Court Opinion

ID: 9609972
Source: CourtListenerOpinion
Date Created: 2023-08-22 03:34:34.470322+00
Date Added: 2024-06-11T18:02:52.880489
License: Public Domain

FABE, Justice,
with whom BRYNER, Justice, joins, dissenting.
I. INTRODUCTION
Because I disagree with the court’s conclusion that health care facilities owe a duty of care to their employees’ spouses to control the spread of common infections such as staph and to warn of their risks, I dissent from the court’s opinion. No other jurisdic*1242tion has concluded that health care facilities owe a duty to protect employees’ spouses or other third parties from staph or other common infections. Furthermore, the D.S.W. factors do not favor imposition of a duty under the circumstances presented here.
II. DISCUSSION
A. The Court’s Analysis Should Distinguish between Common Infections Such as Staph and Rare or Dangerous Diseases Such as AIDS.
This case does not require us to pose the question of whether Our Lady owes a duty to protect employees’ spouses from infections generally. Rather, it presents the narrower question of whether Our Lady owes a duty to protect employees’ spouses from common infections such as staph. The courts that have considered this question have held that a health care provider does not owe such a duty. Because the court’s opinion asks the more general question “whether a residential health care facility owes to the spouses of the facility’s nursing assistants any duty of care to control infections or warn of the danger of infection,” Op. at 1233-1234, it fails to distinguish cases involving rare or dangerous diseases such as AIDS from cases involving ubiquitous, less serious infections such as staph. It therefore misconstrues the duty of a health care provider to protect employees’ or patients’ spouses or other third parties from harm.
The court’s opinion does not rely upon eases addressing the duty owed by a health care provider to protect third parties from common infections. Instead, it finds support in Vallery v. Southern Baptist Hosp., 630 So.2d 861 (La.App.1993), a case involvmg AIDS. Op. at 1236. In Vallery, an AIDS patient bled on the hand of a security guard who did not know the patient had AIDS. Id. at 862. Although the hospital was aware the patient had AIDS, the hospital did not inform the guard that he had been exposed to HIV until the following day, after the guard had sexual relations with his wife. The hospital was found to owe a duty to warn the guard’s wife of the potential danger. Id. at 868-869.
The court’s opinion refers to Vallery as “comparable” to the case at hand. Op. at 1236. I disagree. The Vallery court based its holding in large measure on “policy considerations” not present in this case. Specifically, the court observed that “AIDS is both incurable and fatal” and that simple measures serve to prevent the harm. Id. at 868-69. In contrast, as the court’s opinion acknowledges elsewhere, staph infections are very common,1 “are difficult to contain and normally do not present a threat of serious harm.”2 Op. at 1236. The court’s failure to recognize the crucial distinction between common infections and serious illnesses leads it to reach what I believe is an unprecedented 3 and ill-advised decision.
Health care providers may owe a duty to protect employees’ or patients’ spouses or other third parties from rare or dangerous diseases. In the context of an AIDS diagnosis we have observed with approval that “physicians must use reasonable care to protect third persons from foreseeable exposure to contagious diseases.” Chizmar v. Mackie, 896 P.2d 196, 208 (Alaska 1995). Courts in other jurisdictions have also recognized such a duty in cases where family members are at *1243risk of contracting AIDS,4 developing cancer,5 or falling ill with other potentially fatal diseases.6
Courts have not, however, recognized a duty owed by health care providers to protect employees’ or patients’ spouses or other third parties from staph or other common infections. As one court has reasoned, imposing such a duty “would unduly extend responsibilities and liability of institutions furnishing care to the ill.” Knier v. Albany Med. Ctr. Hosp., 131 Misc.2d 414, 500 N.Y.S.2d 490, 492 (N.Y.Sup.1986). In Knier, a nurse contracted scabies7 after contact with a patient with the disease. Id. 500 N.Y.S.2d at 491. The hospital did not warn the nurse of the patient’s condition. Id. The nurse then passed the disease to her two infant children and her boyfriend, who sued the hospital on a negligence theory for failing to follow hospital procedure and failing to warn the nurse of the danger. Id. at 491-92. The court held that the hospital owed no duty to plaintiffs. Id. at 492. The court reasoned that if it found a duty, there would be no logical reason to limit the class of protected people to the nurse’s family, because “any member of the general public with whom [the nurse] came in'contact could share the same risks of infection as plaintiffs.” Id. at 492.
As Knier addresses, a health care facility’s duty to protect employees’ family members from a common, relatively harmless infection, it provides persuasive support for affirming the trial court m the case before us. Indeed, the facts of Knier present an even stronger argument than those in this case for imposing a duty on the health care provider. The Knier court considered the duty to warn an employee of a danger known to the hospital but not to the employee. In contrast, we consider the duty to warn employees of the danger of infection after the employees had already received treatment for staph. Thus, unlike the Bolieu plaintiffs, the Knier plaintiffs were faced with a hidden danger. Despite these stronger facts, the court in Knier held that the hospital owed no duty to protect the nurse’s family members from a common infection.
Troxel v. A.I. DuPont Inst., 431 Pa.Super. 464, 636 A.2d 1179 (1994), also provides compelling support for affirming the trial court. In Troxel, the plaintiff contracted cytomega-lovirus (CMV), a widespread disease that is “relatively harmless” unless communicated to a pregnant woman who passes it to her unborn child. Id. at 1183. Plaintiff, a pregnant woman, contracted the disease after frequent visits with an infected friend who was a patient in the hospital. Id. at 1180. Plaintiff’s son contracted the disease in útero and died three months after birth. Id. The court held that the hospital had no duty to take steps to prevent the patient from coming into contact with other persons. Id. at 1183. It reasoned that the
transmission of ubiquitous diseases, such as influenza and CMV, may seriously com*1244promise the health of special classes of persons, such as the elderly or the pregnant, but the treatment of such diseases does not impose liability upon the treating physician or health care provider in the event that the disease is communicated by the patient to a third person.
Id. Again, in the case of a common infection, even one with significant health consequences for the particular plaintiff, no duty to third parties was imposed on the health care provider.
Finally, in Livingston v. Gribetz, 549 F.Supp. 238 (S.D.N.Y.1982), a nurse allegedly contracted viral herpes from a patient and sued the patient’s doctor for negligently failing to advise the nurse of proper procedures to avoid infection. Id. at 241. Like Knier, Livingston presents a stronger argument than the case before us for imposing a duty on the health care provider because the nurse was under the defendant’s supervision and in direct contact with the infected patient. Despite the greater foreseeability of danger to the nurse and the stronger causal link between her injury and the defendant’s conduct, the court held that the doctor did not owe a duty to advise the nurse how to avoid infection. See Livingston, 549 F.Supp. at 244. Taken together, these three cases represent the prevailing view that health care providers do not owe a duty to protect third parties from common infections.
The court’s opinion appears even more out of step with the case law from other jurisdictions when considered against the backdrop of cases specifically addressing staph infections. In such cases, courts have consistently refused to find hospitals negligent even when patients, rather than employees’ spouses, have developed staph infections. See, e.g., Roark v. St. Paul Fire & Marine Ins. Co., 415 So.2d 295, 299 (La.App.1982); Sommers v. Sisters of Charity of Providence, 277 Or. 549, 561 P.2d 603, 607 (1977).8 Until today’s decision, neither this court nor any other has held a health care provider hable to its employees’ spouses for common infections that do not present a threat of serious harm.
B. The D.S.W. Factors Do Not Favor Imposition of a Duty under the Circumstances.
The court’s opinion properly identifies D.S.W. v. Fairbanks North Star Borough School District, 628 P.2d 554 (Alaska 1981), as providing the analytic framework for determining whether Our Lady owes a duty of care to its employees’ spouses. The first D.S.W. factor to consider is foreseeability. Id. at 555. As Our Lady concedes, it is foreseeable that employees will be exposed to staph and other common infectious agents at health care facilities such as Our Lady. However, as Our Lady points out, “it is equally foreseeable that such persons will be exposed to these same infectious agents at school, on the bus, at the supermarket, or in any other place where people congregate together.” In other words, because staph is ubiquitous, it is inevitable that some people will contract it wherever they go, including health care facilities.
While foreseeability may be the single most important D.S.W. criterion for imposing a duty of care, it does not necessarily trump the other six. In Schumacher v. Yakutat, 946 P.2d 1255 (Alaska 1997), for example, we recently found that three of the D.S.W. factors, including foreseeability, militated in favor of imposing a duty. Id. at 1257 n. 3. We nevertheless held that “these factors are outweighed by ‘the extent of the burden to the defendant and consequences to the community of imposing [such] a duty.’ ” Id. at 1257 (quoting D.S.W., 628 P.2d at 555). Our analysis must then turn to the other six D.S.W. factors.
The second and third D.S.W. factors are the degree of certainty that the plaintiff suffered injury and the closeness of the connection between the defendant’s conduct and the injury suffered. See D.S.W., 628 P.2d at 555. In this case, the relationship between plaintiffs’ injury and Our Lady’s conduct is nebulous at best. There is simply no way to *1245prove one way or the other that the plaintiffs suffered injury because of any conduct on the part of the defendant. As the court’s opinion observes, staph is common. Op. at 1234 n. 2. The plaintiffs could have been infected anywhere. Although it may be possible to establish with a degree of certainty that the plaintiffs were in fact injured, it is impossible to establish with any degree of certainty that their injuries were the result of any conduct or omission by Our Lady.
The court’s opinion dismisses the second and third D.S.W. factors by arguing that they “do not bear on the legal issue now before us [duty], but on issues of breach of duty, causation, and damages” and that they “should be resolved in the context of causation, not duty.” Op. at 1237-1238. As the court’s opinion itself recognizes, however, duty is the “expression of the sum total of those considerations of policy which lead the law to say that a particular plaintiff is entitled to protection.” Op. at 1235. The certainty of a plaintiffs injury and the closeness of the connection between a defendant’s conduct and the injury suffered are integral parts of that sum total; indeed, they are included in the D.S.W. analysis precisely because they bear on the legal issue of whether a duty exists.
In this case, the implications of finding Our Lady potentially hable for injuries that cannot be traced with any certainty to its conduct suggest that we should not impose a duty. In fact, it was precisely this concern over the absence of a causal connection that informed the analysis in Roark. In Roark, a patient developed a staph infection after undergoing surgery and sued the hospital. See Roark 415 So.2d at 297. In finding that the hospital was not liable, the court observed that it is impossible to trace the origins of staph bacteria and “[t]herefore, it is not possible to establish the hospital’s relationship with, or responsibility for, the subsequent infection.” Id. at 298-99. Because any connection established between Our Lady’s conduct and the staph infections of two of its employees’ spouses is similarly speculative,91 believe that analysis of the second and third D.S.W. factors strongly favors not imposing a duty of care on Our Lady.
The fourth D.S.W. factor is the moral blameworthiness of the defendant’s conduct. See D.S.W., 628 P.2d at 555. The court’s opinion concedes “that Our Lady’s conduct was not morally blameworthy.” Op. at 1238.
The fifth D.S.W. factor is the policy of preventing future harm. See D.S.W., 628 P.2d at 555. The superior court reasoned that imposition of a duty would not prevent future harm. Op. at 1239. I agree. As the court’s opinion concedes, health care facilities are “already required to satisfy high regulatory standards” and “already owe[] tort or statutory duties to patients and employees, the persons most directly threatened by inadequate efforts to control infections.” Op. at 1238. It is therefore unclear what more Our Lady can do to prevent future harm. The court’s opinion suggests that Our Lady can discharge its duty to its employees’ spouses by advising employees of precautions to avoid infecting themselves and their spouses. Op. at 1239. For staph, such precautions principally involve washing hands thoroughly before and after examining a patient.10 Thus, it appears that under the court’s analysis, Our Lady can discharge its duty to employees’ spouses by instructing employees to wash their hands before and after examining patients. Because this is already the standard practice in health care facilities, including Our Lady,11 it is hard to *1246understand how extension of the existing duty will have any effect on preventing future harm.
The sixth D.S.W. factor is the extent of the burden to the defendant and consequences to the community of imposing a duty to exercise care with resulting liability for breach.12 See D.S.W. 628 P.2d at 555. The court’s opinion concludes that “imposing a duty in favor of the spouses would not change Our Lady’s burden.” Op. at 1238. I believe there are at least three ways in which the court’s opinion creates a potentially onerous burden.
First, as the Knier court noted, there is no logical basis for limiting the class of third parties to whom a health care provider such as Our Lady owes a duty of care. See Knier, 500 N.Y.S.2d at 492. Employees’ spouses are no more likely to contract a common infection such as staph from Our Lady’s employees than are other visitors to the facility or other people with whom the employees come in contact. Reason therefore dictates that the duty of care owed by health care providers could extend to protecting a potentially limitless circle of individuals.
Second, as discussed abovej the ubiquitous nature of staph makes it impossible to identify the source of an individual’s infection. See Roark, 415 So.2d at 298-99. Thus, the court’s opinion creates the potential that health care providers such as Our Lady may be held liable for any infection contracted by any visitor or employee’s family member (or by any third party with whom an employee or patient has contact) that conceivably could have originated in the health care facility. In other words, health care providers may be held liable for common infections that cannot be traced with any degree of certainty to their facilities.
Third, if Our Lady owes a duty to protect employees’ spouses from common infections such as staph, there is no reason why it should not owe the same duty to protect them from other widespread, relatively harmless ailments such as influenza or the common cold that, like staph, are impossible to contain. The possibility that a health care provider’s duty could be so broadly construed cautions against imposing a duty. In sum, the court’s opinion potentially exposes health care providers to liability to a limitless circle of individuals for any number of widespread, relatively harmless ailments that cannot be traced with any certainty to the health care facilities. Because this burden is excessive, I believe analysis of the sixth D.S.W. factor militates strongly against imposing a duty of care to protect employees’ spouses from common infections.
Finally, the D.S.W. analysis requires consideration of the availability, cost and prevalence of insurance to cover the risk that an employee’s spouse will contract an infection that originated at Our Lady’s facility. See D.S.W., 628 P.2d at 555. Because the court’s opinion for the first time expands liability to protect employees’ spouses from common infections, it is reasonable to assume that insurance rates do not currently reflect the cost of the risk. The court’s opinion will therefore at best increase the cost of insurance for health care providers, and at worst create a liability for which they cannot insure. In either case, this factor does not favor the imposition of liability.
III. CONCLUSION
No other jurisdiction has concluded that health care facilities owe a duty to protect employees’ spouses from staph or other common infections that do not present a risk of serious harm. Such a duty has only been imposed in the case of rare or dangerous diseases. I would preserve the distinction.13 Furthermore, because it is impossible to establish causation between the plaintiffs’ inju*1247ry and the defendant s conduct, because the court’s opinion will do little if anything to prevent future harm, and because the defendant will potentially be exposed to unduly burdensome liability, I believe that the D.S.W. factors do not weigh in favor of imposing a duty under the circumstances presented here. I therefore respectfully dissent from the court’s opinion.

.The infectious disease specialists who evaluated Bodhmati Oliver and Gwen Bolieu attested to the ubiquity of staph. Dr. Janis stated that "[u]p to 40% of normal people have staphylococcus au-reus in their nose.” Dr. Roberts stated that "[n]asal staph carriage will be found in 20-40% of the adult population at any one time, and over a long period of time about 80% of the population will be found to be carriers at one time or another.” Their comments are consistent with the medical literature on the subject. See, e.g., "Staphylococcal Infections,” Red Book Report on Committee of Infectious Diseases, American Academy of Pediatrics 423-26 (1994).

. See, e.g., Sommers v. Sisters of Charity of Providence, 277 Or. 549, 561 P.2d 603, 605 (1977) (noting that it is not always medically possible to eradicate staph bacteria from under the surface of the skin).

. The court’s opinion remarks in a footnote that "at least one public agency elsewhere requires that the families of health care employees be notified if the employees may have been exposed to a serious danger [tuberculosis].” Op. at --■, n. 9. Again, the court’s opinion disregards the distinction between a serious danger such as tuberculosis and an infection of a significantly less serious nature such as staph.

. See Garcia v. Santa Rosa Health Care Corp., 925 S.W.2d 372, 377 (Tex.App.1996) (holding health care professionals owed duty to inform patient's wife of patient’s probable infection with HIV); see also Reisner v. Regents of Univ. of Cal., 31 Cal.App.4th 1195, 37 Cal.Rptr.2d 518, 519 (1995) (holding that physicians owed duty to patient’s boyfriend to warn patient of her HIV status and of dangers associated' with the disease, even where physicians did not know boyfriend existed).

. See Safer v. Estate of Pack, 291 N.J.Super. 619, 677 A.2d 1188, 1192 (App.Div.1996) (recognizing “narrow” duty of physician "to warn those known to be at risk of avoidable harm from a genetically transmissible condition” invariably leading to cancer).

. See Bradshaw v. Daniel, 854 S.W.2d 865, 872 (Tenn.1993) (recognizing duty of physician to warn patient’s wife of risk of exposure to Rocky Mountain Spotted Fever, a non-contagious disease with 40 percent mortality rate if untreated, where clustering effect of disease put family members at risk of contracting it). The California Supreme Court has also recognized the analogous duty of a psychotherapist to use reasonable care to protect an intended victim when a "patient presents a serious danger of violence." Tarasoff v. Regents of Univ. of Cal., 17 Cal.3d 425, 131 Cal.Rptr. 14, 20, 551 P.2d 334, 340 (1976).

.As the court’s opinion notes, ”[s]cabies is a skin disease caused by infestation with mites. It is transmitted in hospitals primarily through intimate direct contact with an infested person. Treatment for scabies is highly effective in preventing transmission and destroying the mites.” Op. at-n. 3.

. Although Roark and Sommers affirm findings of no negligence and therefore do not address the question of duty, they underscore the difficulties of imposing a duty to protect third parties from staph.

. Evidence presented in this case demonstrates the point. While Dr. Beime speculated, at the workers’ compensation proceedings that Bo-dhmati Oliver's and Gwen Bolieu’s staph infections were work-related, other infectious disease specialists who evaluated Bodhmati Oliver and Gwen Bolieu disagreed. Op. at - - -.

. See John N. Sheagren, Staphylococcus Aureus: The Persistent Pathogen, 310 New Eng. J. Med. 1437, 1441 (1984) (stating that "hand washing continues to be the primary way of effectively preventing the spread of staph, aureus "). The Centers for Disease Control and Prevention Guidelines refer to handwashing as "the single most important measure for preventing spread of infection.” Draft Guideline for Isolation Precautions in Hospitals, 59 Fed.Reg. 55,551, 55,557 (1994).

.Our Lady's Universal Moist Body Substances — Isolation, Policy No. 240.057A requires care givers to "[w]ash hands between each patient contact AND whenever you accidentally *1246contact moist body substances. Be sure to wash hands before and after caring for EACH patient even if you were wearing gloves.” Review of this policy is included in mandatory training sessions for Our Lady’s staff.

. I will only discuss the burden here. As discussed in my analysis of the fifth D.S.W. factor, I believe that extension of the duty will not prevent future harm. Thus, I conclude there will be no beneficial consequences to the community.

. Because the question of how uncommon or severe a disease must be before a duty is imposed is not before us, it need not be answered here.