Court Opinion

ID: 6453722
Source: CourtListenerOpinion
Date Created: 2022-06-25 12:37:02.906603+00
Date Added: 2024-06-11T15:53:08.772619
License: Public Domain

Greaney, J.
(concurring in part and dissenting in part). The undisputed facts of this case are tragic. David E. Sacca, a seventy-five year old, gravely ill man, suffered from, among other ailments, asbestosis, chronic obstructive pulmonary disease, high blood pressure, and metastatic lung cancer. He had never before caused a motor vehicle accident (nor been issued a traffic citation) until March 22, 2002, when he lost control of his motor vehicle and struck and killed Kevin Coombes, a ten year old boy. Sacca’s physical and emotional health quickly declined, and he died four months after the accident. The plaintiff asserts that Sacca had taken several prescription medicines that rendered *196him unable to drive safely and ultimately caused him to lose consciousness while driving on March 22, and further, that Sac-ca’s physician, Dr. Roland J. Florio, failed to warn Sacca of the hazards of driving while taking the prescribed medications. Had Dr. Florio properly cautioned Sacca, the plaintiff argues, the accident would not have occurred. In my view, when a physician who has knowledge of a danger that may be posed to others from a patient’s decision to operate a motor vehicle while under the influence of prescribed medication (a danger of which the public has no way of knowing) does not warn the patient of the risks involved, the physician may be held liable for injuries to others caused by the failure to warn. The imposition of limited liability in such a case, where the circumstances warrant, may prevent tragedies similar to this one in the future.
I cannot agree, however, with the proposition that liability in such a case is justified by principles of ordinary negligence. This concept is incorrect and leads Justice Ireland (and those Justices joining his opinion) to the sweeping conclusion that physicians owe a legal duty of care to virtually everyone who may come in contact with one of his or her patients. This conclusion is unwarranted and goes far beyond what is necessary to resolve this case. The plaintiff, in her complaint, seeks damages for Dr. Florio’s alleged negligent failure to warn Sacca “that his various medications would affect him in a manner so as to make it dangerous for him to operate a motor vehicle and to advise him not to operate a motor vehicle while taking these medications.” For this court to grant more than the requested relief, by creating a precautionary duty previously unknown in common law, would be extraordinary. Accordingly, although I concur in the court’s determination that summary judgment for Dr. Florio should not have been granted, I dissent from the pronouncement, in Justice Ireland’s opinion, that a physician owes a duty of care to everyone foreseeably put at risk by his failure to warn a patient of the effects of his treatment of that patient. My reasons are as follows.
Physicians’ decisions concerning patient care are matters of professional judgment and, with the exception of malpractice claims (which this is not), fall beyond the scope of judicial fact finding. To equate a physician’s prescribing of medication to “unreasonably dangerous” conduct, ante at 189 (Ireland, J., *197concurring), similar to serving alcohol to minors or already inebriated persons or to the reckless storage of firearms, which creates a general affirmative duty of care to others, is an immoderate and indefensible characterization of the medical profession, and one that, as Chief Justice Marshall (post at 203-204 [Marshall, C.J., dissenting]) and Justice Cordy (post at 206 & n.1 [Cordy, J., dissenting]) point out, impermissibly intrudes on the traditional physician-patient relationship held virtually inviolate since the time of Hippocrates. A physician should not, in ordinary circumstances, be held legally responsible for the safety of others on the highway, or elsewhere, based on medical treatment afforded a patient. To a physician, it is the patient (and not a third party with whom the physician has no direct contact) who must always come first. I also am skeptical of the court’s assumption that “existing social values, customs, and considerations of policy” dictate the imposition of an unlimited affirmative duty of care in this case. Luoni v. Berube, 431 Mass. 729, 730 (2000).
It must be recognized, however, that, beyond the traditional, there exists a separate legal relationship between a physician and his or her patient. Based on that relationship, a physician is required to warn the patient of known potentially dangerous side effects of prescribed medication, including the possibility of experiencing drowsiness or loss of consciousness while under the medication’s influence. See Cottam v. CVS Pharmacy, 436 Mass. 316, 321-322 (2002).1 In the usual case, so long as a physician provides his patient with an appropriate warning *198(cautioning the patient about the possible danger of driving), the applicable standard of care has been met, and a physician has no further duty. This is so because many medications may affect a patient’s ability to drive safely, and the physician’s legal duty is to give appropriate warnings to a patient, in. a manner consistent with the warnings advised by the medication’s manufacturer2 and the physician’s personal knowledge of the patient’s over-all health condition, including the effects of additional medications being taken by the patient.
Extending the scope of liability for the benefit of third parties foreseeably put at risk by an uninformed patient’s decision to drive alters neither the physician’s medical decision to prescribe medication nor the physician’s legal duty under the Cottam decision to warn the patient about adverse side effects. Because the foreseeable risk of danger that the patient faces (here, death or bodily injury due to a motor vehicle accident) is the identical risk that the physician may anticipate others, such as the plaintiff’s son, to encounter, there can arise no conflict of professional interest. Contrast Spinner v. Nutt, 417 Mass. 549, 553-554 (1994) (lawyer’s primary duty owed to client bars imposition of secondary duty owed to third parties). The imposition of liability for a failure to warn a patient rests on a physician’s superior knowledge of the risks (to the patient and to others) involved, and the physician’s professional responsibility to ensure that a patient understands the risks involved in taking prescribed medications.
A physician’s advice may not be followed, of course, and a physician has no ability physically to prevent a patient from driving (or engaging in any behavior that may be risky to himself or others). It cannot be said, therefore, that a physician has a duty to control a patient’s behavior once that patient departs from the physician’s office. Contrast Irwin v. Ware, 392 Mass. *199745, 756 (1984), citing W. Prosser, Torts § 56 (4th ed. 1971); Restatement (Second) of Torts § 315(a) (1965) (duty to control conduct of third person to prevent physical harm to another when “special relation exists between the actor and the third person”). There is, however, a recognized measure of authority within the physician-patient relationship, which permits, and even requires, a physician to take steps to influence (or attempt to influence) a patient’s conduct on matters within the scope of that relationship. By informing (or otherwise counselling or advising) a patient of known potential side effects of prescribed medications that might affect the patient’s ability to drive a motor vehicle safely, and where appropriate, warning the patient not to drive at all, a physician may effectively avoid any risk of danger to the patient and to others. See McKenzie v. Hawai’i Permanente Med. Group, Inc., 98 Haw. 296, 308 & n.13 (2002)3; Restatement (Third) of Torts: Liability for Physical Harm § 41(a) (Proposed Final Draft No. 1, 2005) (“actor in a special relationship with another owes a duty of reasonable care to third persons with regard to risks posed by the other that arise within the scope of the relationship”); id. at § 41 comment h (“physician’s duty to the patient is explicitly relational *200[and i]n some cases, care provided to a patient may create risks to others”).4
In sum, a physician’s duty to warn a patient arises entirely within the context of the physician-patient relationship. Further, this duty is owed strictly to the patient, in the sense that a phy*201sitian has no duty to warn others of the dangerous propensities of a patient who drives while on medication known to cause drowsiness or blackouts (either unaware of the danger or despite being aware of the danger). The violation of that duty, however, in the limited circumstances described, may give rise to liability in negligence to others who are foreseeably injured as a direct result of the violation.5
Here, under the summary judgment standard, the plaintiff’s facts, if accepted, would permit a jury to find that because Dr. Florio should have been aware of the side effects of the medications being taken by Sacca, and was aware of Sacca’s dire medical condition, he should have warned Sacca not to drive a motor vehicle at all. The plaintiff must still, of course, demonstrate to a jury that Dr. Florio violated his duty to warn Sacca not to drive while taking the medications and, further, that the violation was the cause of the fatal accident. If the elements of negligence are successfully proved, however, the plaintiff should be allowed to recover damages from Dr. Florio.
Decisions such as this one are necessarily based on the factual situation before the court. Negligence law is not suitable to sweeping pronouncements, and as experience indicates, a revised or expanded tort principle is better left to case-by-case development. I would not preclude other actions to apply the principle, but would leave the contours of the duty to warn to be drawn in future fact-based inquiries.

The interpretation given to Cottam v. CVS Pharmacy, 436 Mass. 316, 321-322 (2002), by Chief Justice Marshall, post at 202-203 & n.1 (Marshall, C.J., dissenting), is more limited than that expressed in the Cottam decision itself. The Cottam court reasoned: “The rationale for [applying the learned intermediary doctrine to prescription drug manufacturers] is that physicians have the duty to inform themselves about the drag and warn their patients as they deem necessary. Physicians, after considering the history and needs of their patients and the qualities of the drug, are required to inform their patients of those side effects they determine are necessary and relevant for patients to know in making an informed decision. . . . Requiring the manufacturer to provide wamings directly to the consumer would interfere with the doctor-patient relationship.” Id. at 321, citing McKee v. American Home Prods. Corp., 113 Wash. 2d 701, 709 & 711 (1989). We held that, “[b]ecause the physician is the appropriate person to perform the duty of warning a patient of the possible side effects of prescription drugs, we now extend [the learned intermediary] *198doctrine to pharmacies.” Id. at 322. My understanding of the import of the Cottam decision, set forth above, is correct.

For example, if the physician is prescribing a sleep aid, the physician should provide the patient with a warning, consistent with the manufacturer’s warning, that with respect to driving a motor vehicle, the patient should avoid taking the sleep aid with alcohol and should not drive, or operate heavy machinery, until the patient knows how he or she will react to the sleep aid, and that the patient should avoid engaging in all hazardous activities (such as operating a motor vehicle or heavy machinery) immediately after taking the sleep aid.

I take issue with the Chief Justice Marshall’s pronouncement, post at 205 (Marshall, C.J., dissenting), that the Supreme Court of Hawai’i, in McKenzie v. Hawai’i Permanente Med. Group, Inc., 98 Haw. 296, 300 (2002), “expressly disavowed] the ‘special relationship’ analysis as ‘inapplicable’ in a case with strikingly similar facts” to this one. The Hawaii court did reject a physicianpátient relationship analysis, but did so in the context of evaluating a claim involving a physician’s misfeasance, i.e., the negligent prescription of medicatian, and not in the context of a claim involving a physician’s nonfeasance, i.e., the physician’s failure to warn. See id. at 300 & n.4. The Hawaii court’s conclusion, that “a logical reason exists to impose upon physicians, for the benefit of third parties, a duty to advise their patients that a medication may affect the patient’s driving ability when such a duty would otherwise be owed to the patient,” almost exactly mirrors my own. Id. at 308. Further, the Hawaii court expressly based that conclusion, as do I, on considerations that (1) a physician has superior knowledge of the risks of which a patient might otherwise be unaware; (2) warning against driving might prevent substantial harm; and (3) imposing a duty on physicians would create little additional burden because the same duty (to warn) already is owed a patient. I remain unconvinced, however, of the correctness of the Hawaii court’s fourth expressed rationale, that “the majority of jurisdictions appear to recognize [such] a duty under some circumstances.” Id. at 307. Other jurisdictions appear to me to be evenly divided on the issue.

The citation to § 41 comment h of the Restatement (Third) of Torts: Liability for Physical Harm § 41 (Proposed Final Draft No. 1, 2005), post at 205 (Marshall, C.J., dissenting), is uncharacteristically imprecise. A more complete, and therefore more accurate, quotation of comment h (that focuses primarily on circumstances in which a physician treats a patient with a communicable disease) is as follows:
“The physician-patient relationship is not among the relationships listed in this Section as creating an affirmative duty. That does not mean that physicians have no affirmative duty to third persons. Some of the obligations of physicians to third parties, such as with patients who are HIV infected, have been addressed by [L]egislatures. In other areas, the case law is sufficiently mixed, the factual circumstances sufficiently varied, and the policies sufficiently balanced that this Restatement leaves to further development the question of when physicians have a duty to use reasonable care or some more limited duty — such as to warn only the patient — to protect third persons. In support of a duty is the fact that an affirmative duty for physicians would be analogous to the affirmative duty imposed on mental-health professionals. ... In fact, the burden on a physician may be less than that on a psychiatrist, because the costs of breaching confidentiality may be lower. Diagnostic techniques may be more reliable for physical disease and the risks that it poses than for mental disease and its risks.
“Many courts have imposed an affirmative duty on physicians when the patient would have preferred a warning or other precaution to benefit a family member or other person with whom a patient has a relationship. ... On the other hand, some courts are concerned that any precaution a physician might take would have little or no effect in reducing the risk, especially for warnings to patients about risks of which they were already aware. These courts might lack confidence in their ability accurately to address factual causation in these cases. They may also be concerned with the administrative costs entailed in identifying the few cases in which causation exists. This Restatement takes no position on how these competing concerns should be resolved.
“If a court does impose an affirmative duty to nonpatients, it must address both the content of the duty and the question of who can recover. For example, a court might limit the scope of a physician’s duty to warning the patient of risks that the patient poses to others. A court might then hold that the physician’s liability extends to any person harmed by the patient’s condition or a more limited class based on relationship with the patient, time, or place.”

I also would reject the plaintiff’s theory that Dr. Florio voluntarily assumed a duty to warn, for reasons set forth by Justice Cordy, post at 207 n.2 (Cordy, J., dissenting).