Court Opinion

ID: 9634868
Source: CourtListenerOpinion
Date Created: 2023-08-22 13:26:55.721258+00
Date Added: 2024-06-11T18:09:12.264313
License: Public Domain

CLIFFORD, Justice,
with whom NICHOLS and WATHEN, JJ., join, dissenting.
I concur with Parts II and III of the court’s opinion, but I respectfully dissent from Part I. Nothing in the record supports a conclusion that Dr. Painter as a general practitioner was in any way on notice that surgery was contraindicated or that the use of pins posed a significant risk. Moreover, the record clearly shows that Mrs. Jacobs had actual knowledge that conservative treatment was a viable alternative when she consented to surgery. Consequently, Dr. Painter’s failure to disclose this fact did not proximately cause her injury.
I.
The theory upon which this case was tried, and upon which the court upholds the jury verdict, was that Dr. Painter, as Mrs. *239Jacobs’ family physician, did not disclose information that he had a duty to disclose and that was necessary to Mrs. Jacobs’ making an intelligent decision regarding treatment, and that his failure to disclose that information proximately caused Mrs. Jacobs’ harm. In particular, Dr. Painter did not disclose to Mrs. Jacobs that conservative treatment was a viable alternative to surgery. See generally Prosser & Keeton, Torts § 32 at 189-93 (5th ed. 1984).
A.
In my judgment, the court errs by grounding its analysis of the existence of Dr. Painter’s duty to disclose on the referral-consultation distinction.1 Neither Mrs. Jacobs’ expert medical witness, Dr. Garger, nor Dr. Painter’s expert medical witness, Dr. Barrett, testified that Dr. Painter’s duty to disclose turned on whether the relationship between Dr. Painter and Dr. Amalfitano was properly characterized as a referral or a consultation. To the contrary, both expert medical witnesses testified that the existence of Dr. Painter’s duty to disclose depended on whether he remained involved to some degree in treating Mrs. Jacobs’ injury. Therefore, Dr. Painter’s duty to disclose arose, as it always has, from the fiduciary character of the physician-patient relationship. See Woolley v. Henderson 418 A.2d 1123, 1128 n. 3 (Me. 1980).
B.
Despite the court’s suggestion to the contrary, malpractice liability premised on breach of a duty to disclose no longer rests entirely on Maine common law. The principles governing the duty of a physician to disclose are set out in Downer v. Veilleux, 322 A.2d 82, 89-93 (Me.1974), and section 2905 of the Maine Health Security Act, 24 M.R.S.A. §§ 2501-2961 (Supp.1986).2 As a *240general practitioner Dr. Painter’s duty to disclose is measured by “the standards of practice among members of the same health care profession with similar training and experience situated in the same or similar communities ...” 24 M.R.S. A. § 2905(1)(A) (emphasis added).3 Moreover, the disclosure must be made in such a manner that “[a] reasonable person [cf. Downer, 322 A.2d at 90 (“patient of ordinary understanding”)], from the information provided by the physician under the circumstances, would have a general understanding of the procedures or treatments and of the usual and most frequent risks and hazards inherent in the proposed procedures or treatment ...” 24 M.R.S.A. § 2905(1)(B).4 Naturally, a general understanding of the “risks and hazards inherent in the proposed procedures or treatment” entails knowledge of the alternatives, including conservative treatment, without which it is impossible for the patient to evaluate the relative merits of any specific procedure or treatment. Downer, 322 A.2d at 90-91. Nevertheless, “where the physician does not know of a risk and should not have been aware of it in the exercise of ordinary care, he is under no obligation to make disclosure” and thus the failure to disclose is not negligent. Sard v. Hardy, 281 Md. 432, 445, 379 A.2d 1014, 1022-23 (1977) (citations omitted).
II. A.
A review of the record leads me to conclude that Mrs. Jacobs, who had the burden of proof throughout, utterly failed to show that in 1980 a general practitioner practicing in Winthrop or a similar community reasonably should have known either that surgery was contraindicated or that use of pins posed a significant risk. The uncon-tradicted evidence was that the authoritative treatises, Campbell’s Operative Or-thopaedics and Rockwood and Green’s Fractures, the only two treatises on the subject produced at trial, contained nothing that would have put a general practitioner, confronted with what both expert medical witnesses acknowledged was an unusual injury, on notice that surgical repair or the use of pins specifically was contraindicated. Cf. Harbeson v. Parke Davis, Inc., 746 F.2d 517, 525 (9th Cir. 1984). Dr. Garger, who asserted to the contrary, referred to no valid source to support the assertion. The evidence, in fact, compels a contrary conclusion.
The information available to Dr. Painter may be summarized as follows. In dislocation of the sternoclavicular joint the medial end of the clavicle becomes dislocated either anteriorly or posteriorly, more frequently anteriorly, with the medial end of the clavicle displaced inferiorly so that it *241overlaps the first rib. Dislocation usually can be treated conservatively, but without some treatment the medial end of the clavicle may become fixed in position and produce a rather unsightly prominence. For people with sedentary occupations this results in little disability. Old, unreduced dislocations and recurrent dislocations may be surgically treated by either resection, binding the clavicle in place with fascial loops, or pins. Neither Campbell nor Rock-wood and Green suggests either that surgery is contraindicated or that use of pins posed a risk of serious bodily injury. Rock-wood and Green in fact suggests that if the dislocation causes annoyance it will probably create problems for the patient and that if it can be repaired it should be.
Both Dr. Garger and Dr. Barrett testified that sternoclavicular dislocations were relatively rare, difficult to treat, and best handled by a specialist. Both testified that Dr. Painter’s referring Mrs. Jacobs to a specialist was therefore good medical practice. Both testified that in such circumstances the general practitioner should grant considerable deference to the opinions and recommendations of the specialist.
In the follow-up January 22 letter, in which he summarized his opinions and recommendations to Dr. Painter, Dr. Amalfita-no specifically identified Mrs. Jacobs as “a large, rugged individual, [who] probably does a lot of heavy lifting, pulling, and tugging” and who had a sternoclavicular separation which was “a long-standing, old injury.” He further pointed out that Mrs. Jacobs had “shifting of the clavicle with nonfixation” and that it might be difficult to make the clavicle stay in the joint. Dr. Amalfitano concluded that “[i]f there is confirmed evidence of sternoclavicular separation, surgical repair certainly is indicated, if the patient wants to have it done.”
On this record, I would conclude as a matter of law that Dr. Painter, as a general practitioner in Winthrop or a similar community in 1980, could not be expected to know either that surgery was contraindicated or that the use of pins presented a risk of serious bodily harm. See Kranda v. Houser-Norborg Medical Corp., 419 N.E.2d 1024, 1037-38 (Ind.Ct.App.1981), petition for reh. denied, 424 N.E.2d 1064 (Ind.Ct.App.1981), appeal dismissed, 459 U.S. 802, 103 S.Ct. 23, 74 L.Ed.2d 39 (1982); Trogun v. Fruchtman, 58 Wis.2d 569, 603-04, 207 N.W.2d 297, 315 (1973). Consequently, had Dr. Painter made any disclosures, they would have been limited to describing precisely the information supplied by the treatises which, if applied to the criteria Dr. Amalfitano set out in his letter to Dr. Painter, lead to the inescapable conclusion, not only that surgery was appropriate, though not absolutely necessary, but also that the use of pins was a viable alternative. In light of this evidence the assertions of Dr. Garger as to it being commonly known that such surgery was contraindicated and posed a serious risk must be entirely discounted for lack of support in the record. See Warren v. Waterville Urban Renewal Authority, 235 A.2d 295, 298 (Me.1967), cert. denied, 390 U.S. 1006, 88 S.Ct. 1249, 20 L.Ed.2d 105 (1968); Brouillette v. Weymouth Shoe Co., 157 Me. 143, 145-46, 170 A.2d 412, 413-14 (1961). Since Dr. Painter could not be expected to know of the specific risk that resulted in injury, he was under no obligation to disclose it. Sard, 281 Md. at 445, 379 A.2d at 1022-23.
B.
Assuming, nevertheless, that Dr. Painter as a general practitioner did know or reasonably should have known of the risk that resulted in injury, Mrs. Jacobs has adduced no evidence to show that Dr. Painter’s failure to disclose the fact that conservative treatment was an appropriate alternative proximately caused her harm. To establish proximate causation, Mrs. Jacobs had to show that had she, as a reasonable person,5 been informed of this fact she would not have submitted to surgery. Downer, 322 A.2d at 92. Consequently, if Mrs. Jacobs had actual knowledge of this fact, Dr. *242Painter’s failure to make a reasonable disclosure would have no causal relation to her injury.6 See, e.g., Vergie M. Lapelosa, Inc. v. Cruze, 44 Md.App. 202, 210-11, 407 A.2d 786, 791-92 (1979), cert. denied, 287 Md. 754 (1980); Fleishman v. Richardson-Merrell, Inc., 94 N.J.Super. 90, 93-95, 226 A.2d 843, 845-46 (App.Div.1967).
The record reveals that Dr. Amalfitano discussed with Mrs. Jacobs on at least three occasions the material risks of the proposed surgery as well as the alternatives, including conservative treatment. Dr. Amalfitano testified that he discussed with her the alternatives and possibilities of treatment, including conservative treat ment, on January 15 at her office visit after leaving Dr. Painter. Again on January 27, the day Mrs. Jacobs was admitted to the hospital, Dr. Amalfitano examined her and discussed her options. Finally on January 29, the eve of the operation, Dr. Amalfitano, as was required by hospital rules, discussed with Mrs. Jacobs the material risks of the proposed surgery and alternative treatment before obtaining Mrs. Jacobs’ signature on a written consent.7 Specifically, Dr. Amalfitano discussed procedure failure, loss of clavicle and loss of life, conservative treatment, resection and pinning. Dr. Amalfitano disclosed to Mrs. Jacobs the fact that the pins sometimes break and do come out but concluded by recommending pinning to Mrs. Jacobs.8
The record compels the conclusion that when she consented to surgery on January 29 Mrs. Jacobs had from her discussions with Dr. Amalfitano actual knowledge that conservative treatment was a viable alternative. Moreover, the signed written consent Dr. Amalfitano obtained after disclosure established a presumption that such consent was valid. 24 M.R.S.A. § 2905(2). Therefore, when Mrs. Jacobs consented to surgery she had a “general understanding” of the proposed treatment and the alternatives, including conservative treatment, conforming to the disclosures required of a general practitioner in Winthrop or similar communities, as measured by the standards of the informed consent statute, 24 M.R. S.A. § 2905(1)(A) & (B). At a minimum, having learned from an unimpeachable source that conservative treatment was a viable alternative, Mrs. Jacobs cannot now be heard to say that Dr. Painter’s failure to disclose the same fact was the proximate cause of her injury.
Therefore, for the foregoing reasons, I would vacate the judgment of the Superior Court for entry of judgment for the defendant.

. The referral-consultation distinction mainly concerns the allocation of responsibilities for the actual management of treatment between physicians. Referral denotes the transfer of responsibility for care of specific problems to another physician. Consultation, on the other hand, is essentially a request for the opinion of a colleague. A referring physician cannot be held vicariously liable for the negligent performance of services by the physician to whom the patient was referred. See Graddy v. New York Medical College, 19 A.D.2d 426, 429-30, 243 N.Y.S.2d 940, 944 (1963), motion to dismiss app. denied 13 N.Y.2d 1175, 248 N.Y.S.2d 54, 197 N.E.2d 541 (1964). This is true even if the referring physician concurrently cares for the patient. See, e.g., Dahlberg v. Ogle, 268 Ind. 30, 35-37, 373 N.E.2d 159, 162-63 (1978); Evans v. Bernhard, 23 Ariz.App. 413, 416-17, 533 P.2d 721, 724-25 (1975); Smith v. Beard, 56 Wyo. 375, 110 P.2d 260, 281 (1941). Here, the cause of action is based not on negligent performance of services but on breach of a duty to disclose. Since physicians who are concurrently treating a patient may have parallel duties to disclose running to the patient, independent of the degree of control each might have over the chosen means of treatment, whether the relationship between the physicians is properly characterized as a referral or consultation is irrelevant.

. In Downer v. Veilleux, 322 A.2d 82, 89-93 (Me.1974), this court rejected technical battery as a theory of recovery when a physician has failed to make adequate disclosures for the majority view that failure to inform a patient of the risks involved in proposed treatment is more properly characterized as a species of medical malpractice sounding in negligence. Nevertheless, this court in Downer expressly left unresolved the scope of the physician’s duty to disclose and the test applicable in determining proximate causation. Id. at 92.
In 1977, three years after Downer was decided and before this court had further developed the case law concerning informed consent, the legislature enacted the Maine Health Security Act, P.L.1977, ch. 492, which implemented legislation recommended by the Pomeroy Commission which had been created to undertake a thorough and comprehensive review of medical and hospital malpractice in Maine and to make concrete proposals for legislation whose effect would be to assure, in the face of a growing crisis generated by the proliferation of medical malpractice claims, the availability of malpractice liability insurance at reasonable cost to physicians and hospitals alike. See P. & S.L.1975, ch. 73. In its Findings and Recommendations submitted to the 108th Legislature the Pomeroy Commission proposed the present section 2905 and specifically noted that
[t]he decisional law of Maine has not fully developed the tests and standards for a physician's duty to inform a patient concerning the nature and possible consequences of proposed treatment or procedures. In the current malpractice climate the confusion and disagreement on this matter in other states has left Maine hospitals and physicians in doubt as to what is required. For this reason the Commission believes statutory clarification is de-sireable [sic]. It recommends a duty to inform based upon the standards of medical *240practice in the community, and an objective test (reasonable person) of the patient's consent to treatment....
Report to the One Hundred and Eighth Legislature (1977) at xxiii (emphasis added). Then, in 1980, this court decided Woolley v. Henderson, 418 A.2d 1123, which likewise supplied the standards omitted in Downer, but which concerned a cause of action that arose before the enactment of section 2905. Consequently, this court expressly noted in Woolley, 418 A.2d at 1130 n. 5, there was no occasion to construe the statute. Since Mrs. Jacobs’ injury occurred in 1980, three years after the enactment of section 2905, the court, in my judgment, must construe the statute and is bound by its provisions. See Informed Consent in Maine; Woolley v. Henderson and the Informed Consent Statute, 34 Me.L.Rev. 311, 321-22 (1982) ("Section 2905(1)(A) establishes the professional standard of disclosure for physicians").

. Basing the duty to disclose upon the standards of medical practice in the community substantially conforms to preexisting law in Maine as applied to general practitioners like Dr. Painter. This court has consistently upheld the inclusion of the community factor as a proper consideration in establishing the duty of a general practitioner, although "strict locality” has never been the rule in Maine. See Taylor v. Hill, 464 A.2d 938, 942-43 n. 1 (Me.1983); Roberts v. Tardif, 417 A.2d 444, 451 (Me.1980).

. Cf. Cobbs v. Grant, 8 Cal.3d 229, 244, 104 Cal.Rptr. 505, 515, 502 P.2d 1, 11 (1972):
[T]he patient’s interest in information does not extend to a lengthy polysyllabic discourse on all possible complications. A mini-course in medical science is not required; the patient is concerned with the risk of death or bodily harm, and problems of recuperation.... [Tjhere is no physician’s duty to discuss the relatively minor risks inherent in common procedures, when it is common knowledge that such risks inherent in the procedure are of very low incidence.
(Footnote omitted.)

. Section 2905(1)(C) precludes recovery if "[a] reasonable person, under all surrounding circumstances, would have undergone such treatment or procedure had he been advised by the physician in accordance with [the appropriate standards of disclosure].”

. See Wheeldon v. Madison, 374 N.W.2d 367, 375 (S.D.1985); Crain v. Allison, 443 A.2d 558, 562 (D.C.App.1982); Sard v. Hardy, 281 Md. 432, 444-45, 379 A.2d 1014, 1022 (1977); Wilkinson v. Vesey, 110 R.I. 606, 627-28, 295 A.2d 676, 689 (1972); Canterbury v. Spence, 464 F.2d 772, 790 (D.C.Cir.1972), cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (1972); Natanson v. Kline, 186 Kan. 393, 409-10, 350 P.2d 1093, 1106 (1960), motion for reh. denied, 187 Kan. 186, 354 P.2d 670 (1960).

. The trial court refused to give Dr. Painter’s requested verbatim section 2905(1) instruction, but did substantially include the provisions of section 2905(1) in its instruction relating to the duties to disclose and proximate causation. However, the trial court refused to instruct the jury on 24 M.R.S.A. § 2905(2) which accords a mandatory rebuttable presumption to a signed written consent:
A consent which is evidenced in writing and which meets the foregoing standards, and which is signed by the patient or other authorized person, shall be presumed to be a valid consent. This presumption, however, may be subject to rebuttal only upon proof that such consent was obtained through fraud, deception or misrepresentation of material fact.
As justification for refusal, the trial court stated that Dr. Amalfitano’s disclosures leading to the written consent were too cursory and inadequate even though Mrs. Jacobs introduced no evidence tending to show fraud, deception or misrepresentation. However, Dr. Painter did not press the point on appeal.

. Dr. Amalfitano further testified that he had treated approximately twelve sternoclavicular separations in his career and had treated six of them conservatively. At least three times Dr. Amalfitano had had problems with pins migrating. Nevertheless, Mrs. Jacobs produced no evidence suggesting that this fact was known to Dr. Painter nor did she show what the likelihood was that this would happen.