Opinion ID: 1290704
Heading Depth: 2
Heading Rank: 1

Heading: Scope of Chiropractic Informed Consent

Text: ¶ 31. The issue in this case concerns the scope of a chiropractor's duty to obtain informed consent from his patient before proceeding with treatment and whether such duty is similar to a medical doctor's duty to obtain informed consent. Boyson argues that a chiropractor's duty to obtain informed consent is subject to the same parameters and limitations as that of a physician and that a failure to obtain informed consent constitutes a separate basis for finding a chiropractor liable in a malpractice action. Hannemann contends that chiropractic informed consent is not governed by the same standards as informed consent in the medical context. Hannemann asserts that a chiropractor's informed consent obligations are limited to the standard form patients sign before beginning treatment. According to Hannemann, informed consent in chiropractic is not a separate basis upon which a chiropractor can be found liable in a malpractice action; rather, it is simply part of the chiropractic standard of care. For the foregoing reasons, we agree with Boyson. ¶ 32. In Murphy, 222 Wis. 2d at 584-85, the court of appeals, with very little analysis, determined that the law of informed consent was facially inapplicable to a chiropractic negligence case. Murphy reasoned that the law of informed consent was based on § 448.30, whose explicit language applies only to physicians. Id. Neither party in the present dispute argues that the law of informed consent is entirely inapplicable to the practice of chiropractic. ¶ 33. A year before Murphy was decided, the Chiropractic Examining Board promulgated Wis. Admin. Code § Chir 11.02, entitled Patient record contents. Wisconsin Admin. Code § Chir 11.02(5) provides: Patient records shall include documentation of informed consent of the patient, or the parent or guardian of any patient under the age of 18, for examination, diagnostic testing and treatment. The code provision was made effective June 1997. Therefore, there is no dispute that a chiropractor has an obligation to obtain informed consent; rather, the question is what that duty entails. As the administrative code does not describe the obligation to secure informed consent or set forth any parameters or limitations on the obligation, we examine the concept of informed consent under our common law. ¶ 34. The concept of informed consent in this state originated in context of medical malpractice. A physician's failure to obtain a patient's permission for a non-emergency procedure was considered an assault and battery, in that it constituted an unwanted touching of another person. Trogun v. Fruchtman, 58 Wis. 2d 569, 596, 598, 207 N.W.2d 297 (1973). The obligation to secure informed consent before performing a procedure was premised on the notion that a person of sound mind has a right to determine, even as against his physician, what is to be done to his body. Id. at 596. ¶ 35. In Trogun, this court determined that it was no longer appropriate to treat the failure to obtain informed consent as an assault and battery and instead recognize[d] a legal duty, bottomed upon a negligence theory of liability, in cases wherein it is alleged the patient-plaintiff was not informed adequately of the ramifications of a course of treatment. Id. at 600. However, even under this negligence-based theory, a physician's obligation to disclose risks and obtain consent is determined in light of what a reasonable patient would want to know when making a medical decision rather than the standard for disclosure in the relevant community. Id. at 601-04. In other words, even under the negligence theory of informed consent, ` the patient's right of self-decision is the measure of the physician's duty to reveal. ' Id. at 602 (quoting Cobbs v. Grant, 502 P.2d 1, 11 (Cal. 1972))(emphasis added). ¶ 36. Therefore, applying the Trogun theory of informed consent, this court has held: [A] physician has a duty to make a reasonable disclosure to his patient of the significant risks in view of the gravity of the patient's condition, the probabilities of success, and any alternative treatment or procedures if such are reasonably appropriate so that the patient has the information reasonably necessary to form the basis of an intelligent and informed consent to the proposed treatment or procedure. Scaria v. St. Paul Fire & Marine Ins. Co., 68 Wis. 2d 1, 11, 227 N.W.2d 647 (1975). The duty is not measured by the standards used in the relevant medical community because: The right to be recognized and protected is the right of the patient to consent or not to consent to a proposed medical treatment or procedure. Because of the patient's lack of professional knowledge, he cannot make a rational reasonable judgment unless he has been reasonably informed by the doctor of the inherent and potential risks. The right of the patient and the duty of the doctor are standards recognized and circumscribed by the law and are not entirely dependent upon the customs of the profession. Id. at 12. ¶ 37. As the duty to disclose the risks of medical procedures and treatment arises from the patient's right to make an informed decision and refuse the bodily intrusion accompanied by the procedure or treatment, there are limits to what a doctor must disclose: A doctor should not be required to give a detailed technical medical explanation that in all probability the patient would not understand. He should not be required to discuss risks that are apparent or known to the patient. Nor should he be required to disclose extremely remote possibilities that at least in some instances might only serve to falsely or detrimentally alarm the particular patient. Likewise, a doctor's duty to inform is further limited in cases of emergency or where the patient is a child, mentally incompetent or a person is emotionally distraught or susceptible to unreasonable fears. Id. at 12-13. ¶ 38. Moreover, a doctor's duty to disclose the risks of treatments or procedures is limited to those risks that a reasonable person would want to know. Id. at 15. Thus, it is not sufficient for a patient to demonstrate that in hindsight he would not have undergone the procedure if he had been appraised of the risks; rather, there must be proof that a reasonable person, when appraised of the risks involved, would not have consented to the procedure in question. Id. ¶ 39. In essence, a doctor must make such disclosures as appear reasonably necessary under circumstances then existing to enable a reasonable person under the same or similar circumstances confronting the patient at the time of disclosure to intelligently exercise his right to consent or to refuse the treatment or procedure proposed. Id. at 13. In other words, A physician who proposes to treat a patient or attempt to diagnose a medical problem must make such disclosures as will enable a reasonable person under the circumstances confronting the patient to exercise the patient's right to consent to, or refuse the procedure proposed or to request an alternative treatment or method of diagnosis. Martin v. Richards, 192 Wis. 2d 156, 176, 531 N.W.2d 70 (1995). However, obtaining informed consent is not necessarily a one-time occurrence: a substantial change in circumstances, be it medical or legal, requires a new informed consent discussion. Fischer v. Wis. Patients Comp. Fund, 2002 WI App 192, ¶ 17, 256 Wis. 2d 848, 650 N.W.2d 75 (citing Schreiber v. Physicians Ins. Co., 223 Wis. 2d 417, 437, 588 N.W.2d 26 (1999)). ¶ 40. Although liability for failure to obtain informed consent is premised on negligence principles, it is nonetheless treated under the law as a separate and distinct form of malpractice: A failure to diagnose is one form of medical malpractice. A failure to obtain informed consent is another discrete form of malpractice, requiring a consideration of additional and different factors. Finley v. Culligan, 201 Wis. 2d 611, 628, 548 N.W.2d 854 (Ct. App. 1996) (citing Knief v. Sargent, 40 Wis. 2d 4, 8, 161 N.W.2d 232 (1968)); Wis JI  Civil 1023). [T]he touchstone of the test [for informed consent] [i]s what the reasonable person in the position of the patient would want to know. Schreiber, 223 Wis. 2d at 427. ¶ 41. We see no reason why these principles of informed consent, while initially developed and applied in the context of medical malpractice, are not equally applicable to chiropractors. Hannemann's main argument against applying the above principles of informed consent is that chiropractors are not medical doctors, do not practice medicine, and are not subject to the same standard of care as physicians. Hannemann is correct that there are obvious differences between the practice of chiropractic and the practice of medicine. [T]he legislature has recognized the practice of chiropractic as a separate and distinct health care discipline.... [B]y limiting chiropractors to the use of chiropractic adjustments and the principles or techniques of chiropractic science in the diagnosis, treatment or prevention of disease while prohibiting the use of traditional medical tools, e.g., drugs or surgery, the legislature has recognized that the practice of chiropractic is distinct from the practice of medicine. Kerkman v. Hintz, 142 Wis. 2d 404, 415-16, 418 N.W.2d 795 (1988). More specifically, [A] chiropractor does not treat or diagnose disease. Instead, a chiropractor's practice is limited to the analysis and correction of subluxation. The chiropractor's function is to locate the subluxation, if it exists, adjust it back to the correct position, and then allow the body to restore itself to normalcy. A medical doctor's practice, on the other hand, is completely opposite. The medical doctor is concerned with the diagnosis and treatment of the diseased area through the use of drugs and surgery or other techniques. Id. at 416. ¶ 42. However, [i]n licensing chiropractors to examine into the cause of departure from complete health and by authorizing chiropractors to diagnose, treat or prevent disease, the legislature has recognized chiropractors as providers of health care. Id. at 415-16. Furthermore, our courts have determined that chiropractors are health care providers under Wis. Stat. § 893.55, which sets forth the limitation period for medical malpractice claims against health care providers. Arenz v. Bronston, 224 Wis. 2d 507, 515, 592 N.W.2d 295 (Ct. App. 1999). Thus, while the practice of chiropractic is separate and distinct from that of medicine, it is nonetheless a health care discipline. Kerkman, 142 Wis. 2d at 415-16. In Arenz, the court of appeals reasoned that chiropractors met the statutory definition of health care provider because, like medical doctors, [t]hey are involved in the diagnosis, treatment or care of their patients, and they are licensed by a state examining board. Arenz, 224 Wis. 2d at 515. ¶ 43. As discussed supra, the concept of informed consent developed out of the right of every person to refuse unwanted medical treatment and control what is done to his body. The doctrine of informed consent comes from the common law and stems from the fundamental notion of the right to bodily integrity[.] Martin, 192 Wis. 2d at 169. These principles continue to form the basis of the modern concept of informed consent. Trogun, 58 Wis. 2d at 602. Thus, the right to informed consent arises not from anything peculiar to the medical profession, but from the notion that an adult has a `right to determine what shall be done with his own body....' Schreiber, 223 Wis. 2d at 426 (quoting Schloendorff v. Soc'y of New York Hosp., 105 N.E. 92, 93 (N.Y. 1914), overruled on other grounds by Bing v. Thunig, 143 N.E.2d 3 (N.Y. 1957)). ¶ 44. Medical doctors are obligated to disclose and discuss the material risks of any given procedure or treatment with their patients so that their patients may make informed decisions as to whether they want to consent to bodily intrusions and proceed with the recommended procedure or treatment. Chiropractors, like medical doctors, are health care professionals involved in the application of procedures and treatments to the human body. We see no reason why the scope of an individual's right to be informed of the risks inherent in bodily intrusions via chiropractic treatment and procedures should be any different from his right to be informed of the risks inherent in bodily intrusions via medical treatment and procedures. ¶ 45. While the two disciplines are distinct forms of health care, there is no logical reason why a patient of chiropractic should not have the same right as a patient of medical practice to be informed of the risks material to proposed treatments or procedures so as to be able to make an informed decision and consent to the proposed treatments or procedures. In other words, while the specific treatments and procedures utilized in the practice of chiropractic and the practice of medicine may differ, there is no reason why the practitioners of these disciplines should not have the same obligation to disclose the material risks of the procedures and treatments they utilize. ¶ 46. We reject Hannemann's repeated assertions that informed consent in chiropractic is merely a one-time obligation that is satisfied by simply providing a form before beginning treatment. The form may be evidence or documentation of the risks disclosed to a patient, but the form itself is not informed consent. Informed consent is mak[ing] such disclosures as will enable a reasonable person under the circumstances confronting the patient to exercise the patient's right to consent to, or to refuse the procedure proposed or to request an alternative treatment or method of diagnosis. Martin, 192 Wis. 2d at 176. In other words, informed consent is a duty to make such disclosures as appear reasonably necessary under circumstances then existing to enable a reasonable person under the same or similar circumstances confronting the patient at the time of disclosure to intelligently exercise his right to consent or to refuse the treatment or procedure proposed. Scaria, 68 Wis. 2d at 13. ¶ 47. Although the specifics of the disclosures will undoubtedly vary between the practice of medicine and the practice of chiropractic, the rules governing the scope and limits of the duty to disclose and obtain informed consent should be the same. The scope and limits of the duty to disclose material risks and obtain informed consent are aptly set forth in Wis JI  Civil 1023.1. While this instruction may need to be modified when applied to chiropractors, this can easily be accomplished. ¶ 48. Hannemann's last argument is that Wis JI  Civil 1023.1 should not apply to chiropractors because the jury instruction is based on § 448.30, which applies only to physicians. Section 448.30 requires physicians to make certain disclosures pertaining to all viable modes of treatment. Schreiber, 223 Wis. 2d at 428. Section 448.30 first became effective in 1982. See § 2, ch. 375, Laws of 1981. In contrast, Wis JI  Civil 1023.1 was first adopted following this court's decisions in Trogun and Scaria in 1975. See Law Note, Wis JI  Civil 1023.1. Moreover, § 448.30 was enacted in order to codify the common-law standards for informed consent set forth in Scaria. See Schreiber, 223 Wis. 2d at 427-28; Law Note, Wis JI  Civil 1023.1. Furthermore, the scope and limitations on the duty of informed consent in Wis JI  Civil 1023.1 all derive from Trogun and its progeny, which adopted the reasonable patient standard for informed consent. See Martin, 192 Wis. 2d at 176; Scaria, 68 Wis. 2d at 13; Trogun, 58 Wis. 2d at 601-04. Therefore, a physician's duty to obtain informed consent, while codified in § 448.30, is not dependent on that statute for its existence. While our common-law informed consent jurisprudence has been codified with respect to one health care profession, we are not prohibited from extending that common law to another health care profession. ¶ 49. In sum, we conclude that a chiropractor's duty of informed consent is to make such disclosures as will enable a reasonable person under the circumstances confronting the patient to exercise the patient's right to consent to, or to refuse the procedure proposed or to request an alternative treatment or method of diagnosis. Martin, 192 Wis. 2d at 176. He must make such disclosures as appear reasonably necessary under circumstances then existing to enable a reasonable person under the same or similar circumstances confronting the patient at the time of disclosure to intelligently exercise his right to consent or to refuse the treatment or procedure proposed. Scaria, 68 Wis. 2d at 13.