the doctor in obtaining consent may have failed to meet his due care duty to disclose pertinent information. In that situation the action should be pleaded in negligence. 104 Cal. Rptr. at 512, 502 P.2d at 8. We agree that there should be such a distinction between battery and malpractice. It is now generally held that an action involving lack of informed consent does not lie within the traditional concepts of battery. Where a patient is informed by a physician as to the nature and extent of the operation but is not reasonably informed of the risk involved, the cause of action is in negligence. Murriello v. Crapotta, 51 App.Div.2d 381, 382 N.Y.S.2d 513 (1976). This failure is considered in most jurisdictions to be a negligent breach of professional standards of conduct. Di Filippo v. Preston, 3 Storey 539, 53 Del. 539, 173 A.2d 333 (1961); Kaplan v. Haines, 96 N.J. Super. 242, 232 A.2d 840 (1967). This line of authority holds that where a physician does not disclose all the information deemed material to his patient's decision, it nullifies the consent obtained prior to treatment. This has become known as the materiality standard. The physician is required to disclose the factors that might reasonably influence the patient in his decision, such as the inherent potential hazards of the proposed treatment, any alternatives to that treatment, and the results likely if the patient remained untreated. There is no New Mexico authority precisely in point. This may well be a case of first impression on the narrow question of whether expert medical testimony is mandatory to establish the care which would be used by reasonably well-qualified specialists in the same field practicing under similar circumstances in disclosing the risks and complications of the procedures employed in an operation. Other than the earlier Demers case, the only New Mexico case that comes close to the question is Woods, supra, which is not wholly analogous to the facts. That case caused a considerable amount of criticism and discussion. Karchmer, Informed Consent: A Plaintiff's Medical Malpractice Wonder Drug, 31 Mo.L.Rev. 29 (1966); Myers, Informed Consent in Medical Malpractice, 55 Cal.L.Rev. 1396 (1967); Plante, supra, 36 Fordham L.Rev. 634; Waltz & Scheuneman, Informed Consent to Therapy, 64 N.W.Univ.L.Rev. 628 (1970). In Woods, supra, the patient claimed that the doctor failed to inform her of the dangers inherent in the medical procedures and told her that no harmful results could occur, knowing that statement to be untrue. Id. 71 N.M. at 223, 377 P.2d at 521. It was shown that the plaintiff had no knowledge of the procedures and no basis on which to predicate her consent to the treatment. There was no medical testimony establishing the causal relationship, and the doctor contended that the lay testimony of plaintiff as to the cause of a physical condition was inadmissible. Mrs. Woods had taken electroshock treatments and claimed that it resulted in loss of hearing. Her testimony was the only evidence on the causal connection between the electroshock treatments and the loss of hearing. This Court considered the duties of a doctor to advise his patient as to the probable consequences and the dangers connected with it, and, in ruling on a motion of the doctor for a directed verdict, stated: A physician who misleads a patient by not only failing to give a warning of reasonable and recognized risks inherent in a treatment after which the patient would have refused the treatment, but by affirmatively assuring her that there are no risks, knowing such statement to be untrue, is liable for the harmful consequences of the treatment. Such a failure to disclose, or the giving of an untrue answer as to the probable consequences of a treatment constitutes malpractice; and a doctor who fails to so advise his client, or gives an untrue answer as to such consequences, is liable for malpractice unless his failure to do so comes within one of the exceptions to the rule requiring candor and disclosure. Under the circumstances of this case, a fact issue was presented for determination by the jury upon which there was no necessity for expert medical testimony. Id. at 229, 377 P.2d at 525. To the extent that Woods may hold that it is never necessary to have medical testimony on the question of the quantum of information to be given a patient about the dangers of medical procedures in order to obtain the consent to an operation, Woods is opposed to the general rule. Many jurisdictions that have decided the issue hold that it is necessary that standards be established by expert medical testimony on this issue, as well as on the issue of causation, so that the acts of the doctor in question may be measured by the usual practices of specialists in the same field under similar circumstances. Plante, supra, 36 Fordham L.Rev. 639. Reading Woods more strictly, it is arguable that the court's decision was based on the misrepresentation practiced by the physician. The case of Canterbury, supra, is by far the best reasoned and authoritative in the field. Canterbury recognized that a majority of the courts at that time made the duty to disclose depend on whether it was the custom of physicians practicing in the community to make the particular disclosure to the patient. E.g., Di Filippo, supra ; Roberts v. Young, 369 Mich. 133, 119 N.W.2d 627 (1963); Aiken, supra . Thus the physician could be held liable for an unreasonable and injurious failure to divulge, but no recovery would be forthcoming unless the omission forsakes a practice prevalent in the profession. However, Canterbury disagreed that there must be an existence and non-performance of a professional tradition. The court claimed that the physician's obligation is not limited by medical practice. The court senses a danger that such a holding would be taken as an affirmative custom to maintain silence. Binding the disclosure obligation to medical usage would be to arrogate the decision on revelation to the physician alone. Respect for the patient's right of self-determination on particular therapy demands a standard set by law for physicians rather than one which physicians may or may not impose upon themselves. Canterbury, 150 U.S.App.D.C. at 275, 464 F.2d at 784. (Footnotes omitted.) In discussing the reasonably prudent person doctrine, the Canterbury court quoted from Wash. Hosp. Center v. Butler, 127 U.S.App.D.C. 379, 383, 384 F.2d 331, 335 (1967): The law requires those engaging in activities requiring unique knowledge and ability to give a performance commensurate with the undertaking; and held that physicians are required to act as reasonable men who possessed their medical talents presumably would, stating: There is    no basis for operation of the special medical standard where the physician's activity does not bring his medical knowledge and skills peculiarly into play.    The decision   is ofttimes a non-medical judgment and, if so, is a decision outside the ambit of the special standard.       When medical judgment enters the picture and for that reason the special standard controls, prevailing medical practice must be given its just due. In all other instances, however, the general standard exacting ordinary care applies, and that standard is set by law.    We hold that the standard measuring performance of that duty by physicians, as by others, is conduct which is reasonable under the circumstances. Canterbury, 150 U.S.App.D.C. at 276, 464 F.2d at 785 (footnotes omitted). Canterbury held that full disclosure is obviously prohibitive and unrealistic. It expects physicians to discuss with their patients every risk of proposed treatment no matter how small or remote: [The physician] cannot know with complete exactitude what the patient would consider important to his decision, but on the basis of his medical training and experience he can sense how the average, reasonable patient expectably would react.    The scope of the standard is not subjective as to either the physician or the patient; it remains objective with due regard for the patient's informational needs and with suitable leeway for the physician's situation.       The topics importantly demanding a communication of information are the inherent and potential hazards of the proposed treatment, the alternatives to that treatment, if any, and the results likely if the patient remains untreated.    There is no bright line separating the significant from the insignificant; the answer in any case must abide a rule of reason. Some dangers  infection, for example  are inherent in any operation; there is no obligation to communicate those of which persons of average sophistication are aware. Even more clearly, the physician bears no responsibility for discussion of hazards the patient has already discovered, or those having no apparent materiality to patients' decision on therapy.    Whenever non-disclosure of particular risk information is open to debate by reasonable-minded men, the issue is for the finder of the facts. Id. 150 U.S.App.D.C. at 278-79, 464 F.2d at 787-88 (footnotes omitted). The Canterbury court recognized exceptions to the general rule of disclosure, such as, when the patient is unconscious or otherwise incapable of consenting, and when the patient is so ill or emotionally distraught as to foreclose a rational decision, or complicate or hinder the treatment. In these cases it becomes a question of sound medical judgment that the risk information would present a threat to the patient's well-being. The court in Canterbury held that there must be a causal connection between the physician's failure to adequately inform and damage to the patient: [A] technique which ties the factual conclusion on causation simply to the assessment of the patient's credibility is unsatisfactory.       It places the physician in jeopardy of the patient's hindsight and bitterness.    Better it is, we believe, to resolve the causality issue on an objective basis: in terms of what a prudent person in the patient's position would have decided if suitably informed of all perils bearing significance.    The patient's testimony is relevant on that score of course but it would not threaten to dominate the findings.          [T]he patient has the burden of going forward with evidence tending to establish prima facie the essential elements of the cause of action, and ultimately the burden of proof  the risk of nonpersuasion  on those elements.   The burden of going forward with evidence pertaining to a privilege not to disclose, however, rests properly upon the physician. Id. 150 U.S.App.D.C. at 281-82, 464 F.2d at 790-91 (footnotes omitted). Most jurisdictions have now accepted an objective test based upon what a prudent person in plaintiff's position would have decided if suitably informed of the significant perils involved. Karp v. Cooley, 493 F.2d 408, 422, n. 18 (5th Cir.1974), cert. denied, 419 U.S. 845, 95 S.Ct. 79, 42 L.Ed.2d 73 (1974); Bowers v. Garfield, 382 F. Supp. 503, 505-6 (E.D.Pa. 1974), aff'd, 503 F.2d 1398 (1974); Cobbs, supra . Under this theory, the cause of action would then be available only if the non-disclosed facts would have altered a reasonably prudent person's decision to undergo treatment, rather than that of the particular patient. Zeleznik v. Jewish Chronic Disease Hospital, 47 App. Div.2d 199, 366 N.Y.S.2d 163, at 171-72 (1975). In discussing the need for expert testimony in non-disclosure cases, the Canterbury court stated that experts are ordinarily indispensable to identify and elucidate for the fact-finder the risks of therapy and consequences of leaving existing maladies untreated, as well as the cause of injuries or disability and the nature and seriousness of any impact upon the patient from risk disclosure. However, that court also recognized that, medical facts are for medical experts and other facts are for any witnesses  expert or not  having sufficient knowledge and capacity to testify to them.    [M]any of the issues    do not reside peculiarly within the medical domain. Lay witness testimony can competently establish a physician's failure to disclose particular risk information, the patient's lack of knowledge of the risk, and the adverse consequences following the treatment. Canterbury, 150 U.S.App.D.C. at 283, 464 F.2d at 792 (footnotes omitted). We approve of and adopt the language from Canterbury repeated herein. In light of the above law, some of the evidence introduced by Demers indicates what amounts to a classic case of common law battery, based on Dr. Gerety's performing an operation which he had, allegedly, been specifically told not to perform; which constituted an unlawful touching. On the other hand, Demers also made allegations which would, if proved, sustain a claim of medical malpractice based on negligence. N.M.U.J.I. Civ. 8.2. However, Demers failed to properly plead or request valid instructions on battery. On the issue of medical malpractice no expert medical testimony was produced to prove causation and a verdict was properly directed on that issue. On the question of the validity of Demers' consent to surgery, the second trial court did not commit error in applying the clear and convincing test to Demers' evidence of drug-induced incompetency, that rule having been established as the law of the case. In any event, the combined record in both trials furnishes no substantial evidence to justify the submission of this issue to the jury or to support a verdict based upon the incompetency of Demers at the time he signed the consent. The Court of Appeals was in error in ordering a new trial. We held in Pharmaseal, supra : Negligence of a doctor in a procedure which is peculiarly within the knowledge of doctors, and in which a layman would be presumed to be uninformed, would demand medical testimony as to the standard of care. However, if negligence can be determined by resort to common knowledge ordinarily possessed by an average person, expert testimony as to the standards of care is not essential. Id. 90 N.M. at 758, 568 P.2d at 594. We see no reason to deviate from the rationale behind the decision in Pharmaseal that the use of expert medical testimony should be employed when the trial court reasonably decides that it is necessary to properly inform the jurors on the issues. This includes establishing the standard of care, treatment and information by which the actions of the physician are to be judged, the manner in which he measures up to the standard and whether his alleged acts were the proximate cause of the injuries involved. We reject the wording in Woods, supra, relied upon by the Court of Appeals, which would establish a principle of full and complete disclosures and to the subjective method of determining the standard for informing the patient. See Demers, supra, 85 N.M. at 645, 515 P.2d at 649. We adopt an objective standard, based on the knowledge or skill of an ordinary patient or physician, as being the most reasonable theory for both parties involved. The Court of Appeals' decision is reversed. The trial court's decision is affirmed. Judgment is hereby granted in favor of Dr. Gerety. IT IS SO ORDERED. McMANUS, C.J., and SOSA, PAYNE and FEDERICI, JJ., concur.