Court Opinion

ID: 9735432
Source: CourtListenerOpinion
Date Created: 2023-08-26 18:15:11.241+00
Date Added: 2024-06-11T18:26:58.531789
License: Public Domain

DICKSON, Justice,
dissenting.
Just last year, in Matter of Lawrance (1991), Ind., 579 N.E.2d 32, 38, this Court proclaimed:
Indiana's common law doctrine of informed consent recognizes the right of the patient "to intelligently reject or accept treatment." Revord v. Russell (1980), Ind.App., 401 N.E.2d 763, 767. Perhaps the strongest explanation of the basis of this rule is contained in Payne v. Marion General Hospital (1990), Ind.App., 549 N.E.2d 1043, 1046, trans. denied: "The patient's right of self-determination is the sine qua non of the physician's duty to obtain informed consent. As Justice (then Judge) Cardozo said: 'Every human being of adult years and sound mind has a right to determine what shall be done with his own body....' Schloendorff v. Society of New York Hospital (1914), 211 N.Y. 125, 129, 105 N.E. 92, 93."
Emphasizing respect for patient autonomy, we acknowledged that liberty interests protected in the Indiana Constitution and public policy values preserved in Indiana statutory and common law reflect "a commitment to patient self-determination." 1 Id. at 39. In seeming disregard of these fundamental principles, however, today's decision rejects the prudent patient standard in informed consent cases. It ignores "the basic human need of self-determination and individual autonomy" in deference to decision-making by physicians. Id.
The central concern of the majority appears to be whether a plaintiff should be permitted to establish an informed consent claim without presenting expert medical testimony. This issue should not blind the Court to the basic values articulated in Lawrance. Nor does the prudent patient standard eliminate the need for a plaintiff to present medical expertise.
The doctrine of informed consent is rooted in the belief, fundamental to American jurisprudence, that every human being of adult years and sound mind has a right to determine what shall be done with his own *105body. Canterbury v. Spence (D.C.Cir.1972), 464 F.2d 772, 780 (citing W. Prosser, Law of Torts § 18 (3d ed. 1964); Restatement of Torts § 49 (1984)) cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518. It is "every man's right to forego treatment or even cure if it entails what for him are intolerable consequences or risks, however warped or perverted his sense of values may be in the eyes of the medical profession, or even of the community, so long as any distortion falls short of what the law regards as incompetency." Bee v. Greaves (10th Cir.1984), 744 F.2d 1387, 1392 (emphasis in original), citing 2 F. Harper & F. James, Jr., The Law of Torts 61 (1986 Supp.), cert. denied, 469 U.S. 1214, 105 S.Ct. 1187, 84 LEd.2d 334. Thus, a physician is required to disclose to the patient the risks of the proposed treatment, the risks of alternate treatments available, and the risk attendant to no treatment at all. LeBeuf v. Atkins (1979), 22 Wash.App. 877, 594 P.2d 923, 927, rev'd on other grounds, 98 Wash.2d 84, 604 P.2d 1287. Only when equipped with this information can the patient meaningfully weigh these risks and decide what course of action is most appropriate. See Bee, 744 F.2d at 1392.
Informed consent is a requisite component of the doctor-patient relationship, attributable in part to the relative lack of parity in that relationship. The trusting patient, typically unlearned in medical science, is highly dependent upon the physician for the information relied upon during the decisional process, imposing upon the physician a unique disclosure obligation toward the patient. Cobbs v. Grant (1972), 8 Cal.3d 229, 104 CalRptr. 505, 502 P.2d 1.
To the physician, whose training enables a self-satisfying evaluation, the answer may seem clear, but it is the prerogative of the patient, not the physician, to determine for himself the direction in which his interests seem to lie. To enable the patient to chart his course understandably, some familiarity with the therapeutic alternatives and their hazards becomes essential.
Canterbury, 464 F.2d at 781 (footnotes omitted).
Cases alleging a lack of informed consent commonly arise in two situations: 1) a physician fails to fulfill the duty to inform the patient of the risks of proposed treatment or 2) a physician administers treatment beyond that authorized by the patient. - Rumple v. Bloomington Hosp. (1981), Ind.App., 422 N.E.2d 1309, 1312. The critical issue in both scenarios is whether the patient was subjected to inherent risks of proposed treatment without being permitted to intelligently reject or accept treatment. Kerr v. Carlos (1991), Ind.App., 582 N.E.2d 860, 864.
Although there is widespread acceptance of the doctrine of informed consent as a theory of liability, there is disagreement concerning the role of expert medical witnesses in determining whether the informed consent of the patient has been obtained. Those invoking the "prudent patient" standard assess the adequacy of the disclosure by requiring mention of all inherent risks which a reasonably prudent patient would consider material in deciding to undergo or forego a particular procedure. While medical expertise would be required to identify the risks of proposed treatment and non-treatment, the fact finder needs no expert guidance to determine the materiality of a particular risk to a patient. - Canterbury, 464 F.2d at 787. The "prudent physician" standard, on the other hand, evaluates the adequacy of the risk disclosure only from the physician's viewpoint. Canterbury, 464 F.2d at 783.
Central to the prudent patient standard is the inclusion of the word "material" to describe the risks of which a patient should be informed. A risk is material when a reasonable person, in what the physician knows or should know to be the patient's position, would be likely to attach significance to the risk or cluster of risks in deciding whether to forego the proposed procedure. Canterbury, 464 F.2d at 787.
It seems obviously prohibitive and unrealistic to expect physicians to discuss with their patients every risk of proposed treatment-no matter how small or remote-and generally unnecessary from the patient's viewpoint as well.... In *106our view, the patient's right of self-decision shapes the boundaries of the duty to reveal. That right can be effectively exercised only if the patient possesses enough information to enable an intelligent choice. The scope of the physician's communications to the patient, then, must be measured by the patient's need, and that need is the information material to the decision.
Id. at 786 (emphasis added) (footnotes omitted).
Expressing a preference for the prudent physician standard, the majority claims support in a statement 2 published by the American Medical Association that acknowledges a patient's right of self-decision and the concomitant need for information adequate for intelligent decisionmak-ing. Yet the AMA "standard" cited by the majority fails to articulate parameters useful to physicians in determining the extent to which risks must be disclosed to a patient. This failure to establish medical criteria is understandable because the extent of disclosure is essentially a non-medical determination. It is only from the perspective of the ordinary person that a fact-finder can realistically determines how much information is "enough" for the ordinary reasonable patient to make an informed decision. As expressed in Canterbury:
Respect for the patient's right of self-determination on particular therapy demands a standard set by law for physicians rather than one which physicians may or may not impose upon themselves.
Canterbury, 464 F.2d at 784 (emphasis added). Similarly, the court in Cobbs emphasizes:
Unlimited discretion in the physician is irreconcilable with the basic right of the patient to make the ultimate informed decision regarding the course of treatment to which he knowledgeably consents to be subjected.
Cobbs, 104 Cal.Rptr. at 514, 502 P.2d at 10.
We further observe that the adoption of a physician-based standard and its deference to the medical profession may invite the possibility of unintentional bias, protective self-interest, or worse. See, eg., Moore v. Regents of the Univ. of Cal. (1990), 51 Cal.3d 120, 271 Cal.Rptr. 146, 793 P.2d 479 (concealed self-interest of physician deriving commercial benefit from patient's spleen cells); Mink v. University of Chicago (N.D.Ill.1978) 460 F.Supp. 713 (concealed fact of medical experiment); see generally Theodore J. Schneyer, Informed Consent and the Danger of Bias in the Formation of Medical Disclosure Practices, Wis.L Rev. 124 (1976), Note, Restructuring Informed Consent: Legal Therapy for the Doctor-Patient Relationship, T9 Yale L.J. 1583 (1970).
The majority expresses concern that the prudent patient standard would onerously require a physician to speculate as to what a hypothetical reasonable prudent patient would "need to know." Sympathy for such a physician plight, however, is eclipsed by the fundamental value of patient autonomy and self-determination.
The prudent patient standard does not eliminate the need for a plaintiff to present expert medical evidence to establish a claim based upon the theory of informed consent. Expert testimony is ordinarily required to establish the nature of the risks inherent in a particular treatment, the probabilities of therapeutic success, the frequency of the occurrence of particular risks, the nature of available alternatives to treatment, and whether or not disclosure would be detrimental to a patient. See Sard v. Hordy (1977), 281 Md. 432, 379 A.2d 1014. Expert opinion is also generally necessary to establish the claimed injury proximately resulted from the non-disclosed risk. Kerr, 582 N.E.2d at 864.
Those elements which are the province of the medical profession must be estab*107lished by the testimony of medical experts in the field of inquiry. Thus, the existence of the risks and alternatives which were present in the particular physical condition would be beyond the knowledge of the layman and would have to be established by medical testimony. On the other hand, those matters which are not within the special province of the training and experience of doctors may be established by the testimony of any witness with knowledge of the particular inquiry, such as whether the patient knew of the risk or whether the average patient would consider the risk in making a decision. There is no need to prove what othér doctors might tell their patients in similar cireumstances. The doe-tor has a duty to disclose the material risks as a matter of law. The testimony of medical experts is not necessary to establish the duty to disclose that which the law requires. Once the existence of a risk has been established by expert medical testimony, there is no need to take the next step and also prove by expert medical testimony that the doctor should have told the patient about the risk. Once it has been established by expert medical testimony that a risk ex- ° isted, then the existence of the risk is the patients' business; and it is not for the medical profession to establish a criteria for the dissemination of information to the patient based upon what the doctors feel the patient should be told.
LeBeuf, 594 P.2d at 928 (citations omitted).
Contrary to the view expressed by the majority, there is substantial and growing recognition of the wisdom of the prudent patient standard expressed in Canterbury and Cobbs and their progeny. Some 22 jurisdictions now favor this patient or materiality-based standard.3 We should follow the lead of our Court of Appeals in this case and in Griffith v. Jones, (1991), Ind.App., 577 N.E.2d 258, and do likewise. This Court should declare the prudent patient standard applicable in informed consent cases.
DeBRULER, J., concurs.

. - Shortly after the publication of Matter of Law-rance, the Journal of the Indiana State Medical Association commented, "The justices of the Indiana Supreme Court are to be praised for their thoughtful and reasoned approach to a difficult issue." James J. Nocon, M.D., J.D., "Doctors, families and difficult decisions: the implications of the Lawrance case," 84 Indiana Medicine 808 (Nov.1991).

. The cited statement is entitled "1992 Code of Medical Ethics Current Opinions," and its preface states that the "opinions which follow are intended as guides to responsible professional behavior, but they are not presented as the sole or only route to medical morality." Preface, p. vil. As such, these opinions are aspirational rather than prescriptive.

. Eg., Fain v. Smith (1985), Ala., 479 So.2d 1150; Pedersen v. Zielski (1992), Alaska, 822 P.2d 903; McKinney v. Nash (1981), 120 Cal.App.3d 428, 174 Cal.Rptr. 642; Lambert v. Stovell (1987), 205 Conn. 1, 529 A.2d 710; Gordon v. Neviaser (1984), D.C., 478 A.2d 292; Griffith v. Jones (1991), Ind.App., 577 N.E.2d 258; Pauscher v. Iowa Methodist Medical Cir. (1987), Iowa, 408 N.W.2d 355; Hondroulis v. Schuhmacher (1988), La., 553 So.2d 398; Zeller v. Greater Baltimore Medical Ctr. (1986), 67 Md.App. 75, 506 A2d 646; Halley v. Birbiglia (1983), 390 Mass. 540, 458 N.E.2d 710; Plutshack v. University of Minnesota Hospitals (1982), Minn. 316 N.W.2d 1; Largey v. Rothman (1988), 110 N.J. 204, 540 A.2d 504; Congrove v. Holmes (1973), 37 Ohio Misc. 95, 66 O.O.2d 295, 308 N.E.2d 765; Scott v. Bradford (1979), Okla., 606 P.2d 554; Zacher v. Petty (1992), 312 Or. 590, 826 P.2d 619 (statutory obligation agrees with prior common law); Moure v. Raeuchle (1992), 529 Pa. 394, 604 A.2d 1003; Dewes v. Indian Health Serv. (D.S.D., 1980), 504 F.Supp. 203; Barklay v. Campbell (1986), Tex., 704 S.W.2d 8; Nixdorf v. Hicken (1980), Utah, 612 P.2d 348; Bertsch v. Brewer (1982), 97 Wash.2d 83, 640 P.2d 711; Cross v. Trapp (1982), 170 W.Va. 459, 294 S.E.2d 446; Keogan v. Holy Family Hosp. (1980), 95 Wash.2d 306, 622 P.2d 1246; see annotation, Modern Status as to General Measure of Physician's Duty to Inform Patient of Risks of Proposed Treatment, 88 A.L.R.3d 1008.