Court Opinion

ID: 9530241
Source: CourtListenerOpinion
Date Created: 2023-08-07 03:58:34.234491+00
Date Added: 2024-06-11T13:28:02.639145
License: Public Domain

*297CLARK, J.
I dissent.
The consent instruction demanded by plaintiffs will impose upon doctors the intolerable burden of having to explain diagnostic tests to healthy patients. To meet their new burden doctors will have to spend the greater part of their day not examining or treating patients, but explaining to them all information relevant to the purposes of diagnostic examinations and tests. Such burden is unreasonable, and the trial court properly refused the instruction. Further, the proposed instruction is erroneous because it is confusing. Counsel’s failure to clarify the instruction at the trial court’s request should preclude any claim of error.
After the birth of her child, Mrs. Truman underwent a routine six-week checkup on 7 January 1964. Defendant had not suggested a pap smear prior to that time because Mrs. Truman stated she had had a pap smear within one year. When defendant suggested she have another, she “put it off.” In February 1964 she consulted defendant for a cyst on her cheek and requested a prescription for birth control pills. In July 1966, defendant treated her for an upper respiratory infection and again for flu a few months later. In March 1968, she received treatment for asthma, and in January and March 1969 for a urinary tract infection. In addition, Mrs. Truman visited defendant several times when her children needed treatment and to discuss family problems.
During her visits, defendant and his staff repeatedly advised Mrs. Truman to have a complete physical examination, particularly a pap smear. On those occasions she either declined or put off their suggestions, limiting her requests to her most immediate health problems. Defendant never explained the purpose of a pap smear to Mrs. Truman believing that any intelligent woman of child bearing age was aware of its purpose.
Mrs. Truman died of cervical cancer in July 1970. At trial expert witnesses testified the disease is often curable if detected in its early stages.
Plaintiffs requested the jury be instructed that it “is the duty of a physician to disclose to his patient all relevant information to enable the patient to make an informed decision regarding the submission to or refusal to take a diagnostic test. [¶] Failure of the physician to disclose to his patient all relevant information including the risks to the patient if the test is refused renders the physician liable for any injury legally re-*298suiting from the patient’s refusal to take the test if a reasonably prudent person in the patient’s position would not have refused the test if she had been adequately informed of all the significant perils.”
I. Duty
A primary consideration in determining whether a new duty should be imposed upon a defendant is the “extent of the burden to the defendant and consequences to the community” in imposing the duty. (Rowland v. Christian (1968) 69 Cal.2d 108, 113 [70 Cal.Rptr. 97, 443 P.2d 561, 32 A.L.R.3d 496]; Coulter v. Superior Court (1978) 21 Cal.3d 144, 153 [145 Cal.Rptr. 534, 577 P.2d 669]; Lipman v. Brisbane Elementary Sch. Dist. (1961) 55 Cal.2d 224, 229-230 [11 Cal.Rptr. 97, 359 P.2d 465].)
The burden of explaining the purposes of a pap smear and the potential risks in failing to submit to one may not appear to be great, but the newly imposed duty upon physicians created by today’s majority opinion goes far beyond. The instruction requires disclosure of all “relevant information to enable the patient to make an informed decision regarding the submission to or refusal to take a diagnostic test.” In short, it applies not only to pap smears, but to all diagnostic procedures allegedly designed to detect illness which could lead to death or serious complication if not timely treated.
Carried to its logical end, the majority decision requires physicians to explain to patients who have not had a recent general examination the intricacies of chest examinations, blood analyses, X-ray examinations, electrocardiograms, urine analyses and innumerable other procedures. In short, today’s ruling mandates doctors to provide each such patient with a summary course covering most of his or her medical education. Most medical tests—like pap smears—are designed to detect illness which might prove fatal absent timely treatment. Explaining the purposes of each procedure to each such patient will obviously take hours if not days.
Few, if any, people in our society are unaware that a general examination is designed to discover serious illness for timely treatment. While a lengthy explanation may result in general examinations for some patients who would otherwise decline or defer them, the onerous duty placed upon doctors by today’s decision will result in reduced care for others. Requiring physicians to spend a large portion of their time *299teaching medical science before practicing it will greatly increase the cost of medical diagnosis—a cost ultimately paid by an unwanting public. Persons desiring treatment for specific complaints will be deterred from seeking medical advice once they realize they will be charged not only for treatment but also for lengthy lectures on the merits of their examination.
The great educational program the majority embark upon, even if justifiable, is a question of public policy for the Legislature to determine: whether the cost warrants the burden, and whether the duty to educate rests with doctors, schools or health departments. Requiring individual doctors to enlighten the public may be found through legislative hearings to be inefficient, not reaching those who need it most—the ones hesitant to consult doctors.
When a patient chooses a physician, he or she obviously has confidence in the doctor and intends to accept proffered medical advice. When the doctor prescribes diagnostic tests, the patient is aware the tests are intended to discover illness. It is therefore reasonable to assume that a patient who refuses advice is aware of potential risk.
Moreover, the physician-patient relationship is based on trust, and forcing the doctor into a hard sell approach to his services can only jeopardize that relationship.
The new duty to explain, imposed by the majority as a matter of law, creates an undue burden on both the doctor and society and should be rejected. Strict tort liability does not extend to professional services. The ordinary duty in medical practice cases calls for determining the community standard of care, the appropriate duty in the instant case. (Barton v. Owen (1977) 71 Cal.App.3d 484, 494-499 [139 Cal.Rptr. 494].) Doctors—or at least the Legislature—rather than judges are in the best position to balance the professional relationship between doctors and patients, to determine how far a doctor should go in selling his services without alienating the patient from all medical care, and to promote the highest level of diagnostic care for the community. In the instant case, evidence as to community medical standard was appropriately received, the case was tried on this basis, and we should not reverse the judgment.
Nothing in Cobbs v. Grant (1972) 8 Cal.3d 229 [104 CaLRptr. 505, 502 P.2d 1] warrants imposition of such an onerous duty—to the con*300trary, that case expressly rejected any such duty. In Cobbs, a doctor performed risky ulcer surgery on a patient which resulted in severe complications. While the surgeon explained the nature of the operation to the patient, he did not discuss the inherent risks.
We pointed out that bodily intrusion is actionable either on the basis of battery or negligence unless the patient consents. (8 Cal.3d at pp. 239-241.) The court reasoned that because patients ordinarily are unlearned in medical science, an adult of sound mind “in the exercise of control over his own body” has a right to determine for himself whether to submit to proposed medical treatment, and that consent to intrusion must be informed to be effective. (8 Cal.3d at p. 242.) We held that the physician who ordinarily has superior knowledge had a “duty of reasonable disclosure of the available choices with respect to proposed therapy and of the dangers inherently and potentially involved in each.” (8 Cal. 3d at pp. 242-243.)
In Cobbs, we expressly circumscribed the duty of the doctor, holding that a “mini-course in medical science is not required,” that “there 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,” that as to common procedures “no warning” is “required as to the remote possibility of death or serious bodily harm,” and that recovery would be permitted only if a “prudent person in the patient’s position” adequately informed of the perils would have declined treatment. (8 Cal.3d at pp. 244-245.)
Thus, Cobbs is not helpful to the majority because the duty of disclosure in that case was imposed to assure consent to the intrusion would be effective. When no intrusion takes place, no need for consent— effective or otherwise—arises.1
Furthermore, contrary to the express limitations in Cobbs, today’s decision requires not only an explanation of the risks of a single procedure but also a “mini-course in medical science,” if not a maxi-course. Simi*301larly, because discovery of serious illness in a general examination of an apparently healthy person is remote, the doctor, contrary to Cobbs, is now required to disclose remote possibilities of illness. Moreover, the Cobbs duty to warn in cases where an adequately informed prudent person would have declined treatment shows a concern for preventing over-selling of services by physicians. By contrast, today’s duty appears designed to increase selling of medical services.
II. The Instruction
A trial court has no duty to modify or edit an instruction offered by either side in a civil case. If the instruction is incomplete or erroneous the trial judge may, as he did here, properly refuse it. (Shaw v. Pacific Greyhound Lines (1958) 50 Cal.2d 153, 158 [323 P.2d 391]; Tossman v. Newman (1951) 37 Cal.2d 522, 525 [233 P.2d 1]; Estate of Dopkins (1949) 34 Cal.2d 568, 575 [212 P.2d 886]; Nelson v. Southern Pacific Co. (1937) 8 Cal.2d 648, 653 [67 P.2d 682]; Ernest W. Hahn, Inc. v. Sunshield Insulation Co. (1977) 68 Cal.App.3d 1018, 1024 [137 Cal. Rptr. 732]; Anaheim Bldrs. Supply, Inc. v. Lincoln Nat. Life Ins. Co. (1965) 233 Cal.App.2d 400, 413 [43 Cal.Rptr. 494].)
The majority opinion and the record reveal factual issues remain to be resolved even if the new duty is imposed. The offered instruction made no mention of those issues. Thus the instruction was deficient and erroneous. Moreover, as the trial court appropriately pointed out the instruction is confusing.
The majority recognize there exists “a question of fact for the jury” whether the risks resulting from refusal to have a pap smear would be known to a reasonable person. {Ante, p. 293.) But nothing in the proposed instruction would advise the jury that the duty to disclose was inapplicable and that liability should not be imposed if the jury found the risks were known to a reasonable person.
The majority also recognize there exists a question of fact whether Mrs. Truman would have taken the test had she been fully informed. {Ante, p. 294.) However, the jury was not advised of this question of fact. Rather, it was told that failure to disclose made the physician “liable for any injury legally resulting from the patient’s refusal to take the test.” The term “legally resulting” was not defined in the instruction or in any other instruction. While “proximate cause” was generally defined by another instruction and some lawyers might equate “legally result*302ing” with “proximate cause,” there is little reason to believe that laymen would equate the two terms. Rather, laymen would anticipate that “any injury legally resulting” would refer to some technical rule of damages, allowing recovery for all injuries excepting certain ones.
Therefore, because the trial court is not required to correct instructions, refusal of the instruction furnishes no basis for reversal.
Before refusing the instruction, the trial judge indicated he was sympathetic to its theory but felt it confusing. He pointed out that a duty to disclose “all relevant” information was too broad, substituted “proximate cause” for “legally resulting,” and made an effort to rewrite the last portion of the instruction to avoid confusing the jury. When his attempts at simplification failed, he advised counsel he would consider a revised version of the instruction. However, counsel presented no revision. The trial judge also pointed out that the jury would be instructed on general negligence and proximate cause principles, including the community standard of medical care.
The trial judge’s observations were correct. The majority state that the burden is “significant” risks rather than “all relevant” information. (Ante, p. 293.) As demonstrated, “legally resulting” is confusing. A mere reading of the instruction shows how confusing the last portion is, and it would be more confusing to jurors who, unlike us, listen to but are not permitted to ponder a written draft.
Finally, conflicting evidence exists as to whether community medical standards required explanation of the risks inherent in refusing a pap smear. As noted above, the majority recognize that whether such explanation is required depends upon factual circumstances. Clearly, the issue was properly before the jury under standard negligence instructions, including instructions on community medical standards.
Refusal to give the requested instruction does not warrant reversal. I would affirm the judgment.
Richardson, J., and Manuel, J., concurred.
Respondent’s petition for a rehearing was denied July 17, 1980. Clark J., Richardson, J., and Manuel, J., were of the opinion that the petition should be granted.

Like Cobbs, all other authority relied on by the majority (Canterbury v. Spence (D.C. Cir. 1972) 464 F.2d 772, 788; Sard v. Hardy (1977) 281 Md. 432, 444 [379 A.2d 1014]; Wilkinson v. Vesey (1972) 110 R.I. 606, 627 [295 A.2d 676, 69 A.L.R.3d 1202]; Waltz & Scheuneman, Informed Consent to Therapy (1970) 64 Nw. U.L.Rev. 628, 639-640), is concerned with whether consent to therapy was informed and therefore effective. The cases involve situations where there has been an intrusion to the body autonomy and it is claimed the intrusion was consensual. Thus, the question of informed consent is crucial. None involves the situation where the patient has refused the intrusion and thus consent is immaterial.