Court Opinion

ID: 9645321
Source: CourtListenerOpinion
Date Created: 2023-08-22 21:20:55.559477+00
Date Added: 2024-06-11T18:11:27.263943
License: Public Domain

Davidson, J.,

dissenting:
In its opinion, the majority fails to consider material facts, fails to consider the central issue decided by the trial *240court, unnecessarily decides issues, and decides those issues erroneously. I respectfully dissent.
I
Viewed in the light most favorable to the appellants,1 the record shows that in 1965, during the eighth month of her first pregnancy, Mrs. Said developed eclampsia and suffered 21 convulsions. It was possible, as a result, that she and her baby might die. An emergency Caesarian section was performed in an effort to save them both. The baby did not survive. In March, 1967, Mrs. Sard gave birth, again by Caesarian section, to a healthy child who survived.
In November, 1967, Mrs. Sard consulted Dr. Hardy concerning her third pregnancy. A few weeks before she was to deliver the baby he pointed out that given her past medical history, it was medically inadvisable for her to become pregnant again. He recommended that she use birth control pills or an intrauterine device, or that she have her tubes tied at the time the third Caesarian section was to be performed. He did not tell her about other methods of birth control such as vasectomy. Mrs. Sard made it plain to the doctor that she did not want any more children by explicitly saying that she had “lost a lot of blood,” “couldn’t afford any more children and didn’t really want any more at that time.” She then told him, “I would rather be sterilized because I believe it might be more safer than taking a pill. That way I will know I am sterilized and won’t have to worry about having to get pregnant again.”
Mrs. Sard did not know and Dr. Hardy did not then advise her that the sterilization procedure which he proposed was fallible and that she could become pregnant even after it was performed. Rather, he told her that if he performed the proposed tubal ligation she would not have any more children.2 He gave her no information as to how successful *241birth control pills or intrauterine devices might be in preventing pregnancy. Believing that the recommended procedure was the only certain method of permanently preventing pregnancy, Mrs. Sard chose that course of treatment. Dr. Hardy advised her to go home and think about her choice. At a subsequent visit, she elected to be “sterilized.” Had she known that the operation was not necessarily effective in all cases, she would not have consented to it.3
*242About 15 minutes before the operations were performed, a nurse told Mrs. Sard that if she wanted to be sterilized she had to sign a hospital form in order to “authorize sterilization.” The form stated in pertinent part that “an operation intended to effect sterilization is not effective in all cases.” Believing the form to be nothing more than an authorization for the sterilization, Mrs. Sard signed it without reading it or having it read to her, after a nurse told her she did not have time to read it. Following the operations, Dr. Hardy told Mrs. Sard, “Have all the fun you want. You don’t have to worry about getting pregnant.” He also stated that she was “guaranteed 100 per cent.” Believing that she was sterile, Mrs. Sard thereafter engaged in sexual relations with her husband. On 11 January 1971, she gave birth by Caesarian section to a normal child.
II
Here, the appellant contends that the question of whether she consented to the performance of the tubal ligation should have been submitted to the jury. She maintains that the evidence was sufficient to show that, because the doctor not only failed to disclose that the proposed sterilization might not prevent a future pregnancy, but rather told her that it would prevent further pregnancies, her consent to its performance was not “informed.” The appellee contends that the evidence that the appellants signed a hospital form, which specifically stated that the proposed sterilization was not effective in all cases, established, as a matter of law, that the appellants’ consent was “informed.” The trial court, assuming without deciding that the appellants’ consent had to be “informed,” applied the basic principle of contract law that one who signs a contract is presumed to know its contents, nature and consequences, and is bound by its terms.4 He agreed with the appellee that the appellants’ consent was “informed.”
*243In my view, the only question decided by the trial judge with reference to the issue of informed consent was whether Mrs. Sard’s signature on the hospital form precluded her recovery.51 believe that this is the only question which need be considered here.61, like the trial court, would assume that the doctrine of informed consent applies in Maryland. I would, however, find that the trial court erred in applying a contract principle associated with arm’s length transactions without considering the fiducial qualities of the doctor-patient relationship.
Under the principles of contract law applicable to arm’s length transactions, one who signs a contract having read it or without reading it or having it read to him is presumed to know its contents, nature and consequences and is bound by *244its terms.7 Even an illiterate who executes a contract under a mistake as to its contents is bound.8
The rationale underlying this presumption is that in an arm’s length transaction the relationship ■ between the parties is such that each is independent of the other, has no duty or obligation to the other, and is responsible solely for protecting his own interests. Accordingly, a signatory to a contract in an arm’s length transaction has an obligation to inform himself and is negligent if he fails so to do.9 As stated in Spitze v. Baltimore & Ohio R.R.: 10
... it would lead to startling results if a person who executes, without coercion or undue persuasion, a solemn release under seal, can subsequently impeach it on the ground of his own carelessness, though at the very time of its execution, he might, had he seen fit, have advised himself fully as to the nature and legal effect of the act he was doing. He cannot, under these circumstances, be heard to complain that an imposition was practised upon him. He cannot invoke his own heedlessness to impeach his solemn release, and then call that heedlessness some one else’s fraud. If he did not know what he was signing, it was his plain duty to inquire. He had no right to act as one who understood what he was doing, unless he intended *245to lead those with whom he was dealing to believe that he did understand the act that he did.
Different considerations are involved when there is a fiducial relationship between the parties. In Herring v. Offutt,11 the Court of Appeals quoted with approval Justice Gardozo, then Chief Judge of the New York Court of Appeals: 12
“ Many forms of conduct permissible in a workday world for those acting at arm’s length, are forbidden to those bound by fiduciary ties. A trustee is held to something stricter than the morals of the market place. Not honesty alone, but the punctilio of an honor the most sensitive, is then the standard of behavior. As to this there has developed a tradition that is unbending and inveterate. Uncompromising rigidity has been the attitude of courts of equity when petitioned to undermine the rule of undivided loyalty by the ‘disintegrating erosion’ of particular exceptions. Only thus has the level of conduct for fiduciaries been kept at a level higher than that trodden by the crowd.”
In a fiducial relationship, one of the parties is justifiably dependent to some extent upon the other. Consequently, the dominant party has certain duties and obligations toward the other and is responsible for protecting the other’s interests. Included among those duties and obligations is a duty to disclose any information which it is important for the other party to know.13 The dependent party is not obligated to inform himself and is entitled to rely upon the dominant party to provide him with the information he *246needs.14 Accordingly, the dependent party’s failure to inform himself does not constitute negligence and such a party is not precluded from showing a lack of knowledge of the contents, nature and consequences of a signed document. In short, where there is a fiducial relationship between the parties, the presumption of knowledge of the contents of a written document does not apply.15 As stated in dicta in Bollock v. Bollock: 16
. . . the natural and ordinary presumption is, that where one in the full possession of his mental faculties executes a deed, will, or other instrument, conferring a benefit upon another, by affixing his signature thereto, that his act is free, intentional, and voluntary.. . . But the presumption is rebuttable, and has no application where a beneficiary under the instrument stands in a confidential relation to the donor. (Emphasis added.)
In Maryland, a confidential or fiduciary relationship is presumed “whenever two persons stand in such a relation to each other that one must necessarily repose trust and confidence in the good faith and integrity of the other,” 17 and “where the one in whom such confidence is reposed is thereby enabled to exert a dominating and controlling influence over the other.” 18 It has long been recognized implicitly that a physician occupies a position of trust and confidence in relation to his patient.19 Courts in other *247jurisdictions agree.20 Thus, the Court of Appeals of Missouri has said:21
A physician occupies a position of trust and confidence as regards his patient — a fiduciary position. It is his duty to act with the utmost good faith. This duty of the physician flows from the relationship with his patient and is fixed by law — not by the contract of employment. The law’s exaction of good faith extends to all dealings between the physician and the patient. A person in ill health is more subject to the domination and influence of another than is a person of sound body and mind. The physician has unusual opportunity to influence his patient. Hence, all transactions between physician and patient are closely scrutinized by the courts which must be assured of the fairness of those dealings. (Citations omitted.)
I am convinced that there are fiducial qualities in the doctor-patient relationship which require the application of principles different from those governing arm’s length transactions. Applying such principles to the instant case would produce a clear result.
Under the doctrine of informed consent, it is the fiducial quality of the relationship between the doctor and the patient which imposes upon the doctor an obligation to disclose to the patient all material facts reasonably necessary to provide the basis of an informed intelligent *248decision as to a proposed treatment. Thus, the U.S. Court of Appeals for the District of Columbia Circuit in determining that it is the doctor’s duty to impart information which the patient has every right to expect, including the available therapy alternatives and the goals expectably to be achieved, has said:22
The patient’s reliance upon the physician is a trust of the kind which traditionally has exacted obligations beyond those associated with arms-length transactions. His dependence upon the physician for information affecting his well-being, in terms of contemplated treatment, is well-nigh abject. As earlier noted, long before the instant litigation arose, courts had recognized that the physician had the. responsibility of satisfying the vital informational needs of the patient. More recently, we ourselves have found “in the fiducial qualities of [the physician-patient] relationship the physician’s duty to reveal to the patient-that which in his best interests it is important that he should know.”
Similarly, the Supreme Court of California has said:23
. . . the patient, being unlearned in medical sciences, has an abject dependence upon and trust in his physician for the information upon which he relies during the decisional process, thus raising an obligation in the physician that transcends arms-length transactions.
It is also the fiducial quality of the relationship which relieves the patient from the obligation to inform himself. If the doctor fails to provide the material facts necessary for an intelligent decision, the patient’s consent to the proposed treatment, being uninformed, is invalid.24
*249If the doctor does provide information to the patient, the patient has the right to rely upon the fact that it is accurate and complete. A patient would not normally expect that a consent form which he was asked to sign would contain material different from that provided by the doctor.25 Because under such circumstances the patient would have no obligation to inform himself, he should not be presumed to know the contents of a signed consent form.26
Here, there was evidence to show that before she decided to undergo a tubal ligation, the doctor told the patient that if the procedure were performed she would not have any more children. Fifteen minutes before the operation, hospital personnel told her that if she wanted to be sterilized she had to sign an authorization form. That form indicated that sterilization is not effective in all cases. In addition, hospital personnel told her that she did not have time to read the form. Under these circumstances, she signed the form without reading it or having it read to her.
In the absence of a presumption that she knew the contents of the document she signed, this evidence was sufficient to raise a question as to whether the patient knew that the proposed tubal ligation would not necessarily be effective.27 Again, assuming without deciding that the *250patient’s consent had to be “informed,” and that the doctor had a duty to disclose accurate, relevant information to the patient, that question should have been submitted to the jury. Accordingly, I would reverse and remand for a new trial.
Ill
The majority fails to consider the question of whether Mrs. Sard’s signature on the hospital form precluded her recovery. Instead, they unnecessarily decide that the doctrine of informed consent is applicable in Maryland and that under that doctrine, a doctor has a duty to make “an adequate disclosure of substantial facts which would be material to the patient’s decision.” They then delineate the scope of the duty to disclose as disclosure of risks of death or bodily harm peculiar to the proposed procedure. They make it plain that there is no need to disclose risks that are likely to be known by the average patient, or that are in fact known by the patient. Moreover, they determine that there is no duty to discuss the relatively minor risks inherent in common procedures when it is common knowledge that such risks are of very low incidence. The majority finds that materiality is “the significance a reasonable person, in what the physician knows or should know is his patient’s position, would attach to the disclosed risk or risks in deciding whether to submit or not to submit to surgery or treatment.” They hold that “a reasonable person, in Mrs. Sard’s position, would attach no material significance to the risk of one chance in fifty that she would derive no benefit from the operation.”
Were I to consider the questions of the scope of the doctor’s duty to disclose and whether there was sufficient evidence of a breach of that duty to require submission to the jury, I would reach the opposite result. I agree with the majority that the scope of the doctor’s duty to disclose information to the patient is determined by the patient’s *251need to know. As stated by the Court of Appeals of Washington: 28
The inquiry as to each item of information ... is “Would the patient as a human being consider this item in choosing his or her course of treatment?”
I do not believe that these “items of information” are limited to disclosure of risks of physical harm resulting from the operation. I would delineate the scope of the doctor’s duty to disclose differently from the majority by clearly articulating that additional factors are included.
Some courts which have considered the scope of the doctor’s duty to disclose have indicated that:
.. . before a patient will be deemed to give an informed consent, it may be necessary that he know the alternative methods of treatment available to him and the inherent dangers and possibilities of success of such alternatives.29 (Emphasis added.)
Other courts have indicated that the duty to disclose not only requires a doctor to provide adequate information, but also accurate information. They recognize that the duty to disclose prohibits a doctor from giving misleading information. As stated by the Supreme Court of New Mexico:29a
A physician who misleads a patient by not only failing to give a warning of reasonable and recognized risks inherent in a treatment after which the patient would have refused the treatment, but by affirmatively assuring her that there are no risks, knowing such statement to be *252untrue, is liable for the harmful consequences of the treatment. Such a failure to disclose, or the giving of an untrue answer as to the probable consequences of a treatment constitutes malpractice; and a doctor who fails to so advise his client, or gives an untrue answer as to such consequences, is liable for malpractice unless his failure to do so comes within one of the exceptions to the rule requiring candor and disclosure. Under the circumstances of this case, a fact issue was presented for determination by the jury . . . (Emphasis added.)
I would hold that under appropriate circumstances, the doctor’s duty to disclose requires him to give a patient adequate and accurate information concerning the alternative methods of achieving a therapeutic goal and the relative chance of success of each of those alternatives. Applying this standard to the instant case would produce a clear result.
Here, the facts, many of which were not even considered by the majority, show that the appellant was not concerned with the possibility of physical harm resulting from the performance of the tubal ligation, but rather was concerned with the question of what available method of birth control would give her the greatest possibility of achieving total, permanent sterility. The record further shows that before she made her decision, her doctor advised her of three available alternative methods of birth control — pills, an intrauterine device, and a tubal ligation. He failed to advise her of other methods such as vasectomy. Moreover, with respect to two of the three suggested methods, birth control pills and intrauterine devices, he gave her no information. He failed to tell her how successful they might be in preventing pregnancy. With respect to the third method, tubal ligation, he gave her misinformation. He not only failed to tell her that that method was fallible, but rather told her that if that procedure were performed, she would not have any more children. Having provided her with this inadequate and inaccurate information, he told her to go *253home and think about which of the alternatives she wished to pursue. Relying upon this inadequate information and misinformation, she elected the tubal ligation procedure.
On the basis of these facts, I cannot conclude, as a matter of law, that the doctor adequately disclosed “substantial facts material to the patient’s decision.” Indeed, on the basis of these facts, I cannot conceive that a reasonable person could reach an intelligent and informed decision as to which of the suggested alternatives should be pursued. I would have concluded that, under the circumstances here, the doctor had a duty to provide the patient with adequate and accurate information concerning available alternative methods of birth control and the relative chance of success of each of those alternatives. I would further have found that the question of whether the doctor breached his duty to disclose should be submitted to the jury.
Moreover, I cannot agree with my colleagues that, as a matter of law, under the present circumstances “a reasonable person, in Mrs. Sard’s position, would attach no material significance to the risk of one chance in fifty that she would derive no benefit from the operation.” 301 believe *254that in determining the significance a reasonable person would attach to a risk, one must consider not only its incidence, but also the severity of its potential consequences. As the court in Canterbury stated:31
A very small chance of death or serious disablement may well be significant; a potential disability which dramatically outweighs the potential benefit of the therapy or the detriments of the existing malady may summons discussion with the patient.
There is no bright line separating the significant from the insignificant; the answer in any case must abide a rule of reason. .. . The disclosure doctrine, like others marking lines between permissible and impermissible behavior in medical practice, is in essence a requirement of conduct prudent under the circumstances. Whenever nondisclosure of particular risk information is open to debate by reasonable-minded men, the issue is for the finder of the facts.
In accord with this rationale, courts in other states have recognized that the jury should determine whether a particular risk should have been disclosed, when there was evidence that that risk was of low incidence but serious consequence.32
*255Here, the record shows that there was a two per cent chance that a person could become pregnant, notwithstanding the performance of a tubal ligation. It also shows that what I regard as serious consequences would flow if a person with Mrs. Sard’s past medical history were to become pregnant again. Pregnancy for any woman entails some physical discomfort. A person with Mrs. Sard’s past medical history would have been told by her own doctor that further pregnancies were medically inadvisable. She would suffer more than the usual physical discomforts of pregnancy. In addition, she would suffer the emotional stress and anxiety created by the fear of serious physical disability or death resulting from the performance of a Caesarian section. Moreover, she would undergo the pain and discomfort associated with that major surgery. Finally, assuming that neither she nor the baby died or were physically harmed, she would have to live with the cost, and, in some instances, the emotional stress of raising an unwanted child. Given the serious consequences which would befall a person in Mrs. Sard’s position, were she to become pregnant, I am unable to conclude, as a matter of law, that in deciding to undergo a tubal ligation such a person would attach no material significance to the fact that she had a two per cent chance of becoming pregnant after that procedure was performed. Under the circumstances here, I believe that the question of whether the doctor made an adequate disclosure of substantial facts which would have been material to the patient’s decision should have been submitted to the jury. Accordingly, I would have reversed.
IV
The majority additionally unnecessarily decides that the evidence was insufficient to require that the question of whether there was a breach of an enforceable express warranty be submitted to the jury. They hold that an alleged express warranty cannot be enforced unless “1) it was made *256before the operation was performed, and was relied upon by the patient in contracting for the service, or 2) it was supported by a separate consideration.” They say that “in the record in this case there is no evidence of a pre-operative warranty.” They find that “there was no evidence in this case of a separate consideration for the alleged express warranty made after the operation.” They conclude that “there was no enforceable warranty.”
Were I to consider the question of whether there was sufficient evidence of a breach of an enforceable express warranty to require submission to the jury, I would reach the opposite result. I agree with the majority that an express warranty made before the operation was performed and relied upon by the patient in contracting for the service can be enforced without a separate consideration.33 I disagree with the majority that here “there is no evidence of a pre-operative warranty.”
In Maryland, the question of whether a doctor’s representation as to the effectiveness of a proposed therapeutic procedure constitutes an enforceable express warranty or is nothing more than an “ordinary medical reassurance” has not been considered. Some courts have recognized that such representations can constitute express warranties.34 Other courts which have considered the question of whether a particular representation is a “warranty” or a “reassurance” have recognized that it involves a question of fact which ordinarily should be submitted to the jury.351 agree.
Here, the record shows that before Mrs. Sard decided to undergo the proposed tubal ligation, the doctor told her that if that procedure were performed she would not have any *257more children.36 She made it plain to her doctor that her reason for electing and undergoing the proposed tubal ligation was the fact that it would result in total permanent sterility. Had she known that the proposed procedure was fallible, she would not have agreed to have the tubal ligation performed.37
This evidence is sufficient to show that here the doctor made an express promise to effect a specific result which was relied upon by Mrs. Sard in contracting for the tubal ligation and before the operation was performed. It was, therefore, sufficient to support a finding that there was a pre-operative express warranty. The issue should have been submitted to the jury. Accordingly, I would have reversed.

. Katz v. Holsinger, 264 Md. 307, 311, 286 A. 2d 115, 118 (1972); Holloway v. Hauver, 22 Md. App. 303, 319, 322 A. 2d 890, 898-99 (1974).

. The majority opinion indicates that there was no evidence to show jthat before the operation the doctor told Mrs. Sard that the proposed tubal ligation would result in permanent sterilization. The record shows that, in both the pre-trial deposition and at trial, Mrs. Sard testified that before she decided to undergo the proposed tubal ligation, the doctor told her that if *241that procedure were performed, she would not have any more children. More particularly, the record shows that at the trial the following colloquy took place:
Q. Now also [in your deposition did you say], “Q. Now did Dr. Hardy or any other doctor you mentioned you have consulted or having been examined by or having been operated upon prior to your decision to be sterilized give you any indication as to the continuing effect of having further children?” Your answer, “Well, Dr. Hardy, all he told me was I would not have no more, I didn’t have to worry about having any more.”
A. That’s what he told me.
Q. He told you before your operation and before your decision to have the sterilization that you would not have any more children?
A. Yes, he did.

. The majority states that the appellants “do not complain that the operation should not have been performed.” The appellants’ pleadings support an inference to the contrary. They state, in pertinent part:
That at all times herein mentioned, said Defendant was negligent in failing to inform the Plaintiff Katie Sue Sard that said surgical procedure and sterilization of her person was not absolute in nature and that a possibility did exist that she could thereafter become pregnant and that the actions and conduct of the Defendant, in failing to properly notify and inform said Plaintiff so that she might declare her decision in accepting or rejecting said surgical procedure, without full information or notice as to the potential results thereof, proximately brought about the Plaintiff s pregnancy and the subsequent birth of her fifth [sic] child.” (Emphasis added.)
The majority also finds that Mrs. Sard “produced no evidence to show that she would have refused the operation if she had known that there was a chance of failure.” Mrs. Sard’s testimony establishes that she was primarily concerned with not having any more children. She objected to the other alternatives and chose the tubal ligation because she was told and believed that that procedure would prevent future pregnancies. Viewed in the light most favorable to the appellant, this testimony supports an inference that had Mrs. Sard been told that the tubal ligation might fail to sterilize her. she would have rejected it. Cobbs v. Grant, 23 Cal.App.3d 236, 100 Cal. Rptr. 98, 102 (1972); Natanson v. Kline, 187 Kan. 186, 354 P. 2d 670, 673-74 (1960); DeBarth v. Swedish Hosp. Medical Center, 81 Wash. 2d 12, *242499 P. 2d 1, 12-13 (1972). See Hamilton v. Hardy, 549 P. 2d 1099, 1105 (Colo. App. 1976).

. See n. 7 below.

. At the trial, the doctor moved for a directed verdict. During argument on the motion, the parties, like the trial judge, assumed that the doctrine of informed consent applied in Maryland. They disagreed as to the extent of the doctor’s duty to disclose. Mrs. Sard contended that the doctor was required to give her accurate information concerning available alternatives and their probability of success. The doctor asserted that he was required only to inforni her of available alternatives and possible physical risks “peculiarly associated with the performance of the procedure.”
While the court expressed the view, in passing, that the patient had to be informed of even a one per cent chance of failure, its decision to grant the motion for directed verdict was not ultimately based either upon the finding that the doctor had a duty to disclose the success rate of the operation, or upon the fact that there was insufficient evidence to show that the doctor violated that duty.

. Maryland Rule 1085. While it has long been recognized in Maryland that a doctor must obtain his patient’s consent before undertaking a therapeutic procedure, the question of whether that consent must be “informed” has not been explicitly determined by the Court of Appeals. Questions such as the scope of the duty to disclose, whether that scope is to be determined by the standards of the §rofession, thus requiring expert opinion evidence or may be etermined by a jury without the aid of expert opinion, whether that scope is to be determined by the objective “reasonable person” standard or a subjective standard, and the scope and extent of a doctor’s privilege not to disclose, have not been resolved by that Court.
New areas of the law presently involve moi’e complexity and controversy than that of informed consent. See generally, Canterbury v. Spence, 464 F. 2d 772 (D.C. Cir. 1972); Natanson v. Kline, 186 Kan. 393, 350 P. 2d 1093 (1960); Informed Consent in Medical Malpractice, 55 Calif.L.Rev. 1396 (1967); Informed Consent — A Proposed Standard for Medical Disclosure, 48 N.Y.U. L.Rev. 548 (1973); 75 Harv.L.Rev. 1445 (1962). In my view, such questions should be resolved by this Court only when absolutely necessary.

. Merit Music v. Sonneborn, 245 Md. 213, 220, 225 A. 2d 470, 474 (1965); Rossi v. Douglas, 203 Md. 190, 199, 100 A. 2d 3, 7 (1953); Western Maryland Dairy Corp. v. Brown, 169 Md. 257, 262, 181 A. 468, 471 (1935) (dictum); Spitze v. Baltimore & Ohio R.R., 75 Md. 162, 171, 23 A. 307, 310 (1892); Wolfe v. Madison Nat’l Bank, 30 Md. App. 525, 531, 352 A. 2d 914, 917 (1976). See Canaras v. Lift Truck Services, 272 Md. 337, 344, 322 A. 2d 866, 870 (1974).

. Rossi, supra, 203 Md. at 199, 100 A. 2d at 7; Wilson v. Pritchett, 99 Md. 583, 593, 58 A. 360, 362 (1904); Spitze, supra, 75 Md. at 169-71, 23 A. at 309-10; Serdenes v. Aetna Life Ins. Co., 21 Md. App. 453, 461-62, 319 A. 2d 858, 863 (1974).

. Merit Music, supra, 245 Md. at 224-25, 225 A. 2d at 474-75; Boyle v. Rider, 136 Md. 286, 291, 110 A. 524, 526 (1920); Smith v. Humphreys, 104 Md. 285, 290-91, 65 A. 57, 59 (1906); Spitze, supra, 75 Md. at 171, 23 A. at 310.

. 75Md. 162, 171, 23 A. 307, 310 (1892).

. 266 Md. 593, 597, 295 A. 2d 876, 879 (1972).

. Meinhard v. Salmon, 249 N. Y. 458, 164 N. E. 545, 546 (1928).

. Herring, supra, 266 Md. at 597, 295 A. 2d at 879; Hall v. Hall, 147 Md. 184, 191-92, 127 A. 858, 861 (1925); Williams v. Williams, 63 Md. 371, 397-98 (1885); Todd v. Grove, 33 Md. 188, 192 (1870); see also Gingell v. Backus, 246 Md. 83, 92, 227 A. 2d 349, 353 (1967).

. Desser v. Woods, 266 Md. 696, 709, 296 A. 2d 586, 593 (1972); Herring, supra, 266 Md. at 600-01, 295 A. 2d at 880-81; see also Merchants Mortgage Co. v. Lubow, 275 Md. 208, 215-16, 339 A. 2d 664, 669 (1975).

. Desser, supra, 266 Md. at 708-09, 296 A. 2d at 593; Farmer v. O’Carroll, 162 Md. 431, 444-46, 160 A. 12, 17 (1932); Cumberland Coal & Iron Co. v. Parish, 42 Md. 598, 606-07 (1875); Todd, supra, 33 Md. at 195-96.
In addition to establishing the inapplicability of the presumption of knowledge, these cases further shift the burden of proof on the question of knowledge from the dependent party to the dominant party.

. 169 Md. 407, 410-11, 182 A. 317, 318 (1935).

. Gaver v. Gaver, 176 Md. 171, 185, 4 A. 2d 132, 139 (1939).

. Tracey v. Tracey, 160 Md. 306, 318, 153 A. 80, 85 (1931).

. Williams, supra, 63 Md. at 404 (dissenting opinion); Todd, supra, 33 Md. at 194,

. Canterbury, supra, 464 F. 2d at 782; Sheets v. Burman, 322 F. 2d 277, 279 (5th Cir. 1963); Lilly v. Comm’r of Internal Revenue, 188 F. 2d 269, 271 (4th Cir. 1951), rev’d on other grounds, 343 U. S. 90 (1952); Hammonds v. Aetna Casualty & Surety Co., 243 F. Supp. 793, 802-03 (N.D. Ohio 1965); Berkey v. Anderson, 1 Cal.App.3d 790, 82 Cal. Rptr. 67, 77-78 (1970); Stacey v. Pantano, 177 Neb. 694, 131 N.W.2d 163, 165 (1964); Demers v. Gerety, 87 N. M. 52, 529 P. 2d 278, 280 (1974); Allison v. Blewett, 348 S.W.2d 182, 184 (Tex.Civ.App. 1961); Hunter v. Brown, 4 Wash. App. 899, 484 P. 2d 1162, 1166 (1971); Mason v. Ellsworth, 3 Wash. App. 298, 474 P. 2d 909, 916 (1970); 41 Am. Jur., Physicians & Surgeons, § 74; see Davis v. Arizona State Dental Board, 57 Ariz. 239, 112 P. 2d 870, 877 (1941); Mattingly v. Sisler, 198 Okl. 107, 175 P. 2d 796, 799 (1946); Alexander v. Knight, 197 Pa. Super. 79, 177 A. 2d 142, 146 (1962); Hodge v. Shea, 252 S. C. 601, 168 S.E.2d 82, 84, 87 (1969).

. Moore v. Webb, 345 S.W.2d 239, 243 (Mo. 1961).

. Canterbury, supra, 464 F. 2d at 782.

. Cobbs v. Grant, 104 Cal. Rptr. 505, 513, 502 P. 2d 1, 9 (1972).

. Canterbury, supra, 464 F. 2d at 783; Dunham v. Wright, 423 F. 2d 940, 943-44 (3d Cir. 1970); Berkey, supra, 82 Cal. Rptr. at 77; Salgo v. Leland Stanford Jr. University Bd. of Trustees, 154 Cal.App.2d 560, 317 P. 2d 170, *249181 (1957); Natanson v. Kline, 186 Kan. 393, 350 P. 2d 1093, 1106-07 (1960); Getchell v. Mansfield, 260 Ore. 174, 489 P. 2d 953, 954-55 (1971); Cooper v. Roberts, 220 Pa. Super. 260, 286 A. 2d 647, 649 (1971); Gray v. Grunnagle, 423 Pa. 144, 223 A. 2d 663, 674 (1966); Ball v. Mallinkrodt Chemical Works, 53 Tenn. App. 218, 381 S.W.2d 563, 567 (1964); Holt v. Nelson, 11 Wash. App. 230, 523 P. 2d 211, 216 (1974).

. Campbell v. Oliva, 424 P. 2d 1244, 1251 (6th Cir. 1970).

. See Campbell, supra, 424 F. 2d at 1251; Gray, supra, 223 A. 2d at 674.
See also n. 13 above. The cases there cited establish not only that where there is a fiducial relationship, a presumption of knowledge of the contents, nature and consequences of a signed document is inapplicable, but also that the burden of proof on the question of knowledge is shifted.
The Court of Appeals of Maryland has placed the burden of proof in malpractice actions upon the patient. State, ex rel. Janney v. Housekeeper, 70 Md. 162, 171, 16 A. 382, 384 (1889). I wish to make it clear that I would not here incorporate into malpractice actions all of the ramifications of fiduciary law. While I would hold that under the present circumstances a presumption of knowledge is inapplicable, I would not shift the burden of persuasion on the question of knowledge from the patient to the doctor. See Demers, supra, 529 P. 2d at 280.

. It is unnecessary to consider whether the husband knew or should *250have known the contents of the consent form. The wife’s consent, not her husband’s, was necessary. Housekeeper, supra, 70 Md. at 170, 16 A. at 384.

. Miller v. Kennedy, 11 Wash. App. 272, 522 P. 2d 852, 860 (1974).

, Dunham, supra, 423 F. 2d at 944. See Canterbury, supra, 464 F. 2d at 782, n.27; Russell v. Harwick, 166 So. 2d 904, 905 (Fla. 1964); Bang v. Charles T. Miller Hosp., 251 Minn. 427, 88 N.W.2d 186, 190 (1958); Gray, supra, 223 A. 2d at 669-70; Miller, supra, 522 P. 2d at 860; Hunter, supra, 484 P. 2d at 1167. See also, Powell, “Consent to Operation,” 21 Md.L.Rev. 189, 192-93 (1961); Louisell & Williams, Medical Malpractice § 22.01 (1976).

. Woods v. Brumlop, 71 N. M. 221, 377 P. 2d 520, 525 (1962). See Berkey, supra, 82 Cal. Rptr. at 77,

. In reaching their conclusion, the majority considered three factors:
1) that “the physical harm to the patient was zero;”
2) “that there was one chance in fifty that the benefit would be zero;”
3) that Mrs. Sard "produced no evidence to show that she would have refused the operation if she had known that there was a chance of failure.”
The fact that physical harm resulting from the operation was zero is irrelevant. The question here is not whether the doctor violated a duty to disclose risks of bodily harm peculiar to the proposed procedure, but rather whether the doctor violated a duty to disclose alternative methods of treatment and their success rates. Moreover, while physical harm to the patient resulting from a breach of the duty to disclose is relevant to the issue of proximate cause and damages, it has no bearing on the issues of the scope of the duty to disclose and the breach of that duty.
Mrs. Sard did, in my view, produce evidence that she would not have consented to the operation had she known that there was a chance of failure. See n.3 above. Even if she had failed to produce such evidence, that fact would be irrelevant. Evidence that disclosure would not have resulted in a decision against the proposed procedure, like evidence of physical harm resulting from a failure to disclose risks, is relevant to the issue of proximate cause, and has no bearing on the issues of the scope of the duty to disclose and the breach of that duty. See Canterbury, supra, 464 F. 2d at 790-91.

. Canterbury, supra at 788.

. Canterbury, supra, 464 F. 2d 772 (1% risk of paralysis); Cobbs, supra, 104 Cal. Rptr. 505 (5% risk of injury to spleen); Berkey, supra, 82 Cal. Rptr. 67 (“rare and remote” incidence of foot drop); Hamilton v. Hardy, 549 P. 2d 1099 (Colo. App. 1976) (“possible relationship” between the use of oral contraceptives and thromboembolism); Coleman v. Garrison, 349 A. 2d 8 (Del. Supr. 1975) (l%-2% chance of pregnancy after a tubal ligation); Fogal v. Genesee Hospital, 41 A.D.2d 648, 344 N.Y.S.2d 552 (1973) (“rare and unlikely” possibility of necrotic injuries); Cooper, supra, 286 A. 2d 647 (1 in 2500 risk of perforation of stomach); Hunter, supra, 484 P. 2d 1162 (“minimal risk1’ that “dermabrasion” might not be successful in removing dark pigmentation spots from patient’s face); Bowers v. Talmage, 159 So. 2d 888 (Fla. 1963) (3% risk of paralysis). Contra, Starnes v. Taylor, 272 N. C. 386, 158 S.E.2d 339 (1968) (¼ of 1% risk of perforation of esophagus); Mason v. Ellsworth, 3 Wash. App. 298, 474 P. 2d 909 (1970) (¼ to ¾ of 1% risk of perforation of esophagus).
It is interesting to note that in Cobbs, supra, 104 Cal. Rptr. 505, and Wilkinson v. Vesey, 295 A. 2d 676 (R.I.1972), upon which the majority relies *255to establish the standard for the duty to disclose, the question of adequate disclosure was submitted to the jury. In Cobbs, there was a 5% possibility of injury to the spleen.

. Guilmet v. Campbell, 385 Mich. 57, 188 N.W.2d 601, 605-607 (1971). Contra, Coleman, supra, 349 A. 2d at 11; Rogala v. Silva, 16 Ill.App.3d 63, 305 N.E.2d 571, 573 (1973).

. Custodio v. Bauer, 251 Cal.App.2d 303, 59 Cal. Rptr. 463, 471 (1967); Vilord v. Jenkins, 226 So. 2d 245, 246 (Pla. App. 1969). See 41 Am. Jur., Physicians & Surgeons § 105.

. Crawford v. Duncan, 61 Cal. App. 647, 215 P. 573, 574 (1923); Guilmet, supra, 188 N.W.2d at 606; Hawkins v. McGee, 84 N. H. 114, 146 A. 641, 643 (1929). See Perin v. Hayne, 210 N.W.2d 609, 616 (Iowa 1973).

. See n.2 above.

. See n.3 above.