Opinion ID: 2521221
Heading Depth: 3
Heading Rank: 1

Heading: Negligent Prescribing Decisions

Text: 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.