Opinion ID: 2521221
Heading Depth: 2
Heading Rank: 2

Heading: Determining Whether to Impose a Duty

Text: Regarding the imposition of a duty of care, this court has noted generally that: In considering whether to impose a duty of reasonable care on a defendant, we recognize that duty is not sacrosanct in itself, but only an expression of the sum total of those considerations of policy which lead the law to say that the particular plaintiff is entitled to protection. Waugh v. University of Hawaiì, 63 Haw. 117, 135, 621 P.2d 957, 970 (1980); Kelley v. Kokua Sales & Supply, Ltd., 56 Haw. 204, 207, 532 P.2d 673, 675 (1975). Legal duties are not discoverable facts of nature, but merely conclusory expressions that, in cases of a particular type, liability should be imposed for damage done. Id. (quoting Tarasoff [v. Regents of the Univ. of California], 17 Cal.3d 425, 131 Cal.Rptr. 14, 551 P.2d [334,] 342 [(Cal.1976)]). In determining whether or not a duty is owed, we must weigh the considerations of policy which favor the appellants' recovery against those which favor limiting the appellees' liability. Waugh, 63 Haw. at 135, 621 P.2d at 970; Kelley, 56 Haw. at 207, 532 P.2d at 675. The question of whether one owes a duty to another must be decided on a case-by-case basis. Waugh, 63 Haw. at 135, 621 P.2d at 970. However, we are reluctant to impose a new duty upon members of our society without any logical, sound, and compelling reasons taking into consideration the social and human relationships of our society. Birmingham v. Fodor's Travel Publications, Inc., 73 Haw. 359, 370-71, 833 P.2d 70, 76 (1992) (holding that a publisher of a work of general circulation, that neither authors nor expressly guarantees the contents of its publication, has no duty to warn the reading public of the accuracy of the contents of its publication); Johnston v. KFC Nat'l Management Co., 71 Haw. 229, 232-33, 788 P.2d 159, 161 (1990) (declining to impose a duty upon non-commercial suppliers of alcohol, i.e., social hosts, to protect third parties from risk of injuries that might be caused by adults who consume the social hosts' alcohol). Blair, 95 Hawai`i at 259-60, 21 P.3d at 464-65 (citing Lee, 83 Hawai`i at 166, 925 P.2d at 336). We now turn to these policy considerations and the cases from other jurisdictions that the parties call to our attention. We begin by noting that, although the certified question inquires whether a duty is owed to a third party injured in an accident caused by an adverse effect of negligently prescribed medication, the facts supplied by the district court suggest that the McKenzies' negligence claim appears to rest on three general theories. First, the McKenzies claim that the decision to prescribe prazosin in the first instance constituted negligence. Second, the McKenzies claim that the manner in which Dr. Washecka prescribed the prazosin was negligent, namely, that the dosages were too high. Third, the McKenzies claim that Dr. Washecka was negligent because he did not provide Wilson with adequate warning of the danger associated with driving an automobile while taking the medication. The first two theories involve decisions such as whether to prescribe a medication at all, which particular medication to prescribe, and the particular dosage level or schedule to prescribe [hereinafter, prescribing decisions]; the latter theory involves failure to warn. Although the cases relied upon by the parties do not always expressly delineate this distinction, the distinction is often a key factor in their outcome. Accordingly, we consider the question of duty with respect to negligent prescribing decisions and negligent failure to warn separately. For each issue, we shall weigh the considerations of policy which favor recovery against those which favor limiting liability to determine if any logical, sound, or compelling reason exists to impose a new duty. [6]
The McKenzies argue that the fair allocation of the costs of harm and the need for fair compensation to victims mandates that physicians owe a duty to non-patient third parties injured as a result of negligent prescribing decisions. Wilson suggests that physicians owe a duty to the public generally. Indeed, other courts have recognized that imposition of a tort duty upon physicians for the benefit of the general public is not new. See generally Gooden v. Tips, 651 S.W.2d 364, 370-71 (Tex.Ct.App.1983) (discussing statutory requirement that physicians report the existence of certain sexually transmitted diseases to health authorities); Welke v. Kuzilla, 144 Mich.App. 245, 375 N.W.2d 403, 406 (1986) (noting generally in discussion of duty that highway safety is an important public concern). All of the foregoing policy considerations are important. In addition, the McKenzies cite to a number of cases, discussed infra, where other courts appear to have permitted actions involving allegations of negligent prescribing decisions to proceed. In support of its argument that a physician never owes a duty to non-patients, Kaiser cites to, inter alia, Lester v. Hall, 126 N.M. 404, 970 P.2d 590 (1998). In Lester, the plaintiff, a non-patient of the defendant physician, was injured by the physician's patient in an auto accident. See id. at 591. The plaintiff alleged that the physician negligently monitored his patient's medication and failed to warn his patient that the medication, lithium, could impair the patient's driving ability. Id. The patient had last seen the physician five days before the accident. Id. Answering a certified question from the United States District Court for the District of New Mexico, the New Mexico Supreme Court held that the doctor owed no duty to the non-patient plaintiff. Id. In so holding, the court considered several important policies in balancing the likelihood of injury, the magnitude of the burden of guarding against it and the consequences of placing that burden upon the defendant[,] id. at 592 (citations omitted), a duty analysis similar to our own. Most significantly, the court was concerned that the extension of a duty to non-patients would have a potentially serious chilling effect on the use of prescription medication in medical care and that it would intrude upon the indispensable loyalty which physicians must maintain towards their patient regarding their medical care and treatment decisions insofar as physicians would have to choose between prescribing beneficial medications to their patients and the risk that their prescribing decisions may result in liability to unknown third parties. See id. at 593; accord Webb v. Jarvis, 575 N.E.2d 992, 997 (Ind.1991). Prescribing decisions must take into account complicated issues concerning the potential benefits and risks to individual patients. Moreover, although we do not believe that doctors would altogether stop prescribing beneficial medications to their patients because of the risk of liability to third parties, an expansion of such liability would certainly discourage some prescriptionsparticularly, as amicus curiae HMA points out, the prescription of psychiatric medications that necessarily have behavioral effects. The social utility of these medications is enormous, and we do not want to discourage their use. The risk of tort liability to individual patients should be enough to discourage negligent prescribing decisions. As discussed infra, the risk of injury to non-patient third parties can be readily addressed through the more narrow question of whether there is a duty to warn patients against driving while under the influence of the medication. Moreover, controversially but realistically, physicians and patients must consider factors such as cost, cost-effectiveness, and availability of insurance coverage in prescribing decisions. Insurers likewise must consider treatment effectiveness and cost in determining which treatments to pay for and which medications to include on hospital and clinic formularies. A decision to cover one type of treatment may preclude funding for another. In this case, for example, the McKenzies seek to hold Kaiser accountable for what they suggest is Kaiser's decision to require its physicians to prescribe prazosin instead of other preferable but more expensive medications. Health care policy decisions require a complicated array of considerations by a variety of private and public decision makers, which include physicians, other professionals, regulators, employers, patients, and other health care consumer representatives who have a stake in such decisions. We believe that these policy decisions are better left to the aforementioned stakeholders than to judges and juries, at least with respect to non-patient third parties injured in automobile accidents. Similarly, individual treatment decisions are best left to patients and their physicians. [D]octors should not be asked to weigh notions of liability in their already complex universe of patient care. Lester, 970 P.2d at 593 (internal quotation marks omitted). Accordingly, considering the social utility of medications, the multitude of issues that already must be considered in prescribing decisions, the reality that existing tort law which is applicable to the individual patient should be sufficient to discourage negligent prescribing decisions, and the fact that imposing a duty to warn may readily reduce the risk to third parties, we discern no logical, sound, or compelling reasons, under the present circumstances, to introduce into the already complex universe of patient care the additional risk of tort liability to non-patient third parties injured in automobile accidents. To the extent that certain cases relied upon by the McKenzies involve negligent prescribing decisions, we believe they are distinguishable from the instant case. The cases cited by the McKenzies involve the prescription of controlled substances, which are well-knowneven to the lay observer to be commonly abused and, when abused, to cause impairment in many respects, including the impairment of driving ability. Further, the cases involve circumstances where it is obvious from the context that the third party presented an unreasonable hazard to others. For example, in Zavalas v. Olivares, 124 Or.App. 166, 861 P.2d 1026 (1993), the plaintiffs were killed or injured in an automobile accident caused by a patient who overdosed on heroin and Xanax (alprazolam), a controlled substance similar to Valium (diazepam). [7] Id. at 1026-27. The physician was purportedly easy about prescribing Xanax and prescribed one hundred tablets to the patient the first time he met her without obtaining a complete history because he was pressed for time. Id. at 1027. The physician also did not examine the patient's arms and, thus, did not notice the needle marks thereon. Id. Three days later, the physician refilled the prescription, and several days thereafter, the patient caused the accident. Id. At the time of the accident the patient was found to have Xanax, heroin, cocaine, and marijuana in her system. Id. Reversing a grant of summary judgment in favor of the physician, the Oregon Court of Appeals held that it was unwilling to categorically state, as a matter of law, that the physician did not owe a duty to the plaintiffs under any set of facts. Id. at 1029. Similarly, in Welke, the Michigan Court of Appeals reversed a grant of summary judgment in favor of the defendant doctor where the doctor had allegedly improperly prescribed controlled substances to a patient who killed the plaintiff in an auto accident. Welke, 375 N.W.2d at 404; see also Welke v. Kuzilla, 140 Mich.App. 658, 365 N.W.2d 205, 208 (1985) (Bronson, J., dissenting). [8] The doctor had also injected his patient, a friend who was driving the doctor's car at the time of the accident, with an unknown substance the night before. Welke, 375 N.W.2d at 404. Finally, in Watkins v. United States, 589 F.2d 214 (5th Cir.1979), the United States Court of Appeals for the Fifth Circuit, applying Alabama law and considering a challenge to the sufficiency of the evidence, affirmed a verdict in favor of a plaintiff who was injured in an automobile accident proximately caused by the defendant physician's prescription to the driver of a large amount of Valium several days earlier. Id. at 217. In so doing, the Fifth Circuit emphasized the trial court's finding that the prescribing physician had failed to inquire into the patient's recent psychiatric history, which the appeals court implied would have plainly preclude[d] the prescription. See id. It is widely known, even among the lay public, that individuals who abuse controlled substances can be impaired by those substances. It is also widely known that individuals who abuse controlled substances often seek to obtain access to these substances by a variety of means, including misrepresenting their need for the drugs to physicians and other health care providers. The facts in the cases relied upon by the McKenzies implicate the foregoing concerns where it was foreseeable that the patient could not be expected to take the medicine prescribed ... in the manner intended. See Gooden, 651 S.W.2d at 365. Finally, the serious adverse effects of drug abuse and the fact that abusers of controlled substances can be dangerous to themselves and others cannot be seriously disputed; for this reason, the prescribing of controlled substances is already highly regulated to a degree not present with other medical interventions. Thus, the prescribing of controlled substances represents a unique set of circumstances and implicates policy considerations not applicable to the case at bar. [9] Accordingly, without deciding whether we would carve out an exception in a case involving controlled substances, we hold that a physician does not owe a duty to non-patient third parties injured in an automobile accident caused by the patient's adverse reaction to a medication negligently prescribed by the physician three days earlier where the negligence involves prescribing decisions as that term is used in this opinion.
If Dr. Washecka owes any duty to the McKenzies in this case, such a duty arises from negligently failing to warn Wilson about the risk of operating a vehicle while under the influence of the medication. The strongest support for this proposition in the case law can be found in Kaiser v. Suburban Transportation System, 65 Wash.2d 461, 398 P.2d 14 (1965). In Kaiser, the defendant physician prescribed a sedating antihistamine to his patient, whom the physician knew to be a bus driver. Id. at 15-16. After taking the first dose of the medication the following morning, the driver went to work and was involved in an accident after falling asleep while driving the bus. Id. at 19 (Hale, J., dissenting). The driver had apparently felt groggy before the accident but continued to drive nonetheless. Id. A passenger on the bus was injured in the accident and sued the doctor and the bus company. Id. at 15 (majority opinion). The trial court dismissed the case against the doctor at the conclusion of the evidence on the grounds that the evidence did not show any standard of care to which the doctor was bound and that, even if the doctor was negligent in not warning the driver that the medication may cause sedation, the driver's negligence in failing to stop when he began to feel drowsy was an intervening cause. Id. The trial court, therefore, directed a verdict against the driver. Id. The Washington Supreme Court reversed. Id. at 19. In so doing, the supreme court noted that the evidence suggested that the doctor may not have informed his bus driver-patient of the dangerous side effects of drowsiness or lassitude from the drug and that expert evidence suggested that it was negligent not to do so. Id. at 16. The court also held that the plaintiff was entitled to judgment as a matter of law on the issue of liability against either the bus driver, the doctor, or both, depending upon whether the doctor had informed the driver of the risk of drowsiness and whether the driver was contributorily negligent. Id. at 18-19. In remanding the case, the court held that: The jury should be directed that (a) in the event it finds no warning was given the bus driver as to the side effects of the drug, it shall bring in a verdict against ... the doctor; (b) in the event the jury finds the bus driver failed to exercise the highest degree of care, even though he was given no warning as to the side effects of the drug, the jury shall also bring in a verdict against the bus company and the driver; and (c) in the event the jury finds that a warning of the side effects of the drug was given to the bus driver, then the verdict shall be against the bus company and the driver only. Id. at 19. Thus, the basis of the doctor's duty to the non-patient bus passenger stemmed solely from the need to warn his patient, a bus driver, of the potential side effect of drowsiness. Indeed, in many of the cases discussed in the previous section in which it was determined that a physician may owe a duty to non-patients, it appears that the physician's failure to warn his or her patient of the potential effects of the patient's medication or condition on driving ability was the predominant factor in the court's decision. In Gooden, for example, the Texas Court of Appeals reversed the trial court's grant of judgment on the pleadings in favor of the physician defendant where the physician allegedly prescribed Quaalude to a patient who subsequently injured the plaintiff in an auto accident. See Gooden, 651 S.W.2d at 365. The patient had been a patient of the doctor for twenty years and the physician was aware of the patient's drug abuse problems. See id. The court held that the physician may have had a duty to warn his patient not to drive. Id. at 370 (emphasis in original); see also Freese, Myers, and Duvall, supra note 9. Moreover, although the courts in Welke and Schuster did not expressly discuss the failure to warn issue as a predominant factor in their reasoning, failure to warn may have played some role in the decision not to preclude all chance of liability before trial. See Welke, 365 N.W.2d at 208 (decided at summary judgment stage); Schuster, 144 Wis.2d at 229-30, 424 N.W.2d at 161-62 (decided on pleadings). In these cases, failure to warn was included among several other claims which both courts allowed to proceed. Kaiser relies primarily upon Lester, Webb, Werner v. Varner, Stafford & Seaman, P.A., 659 So.2d 1308 (Fla.App.1995), Conboy v. Mogeloff, 172 A.D.2d 912, 567 N.Y.S.2d 960 (App.Div.1991), and Kirk v. Michael Reese Hospital & Medical Center, 117 Ill.2d 507, 111 Ill.Dec. 944, 513 N.E.2d 387 (1987), to support its argument that there should never be a duty to non-patient third parties. However, these cases offer weak support for the proposition that there is never a duty to warn of the risks of operating a vehicle while taking medication. Although the rationale relied upon in Lester and Webb (that the beneficial use of medications will be chilled) and the other considerations discussed earlier may be compelling justification for refusing to extend a duty to non-patient third parties for negligent prescribing decisions, these considerations are less persuasive when applied to the question whether physicians owe a duty to third parties to warn their patients of the potential effect on driving ability. [10] Whether there is a duty in such circumstances must again be determined by balancing the considerations in favor ofand againstimposing such a duty. It appears obvious that warning a patient not to drive because his or her driving ability may be impaired by a medication could potentially prevent significant harm to third parties. There is little [social] utility in failing to warn patients about the effects of a drug or condition that are known to the physician but are likely to be unknown to the patient. Praesel v. Johnson, 967 S.W.2d 391, 398 (Tex.1998). Furthermore, a physician already owes a duty to his or her patient under existing tort law to warn the patient of such a potential adverse effect. Thus, imposition of a duty for the benefit of third parties is not likely to require significant changes in prescribing behavior. One consideration opposing imposition of a duty to warn derives from the fact that warnings may not be effective in all circumstances. Sometimes, the incremental benefit to be obtained from requiring warnings may not be significant. [11] For example, the court in Lester expressed doubt about the effectiveness of warnings: In determining whether to erect a legal duty to warn, we must also consider the efficacy of that warning in preventing injury to third parties. We cannot simply assume that a person who is advised not to drive will actually respond and refrain from driving. The consequences of placing a legal duty on physicians to warn may subject them to substantial liability even though their warnings may not be effective to eliminate the risk in many cases. Unfortunately, many patients do not heed the admonitions of their physicians even though the consequences may be life-threatening to the patient or others. Id. at 597 (quoting Praesel, 967 S.W.2d at 398). In Lester, however, the plaintiff did not claim that the medication had been prescribed for the first time by the defendant physician five days before the automobile accident; rather, the plaintiff claimed that the physician had last treated the patient five days before the accident. Lester, 970 P.2d at 591. A warning is less necessary where a patient has previously taken the prescribed medication and is presumably aware of the medication's effect upon himself or herself. From the perspective of the physician, the foreseeability of injury to non-patients due to automobile accidents is considerably less under such circumstances. Moreover, it cannot be assumed that warnings will necessarily or usually be ineffective. For example, in Myers, the California appeals court held that a complaint stated a cause of action against the defendant doctors for negligently failing to warn their patient against driving in an uncontrolled diabetic condition complicated by the fact that the patient was emotionally distraught after learning that she was carrying a dead fetus. Myers, 193 Cal.Rptr. at 733-34. The plaintiff was injured in an accident caused by the patient shortly after she left the clinic to drive to the hospital at the doctors' behest. Id. One of the reasons offered by the court for imposing a duty was that the doctors could easily have warned their patient not to drive in her irrational and uncontrolled diabetic condition. Id. at 735. The court noted that such a warning would likely have been effective: [h]aving otherwise complied with her doctors' professional recommendations, [the patient] presumably would have continued to follow their advice had [the doctors] warned her not to drive. Id. [12] In many circumstances, however, the dangers associated with driving and a particular medication may already be commonly known or already known to the individual patient. In a related context, the court in Praesel, concluding that physicians do not owe a duty to non-patients to warn seizure patients against driving, reasoned: Balancing both the need for and the effectiveness of a warning to a patient who already knows that he or she suffers from seizures against the burden of liability to third parties, we conclude that the benefit of warning an epileptic not to drive is incremental but that the consequences of imposing a duty are great. The responsibility for safe operation of a vehicle should remain primarily with the driver who is capable of ascertaining whether it is lawful to continue to drive once a disorder such as epilepsy has been diagnosed and seizures have occurred. Accordingly, we decline to impose on physicians a duty to third parties to warn an epileptic patient not to drive. Praesel, 967 S.W.2d at 398. Thus, the scope of the physician's duty may be limited in situations where the danger is obvious, a warning would be futile, or the patient is already aware of the risk through other means. To summarize, we balance the considerations in favor of imposing a duty to warn for the benefit of third parties against the considerations militating against imposition of a duty. The primary considerations favoring a duty are that: (1) it is evident that a patient who is unaware of the risk of driving while under the influence of a particular prescription medication will probably do so; (2) warning against such activity could prevent substantial harm; (3) imposing a duty would create little additional burden upon physicians because physicians already owe their own patients the same duty; and (4) the majority of jurisdictions appear to recognize a duty under some circumstances. The primary consideration militating against the imposition of a duty is that it may not be worth the marginal benefit, in some circumstances, where the effectiveness of the warning is minimal or where the reasonable patient should be aware of the risk. Such circumstances may include, e.g., situations where patients have previously taken a particular medication and where patients are prescribed medications commonly known to affect driving ability. [T]he relative knowledge of the risk as between a patient and a physician is [a] factor to consider in deciding the threshold question of whether a physician owes a duty to third parties to warn a patient. Praesel, 967 S.W.2d at 398. [13] Balancing these considerations, we believe that a logical reason exists to impose upon physicians, for the benefit of third parties, a duty to advise their patients that a medication may affect the patient's driving ability when such a duty would otherwise be owed to the patient. As presented, the facts in this case do not suggest that the adverse effects of prazosin are commonly known by the lay public; nor do the facts suggest that Wilson was likely to know the adverse effects without a warning. Dr. Washecka was in a far better position to have such knowledge. Wilson had started taking the medication only three days earlier and, from Dr. Washecka's instructions as they are presented to us, it appears that the medication was still being adjusted to its effective dosage. The facts presented to us thus do not indicate that Wilson would be expected to have sufficient past familiarity with its effects to preclude imposition of a duty. Under these circumstances, if Dr. Washecka owed Wilson a duty to inform him about the effects that prazosin may have on his driving ability ( i.e., if it would have been negligent not to inform his own patient), then Dr. Washecka owes the McKenzies a duty to inform Wilson about the possibility that prazosin would adversely affect Wilson's driving ability. We emphasize that our answer to the certified question is not intended, without more, to resolve the questions whether Dr. Washecka in fact owed Wilson a duty to warn him regarding the effects that prazosin may have on his driving ability, whether any warnings that Wilson received were adequate, or whether Dr. Washecka's conduct was the legal cause of any injury. These must be determined in the course of the subsequent proceedings.