Opinion ID: 1286646
Heading Depth: 1
Heading Rank: 2

Heading: Informed ConsentStandard of Care

Text: Defendants assert that plaintiffs' informed consent claim should not have been submitted to the jury inasmuch as plaintiffs failed to introduce any expert testimony regarding the risks that Dr. Madison was under a duty to disclose. In Block v. McVay, 80 S.D. 469, 126 N.W.2d 808 (1964), defendant-physician discovered a hard lump under plaintiff's skin. Defendant believed that the lump was a potentially cancerous tumor in a lymph node that could indicate the spreading of cancer in the plaintiff's body. Defendant advised plaintiff that the surgical procedure involved in removing such a lymph node was a routine one. He did not discuss with her any potentially hazardous consequences associated with the operation because, as the evidence established, there usually were none. During the operation, defendant determined that the lump was not a cancerous tumor of a lymph node, but a neurofibroma, i.e., a benign nerve tumor. Defendant removed the neurofibroma, but in doing so severed some minute nerve fibers causing a continuing neurological defect in plaintiff's right arm. Plaintiff brought a malpractice action, contending that defendant had negligently failed to advise her of the possibility of nerve damage of the type she ultimately sustained. In affirming the trial court's entry of a directed verdict for defendant, this court held, inter alia: There is no evidence in this case to show that there were any substantial risks or hazards inherent in an operation for removal of a lymph node tumor in this area. Again, the unfortunate result of the operation does not supply this lack nor do we feel that such matters are within the common knowledge of laymen. 80 S.D. at 477, 126 N.W.2d at 812. In Cunningham v. Yankton Clinic , P.A., supra, we indicated that Block did not expressly resolve the question whether expert testimony is required before an informed consent claim may be submitted to the jury. In concluding that it was unnecessary to address the question directly, we stated: [W]e need not decide whether an informed consent case may be proven without expert testimony since [the doctor] admitted on adverse examination that the standards of the medical practice in his community would require him to advise her of the ramifications of the removal of the pin. Id. at 512 (footnote omitted). A majority of jurisdictions that recognize a cause of action for negligent disclosure adhere to the so called professional rule, which places the burden on the plaintiff to prove by a preponderance of the expert medical testimony that the reasonable medical practitioner would have made disclosure under the circumstances. See, e.g., Tant v. Women's Clinic, 382 So.2d 1120 (Ala.1980); Fuller v. Starnes, 268 Ark. 476, 597 S.W.2d 88 (1980); Woolley v. Henderson, 418 A.2d 1123 (Me.1980); Llera v. Wisner, 171 Mont. 254, 557 P.2d 805 (1976); Winkjer v. Herr, 277 N.W.2d 579 (N.D.1979); Roark v. Allen, 633 S.W.2d 804 (Tex.1982). See also 52 A.L. R.3d 1084 (1973). Consequently, the dimensions of the disclosure duty are delineated through the medium of expert medical testimony. Under this view, a physician can be found to have breached his duty to disclose only upon a showing that his conduct fell below the standard deemed acceptable by his peers in the medical profession. Alternatively, an increasing number of courts have rejected the majority rule, opting instead in favor of a patient-oriented standard. See, e.g., Canterbury v. Spence, 464 F.2d 772, cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (D.C.Cir.1972); Cobbs v. Grant, 8 Cal.3d 229, 104 Cal.Rptr. 505, 502 P.2d 1 (1972); Logan v. Greenwich Hosp. Ass'n, 191 Conn. 282, 465 A.2d 294 (1983); Crain v. Allison, 443 A.2d 558 (D.C.App.1982); Harnish v. Children's Hospital Medical Center, 387 Mass. 152, 439 N.E.2d 240 (1982); Wilkinson v. Vesey, 110 R.I. 606, 295 A.2d 676 (1972); Cross v. Trapp, 294 S.E.2d 446 (W.Va.1982); Scaria v. St. Paul Fire & Marine Ins. Co., 68 Wis.2d 1, 227 N.W.2d 647 (1975). See also 88 A.L.R.3d 1008 (1978). In place of the reasonable medical practitioner standard, this approach utilizes an objective, reasonable person standard. Under this approach, the trier of fact could find that a physician acted unreasonably under the circumstances in failing to disclose material information to his patient despite unrebutted expert medical testimony that the physician's conduct was reasonable. The seminal decision championing rejection of the professional rule is Canterbury v. Spence, supra . In Canterbury, plaintiff alleged that the defendant physician had failed to inform him of the risk of paralysis inherent in a laminectomy procedure. The trial court granted a directed verdict for the defendant, noting there was insufficient evidence to support plaintiff's claim. The Court of Appeals for the District of Columbia reversed, stating: We agree that the physician's noncompliance with a professional custom to reveal, like any other departure from prevailing medical practice, may give rise to liability to the patient. We do not agree that the patient's cause of action is dependent upon the existence and nonperformance of a relevant professional tradition .... Nor can we ignore the fact that to bind the disclosure obligation to medical usage is 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. 464 F.2d at 783-84 (footnotes omitted). We agree that the right to know to be informedis a fundamental right personal to the patient and should not be subject to restriction by medical practices that may be at odds with the patient's informational needs. Accordingly, we adopt the Canterbury v. Spence rule that the standard measuring the performance of the physician's duty to disclose is conduct which is reasonable under the circumstances. Id. at 785. Consistent with our decision in Cunningham v. Yankton Clinic , P.A., supra, we deem a reasonable disclosure to be one which apprises the patient of all known material or significant risks inherent in a prescribed medical procedure, as well as the availability of any reasonable alternative treatment or procedures. 262 N.W.2d at 511. Additionally, material risks incident to abstention from treatment should also be disclosed. A risk is generally defined as material when a reasonable person, in what the physician knows or should know to be the patient's position, would be likely to attach significance to the risk or risks in deciding whether to submit to the proposed medical treatment or procedure. See Canterbury, 464 F.2d at 787; Wilkinson v. Vesey, 110 R.I. at 627, 295 A.2d at 689; Harnish v. Children's Hospital Medical Center, 387 Mass. at 155, 439 N.E.2d at 243. Materiality, therefore, is the cornerstone upon which the physician's duty to disclose is based. Our decision today should not be construed as obviating the need for expert medical testimony in all informed consent cases. The risks associated with a particular method of treatment, the frequency or probability of their occurrence, alternatives to treatment, risks accompanying such alternatives, and the consequences of remaining untreated are examples of where expert medical evidence would generally be necessary to edify a lay jury. See, e.g., Canterbury v. Spence, 464 F.2d at 791-92; Wilkinson v. Vesey, 110 R.I. at 624-625, 295 A.2d at 688; Sard v. Hardy, 281 Md. 432, 447-448, 379 A.2d 1014, 1024 (1977); Harnish v. Children's Hospital Medical Center, 387 Mass. at 152, 439 N.E.2d at 243; Cornfeldt v. Tongen, 262 N.W.2d 684, 702 (Minn.1977); Miller v. Kennedy, 11 Wash.App. 272, 283-284, 522 P.2d 852, 861 (1974), aff'd 85 Wash.2d 151, 530 P.2d 334 (1975). As stated by the Supreme Court of Appeals of West Virginia in Cross v. Trapp, supra : [A]lthough expert medical testimony is not required under the patient need standard to establish the scope of a physician's duty to disclose medical information to his or her patient, expert medical testimony would ordinarily be required to establish certain matters including: (1) the risks involved concerning a particular method of treatment, (2) alternative methods of treatment, (3) the risks relating to such alternative methods of treatment and (4) the results likely to occur if the patient remains untreated. 294 S.E.2d at 455. Inasmuch as there is no duty to disclose unless the physician knew or should have known of the risk to be disclosed, Cornfeldt v. Tongen, 262 N.W.2d 684, 699, expert testimony will ordinarily be necessary to establish this predicate to liability for nondisclosure. What the physician should know involves professional expertise and can ordinarily be proved only through the testimony of experts. Harnish v. Children's Hospital Medical Center, 387 Mass. at 156, 439 N.E.2d at 243. See also Reinhardt v. Colton, 337 N.W.2d 88 (Minn.1983). Also, our holding does not mandate that a physician chart in exacting detail for the patient each proposed medical procedure. A physician need not discuss extremely remote risks; risks already known to the patient or those of which persons of average sophistication are aware. Canterbury, 464 F.2d at 788. Furthermore, a physician must also be permitted to exercise some discretion where full disclosure would be detrimental to the patient's well being, as patients occasionally become so ill or emotionally distraught on disclosure as to foreclose a rational decision, or complicate or hinder the treatment, or perhaps even pose psychological damage to the patient. Id. at 789 (footnote omitted). In these exceptional situations, a physician retains a qualified privilege to withhold information from the patient. Id.; see e.g., Scaria, 68 Wis.2d at 11-12, 227 N.W.2d at 653. Also, as we stated in Cunningham, supra, a physician is not required to obtain the patient's consent in an emergency situation where the patient is in immediate danger. 262 N.W.2d at 511. Finally, we take note of what is axiomatic to the law of negligence. Establishing a breach of the physician's duty to disclose is only a predicate to the imposition of liability. Plaintiff must also demonstrate that the undisclosed risk manifested itself, causing the complained-of injury, and, secondly, that had the risk been disclosed plaintiff would have refused treatment. Whether plaintiff would have refused treatment is resolved by applying a reasonably prudent person standard. The applicable test is whether a reasonable person in the patient's position would not have agreed to the proposed treatment if adequately apprised beforehand of the material risk which resulted in injury. See, e.g., Canterbury, 464 F.2d at 791; Cornfeldt v. Tongen, 262 N.W.2d at 701; Scaria, 68 Wis.2d at 13-14, 227 N.W.2d at 654; Wilkinson, 110 R.I. at 627, 295 A.2d at 689.