Opinion ID: 2544529
Heading Depth: 3
Heading Rank: 2

Heading: Jury Instructions Concerning the Standard for Deciding Breach of Duty To Disclose

Text: Marsingill next claims that the trial court erred in rejecting her proposed jury instructions regarding Dr. O'Malley's duty to give her adequate information during the February 14 phone call. As previously mentioned, Marsingill pursued two alternative theories of liability at trial that remain relevant on appeal. Under the first theory, she claimed that Dr. O'Malley lacked sufficient knowledge and skill to advise her properly as to her treatment choices and that these deficiencies caused him to commit malpractice by giving her deficient advice. Under the second theory, Marsingill claimed that a physician owes a duty to give patients enough information to make intelligent treatment choices. Marsingill claimed that Dr. O'Malley breached this duty of disclosure by failing to adequately inform her about the potential seriousness of her symptoms and the risks of failing to seek immediate examination and emergency room treatment. Marsingill proposed separate jury instructions covering these theories. Her proposed instruction on her claim for failure to inform would have directed the jury that the question whether Dr. O'Malley breached his duty to give her sufficient information must be measured from the standpoint of the reasonable patient. The trial court rejected this instruction and instead used a single instruction for both the medical malpractice theory and duty-to-inform theory. Although this instruction advised the jury of the separate factual basis underlying each of Marsingill's theories, it effectively treated both as medical malpractice claims, requiring the jury to determine whether Dr. O'Malley had given Marsingill sufficient evidence to meet his duty to inform by relying exclusively on expert testimony concerning whether the doctor's advice breached the professional standard of care. Marsingill challenges the trial court's ruling, asserting that the reasonable patient standard should have governed the jury's determination of whether Dr. O'Malley breached his duty to give her enough information to make an intelligent treatment choice. [12] We agree. Marsingill's alternate theory of liability did not question the competency of any medical care or treatment administered by Dr. O'Malley and so did not depend on whether he breached the professional standard of care that governs a general surgeon; rather it questioned the adequacy of the information that he disclosed concerning Marsingill's treatment options, asserting that the doctor owed her a duty of disclosure and that he breached this duty. Our decisions have previously distinguished between the standard that governs a physician's duty to render adequate care and the standard that governs a physician's duty to disclose or inform. We first noted the distinction in Pedersen v. Zielski: The physician-patient relationship is one of trust. Because the patient lacks the physician's expertise, the patient must rely on the physician for virtually all information about the patient's treatment and health. A physician therefore undertakes, not only to treat a patient physically, but also to respond fully to a patient's inquiry about his treatment, i.e., to tell the patient everything that a reasonable person would want to know about the treatment. [13] Elaborating further on this distinction in Korman v. Mallin, [14] we noted that Alaska's informed consent statute [15] requires physicians to disclose the common risks and reasonable alternatives to a proposed treatment or procedure but fails to specify what standard governs the scope of the disclosure requirement. [16] After observing that the law traditionally measured a physician's duty to disclose by the professional standard in the field, Korman rejected that approach in favor of the modern trend of case law, which measure[s] the physician's duty of disclosure by what a reasonable patient would need to know in order to make an informed and intelligent decision. [17] Korman went on to hold that expert testimony does not play a determinative role in the context of the reasonable patient rule: Under this modern view, expert testimony concerning the professional standard of disclosure is not a necessary element of the plaintiff's case because the scope of disclosure is measured from the standpoint of the patient. [18] Emphasizing that a physician must disclose those risks which are `material' to a reasonable patient's decision concerning treatment, [19] Korman borrowed from the Louisiana Supreme Court's decision in Hondroulis v. Schuhmacher [20] to explain that, although expert testimony remains relevant in narrowing the field of risks that are potentially material, materiality itself must ultimately be judged by asking what a reasonable patient would want to know: The determination of materiality is a two-step process. The first step is to define the existence and nature of the risk and the likelihood of its occurrence. Some expert testimony is necessary to establish this aspect of materiality because only a physician or other qualified expert is capable of judging what risk exists and the likelihood of its occurrence. The second prong of the materiality test is for the trier of fact to decide whether the probability of that type of harm is a risk which a reasonable patient would consider in deciding on treatment. The focus is on whether a reasonable person in the patient's position would attach significance to the specific risk. This determination does not require expert testimony. [21] In the present case, Marsingill insists that Korman 's reasonable patient rulenot the professional standard of care in the fieldgoverned the scope of Dr. O'Malley's duty to give her enough information to enable her to make an intelligent treatment decision. [22] Dr. O'Malley responds that neither Korman nor Alaska's informed consent law should extend to this case because the duty of disclosure they describe simply does not apply unless the physician recommends or proposes a specific treatment or procedure. [23] According to Dr. O'Malley, in the present case, [t]he factual predicate for the ... duty to disclose, i.e., a recommended treatment or procedure is totally absent. Hence, Dr. O'Malley contends, Marsingill's theory that Dr. O'Malley failed to adequately appreciate and communicate the seriousness of her condition was properly included in the ordinary medical negligence instruction. But on the particular facts of this case, Dr. O'Malley's position is unpersuasive. We assume for present purposes that Dr. O'Malley is correct in asserting that Korman and Alaska's implied consent statute both extend only to situations involving recommendations for specific medical procedures and treatment. Yet when Marsingill called Dr. O'Malley on the night of February 14, she was seeking a recommendation for treatment of her abdominal pain and distress. Uncontradicted evidence establishes that Dr. O'Malley advised her to go to the emergency room for treatment that would likely entail having a nasogastric tube inserted into her stomach. And despite Dr. O'Malley's argument to the contrary, the record supports the conclusion that this advice amounted to a recommendation for treatment. [24] Furthermore, there was evidence that Dr. O'Malley acquiesced in Marsingill's decision not to go to the emergency room. In the context of a pre-existing patient/physician relationship involving post-operative care, a physician's recommendation to do nothing in the face of threatening symptoms is the equivalent of a treatment recommendation and should be accompanied by a duty of disclosure. A physician's acquiescence in a patient's decision not to seek treatment in the same circumstances should likewise be regarded as equivalent to a treatment recommendation subject to the same duty. As we have previously mentioned, Section 8.08 of the AMA Code of Medical Ethics gives rise to a duty of disclosure in such situations, requiring that patients be given enough information to enable an intelligent choice. All six expert witnesses at trial agreed that this duty to inform applied in Marsingill's case. Indeed, even Dr. O'Malley conceded that the duty attached, expressly acknowledging that he had an obligation to give [Marsingill] enough information so that she could make an intelligent choice as to whether she should go to the emergency room. Hence, no one disagreed that a duty of reasonable disclosure existedthat Dr. O'Malley did in fact have a duty to give Marsingill enough information to make an intelligent choice about immediately going to the emergency room for treatment; the only significant disagreement centered on issues concerning the scope and breach of the duty to inform. [25] Yet these are precisely the issues that Korman describes as lying outside the realm of professional expertise and as falling within the fact-finding powers that the reasonable patient rule assigns to lay jurors. In denying the request for an instruction on the reasonable patient standard, then, the superior court deprived Marsingill of her right to have the jury decide the issue directly, from the standpoint of a reasonable patient. The court instead required the jury to filter its decision through the experts' views of what patients should be told. Because the instructions hinged the determination of breach entirely on the testimony of competing experts rather than on the common sense and experience of the jury, we must conclude that giving those instructions amounted to reversible error. [26]