Opinion ID: 1969179
Heading Depth: 1
Heading Rank: 2

Heading: The Case as to Dr. Levin

Text: Dr. Levin's defense is in sharp contrast to that of Dr. Cucinotta. It is in effect a confession and avoidance. He admits that he paid little or no attention to the written warnings relative to Chloromycetin, that he prescribed the drug extensively and indiscriminately for all kinds of viral infections, whether serious or not; and that he authorized two refills of Chloromycetin for Mary Ann by telephone, without ever having had her as a patient or examining her at the times of the authorizations. Dr. Levin seeks to avoid any liability for this course of conduct in that he felt Chloromycetin was a safe drug because of the representations of the Parke, Davis detail men and because the drug had never caused any trouble on the numerous prior occasions that he had prescribed it; that he knew Dr. Cucinotta and relied on the soundness of his prescription of the drug for Mary Ann; and that Mrs. Incollingo was a patient of his and he wanted to accommodate her, and she told him that she could not then contact Dr. Cucinotta. [7] When asked whether in his opinion it was an exercise of reasonable and accepted practice by physicians in the Philadelphia community between 1958 and 1960 to order antibiotics over the telephone without seeing the patient, Dr. Levin replied in the affirmative. As reasons for this opinion he stated that the patient perhaps couldn't afford to come to the office, might be too ill to come, or it may be part of a joint practice for a second doctor to renew a prescription written by his colleague who may be away. Distance or weather might also be factors, he said. Except for the fact that Mary Ann was reportedly sick, none of these extenuating circumstances was here present. In March Dr. Levin was again called by Mary Ann's mother, who said the Chloromycetin wasn't helping the child, that she preferred Achromycin. She asked the doctor to get it for her. She was steering the entire therapy, said Dr. Levin, so I acceded to her wishes. In April Mrs. Incollingo called yet another time, asserting that Mary Ann's physician could not be reached, that the child had a virus again, and a sore throat, and that she would like to have the Chloromycetin prescription renewed once more. I told her, said Dr. Levin, I would be glad to do it this one time, but I didn't think I would care to renew it again because I felt this was a dangerous drug to be kept on using, to keep on using. There was testimony that the indiscriminate use of Chloromycetin was widespread in the community at the time. There was also testimony critical of Dr. Levin's treatment by Dr. Cucinotta and by Dr. Howell, a hemotologist called on behalf of Dr. Cucinotta, but it did not go to the extent of stating that what he did violated the standards of the profession at the time. This is not, however, an end of the matter. Under the Donaldson formulation, quoted above, the standard of possessing and employing the skill and knowledge usually possessed by physicians in the same or a similar locality is qualified importantly by the phrase giving due regard to the advanced state of the profession at the time of the treatment. It is also an integral part of our rule that in employing the requisite skill and knowledge, the doctor must exercise the care and judgment of a reasonable man. In this case, it is clear that full information relative to Chloromycetin was available in medical literature, and indeed that Dr. Levin read materials other than Parke, Davis literature. Was Dr. Levin using the care and judgment of a reasonable man in renewing prescriptions of a drug, the propensities of which were readily ascertainable, for a person who was not his patient, whom he had never seen, as a favor to her mother whose good will as a patient he wished to retain? There was no evidence that this course of conduct was in accord with the professional standard of conduct in the community at the time. A review of the record satisfies us that this question was fairly raised by the evidence, and that its resolution was for the jury. It is argued on behalf of Dr. Levin that unlike other areas of negligence, in a malpractice action, the medical profession sets its own standard of conduct by establishing its own custom of practice. This would be to say that as long as a course of conduct, however unreasonable by ordinary standards, is the norm for the group, all members of the group are thereby insulated from liability so long as they do not deviate therefrom. That is not the law. It is true, as Chief Justice MAXEY stated in Hodgson v. Bigelow, 335 Pa. 497, at 518, 7 A. 2d 338 (1939), that A departure from established standards of practice, unless justified by circumstances, often makes out a prima facie case of malpractice; it does not follow that a prima facie case of malpractice cannot be made out if there has been no departure from the norm. In the words of Mr. Justice HOLMES in another context, What usually is done may be evidence of what ought to be done, but what ought to be done is fixed by a standard of reasonable prudence, whether it is usually complied with or not. Texas & Pacific Railway Co. v. Behymer, 189 U.S. 468, 470, 47 L. Ed. 905 (1903), quoted in Forry v. Gulf Oil Corp., 428 Pa. 334, 342, n.10, 237 A. 2d 593 (1968) (a product liability case). Thus, the statement that A physician is required to exercise only such reasonable skill and diligence as is ordinarily exercised in his profession, as given in our opinion in Duckworth v. Bennett, 320 Pa. 47, 50, 181 Atl. 558 (1935), Saltzer v. Reckord, 319 Pa. 208, 212, 179 Atl. 449 (1935), and other cases is not to be taken in isolation, and in disregard of the admonition to give due regard to the advanced state of the profession and to exercise the care and judgment of a reasonable man in the exercise of medical skill and knowledge. The quoted statement is true within its intended limits and is based on the lack of inherent medical competency of a lay jury. It was not intended to prevent a jury from weighing professional expert opinion as to whether or not a particular act or treatment was done with reasonable care and judgment, where there is no clear evidence of custom. Thus, for example, in Davis v. Kerr, 239 Pa. 351, 86 Atl. 1007 (1913), where a sponge was left at the site of an operation, this Court disapproved a charge which would have exonerated the defendant doctor if you find that the practice or custom to have the nurses count the sponges is a reasonable and proper custom or practice. Said the Court, The instruction not only misconceives the purpose and object of the rule or practice, but treats it as a rule defining the whole duty of a surgeon, limiting his responsibility accordingly. The Court held, to the contrary, that responsibility could not be so limited by custom, and that there was a duty on the surgeon before the counting of the sponges by the nurses began so to employ his skill or observation [as] to assure himself that no foreign substance had been allowed to remain within. (p. 357) It was held that the proper inquiry was, In a word, did he do all that reasonable care and skill would require? (p. 358) That inquiry was equally pertinent as to Dr. Levin in the instant case. Dr. Levin in effect argues that he should have been exonerated as a matter of law because the information disseminated by Parke, Davis concerning its drug was ambiguous, inadequate and incomplete in the light of the knowledge possessed by Parke, Davis, and that therefore the medical profession, and particularly he himself, was caused to use Chloromycetin indiscriminately. Dr. Levin testified that the drug was considered to be very safe, and there was no reason for me to suspect any toxicity. He stated he was aware of the warnings in the precautionary statements on the wrapper of the drug, but the drug detail men practically ignored it. It was played down . . . we didn't concern ourselves with this small inadequate description [of warnings]. We decline to accept the proposition that a qualified doctor can so easily turn himself into a dupe. As indicated heretofore, the Parke, Davis warnings were there to read if he would, and the dangers of the drug were by 1960 also revealed in other medical literature to which the doctor had access and which he said he read. Indeed, as quoted above, the doctor at one point testified that the drug was dangerous to keep on using. The court below was correct in not permitting him to take refuge behind the asserted liability of the manufacturer. Dr. Levin argues, finally, that no causal connection was established between the doses of Chloromycetin he prescribed and the minor plaintiff's aplastic anemia; that the damage had already been done before the administration of the doses which he authorized. In light of all the evidence, including the pathological findings from a post-mortem examination, there could be no substantial doubt that the immediate cause of death was aplastic anemia induced by Chloromycetin. This established, it became defendants' burden to prove which series of dosages  those of Dr. Cucinotta or Dr. Levin or of both  were the fatal ones. Although the evidence appears to have been stronger that it was Dr. Cucinotta's dosages rather than those authorized by Dr. Levin which were the causative agent, it was not sufficient as a matter of law to rule out Dr. Levin's dosages as a contributory causative factor. Thus the matter was properly submitted to the jury [8] and its verdict that both doctors were jointly liable is factually supportable. See Restatement (Second) of Torts, § 433B (2) and (3); cf. Harper and James, Torts, § 10.1, p. 702 (1956); Snoparsky v. Baer, 439 Pa. 140, 266 A. 2d 707 (1970).