Court Opinion

ID: 2736095
Source: CourtListenerOpinion
Date Created: 2014-09-23 17:00:42.930698+00
Date Added: 2024-06-11T10:03:37.067880
License: Public Domain

United States Court of Appeals
                        For the First Circuit

No. 12-2013

                  MARIA SANTANA-CONCEPCIÓN, ET AL.,

                       Plaintiffs, Appellants,

              CONJUGAL PARTNERSHIP CRUZ-SANTANA, ET AL.,

                             Plaintiffs,

                                  v.

       CENTRO MÉDICO DEL TURABO, INC., d/b/a Hospital HIMA
      San Pablo Bayamón; DR. JULIO ROSADO-SÁNCHEZ, ET AL.,

                        Defendants, Appellees,

  HIMA SAN PABLO PROPERTIES, INC.; GRUPO HIMA SAN PABLO, INC.,

                             Defendants.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
                 FOR THE DISTRICT OF PUERTO RICO

          [Hon. Salvador E. Casellas, U.S. District Judge]

                                Before

                          Lynch, Chief Judge,
                 Torruella and Lipez, Circuit Judges.

     Glenn Carl James for appellants.
     José Arturo González-Villamil, with whom Bufete González-
Villamil was on brief, for appellees Centro Médico del Turabo,
Inc., Hima San Pablo Bayamón and its insurer HIMA San Pablo Captive
Insurance Company Limited.
     José A. Miranda-Daleccio, with whom Miranda Cárdenas & Córdova
was on brief, for appellees Dr. Julio Rosado-Sánchez and the
conjugal partnership Rosado-Philippi.
September 23, 2014
          LIPEZ, Circuit Judge.    This is a medical malpractice and

informed consent case from Puerto Rico involving claims by the

patient and her children. The district court held that the statute

of limitations barred the claims brought by the patient and her

adult children, granting summary judgment to the defendants on that

basis.   Given that the statute of limitations does not apply to

minor children until they reach majority age, the district court

addressed the merits of their malpractice and informed consent

claims. Concluding that the "error of judgment" defense foreclosed

malpractice liability and that the failure of proof on causation

foreclosed liability for lack of informed consent, the court

granted summary judgment on those claims as well.    We affirm.

                                  I.

          We recount the facts in the light most favorable to the

appellants, who were the non-moving party at summary judgment.

O'Connor v. Steeves, 994 F.2d 905, 907 (1st Cir. 1993).

          On     August     16,         2006,   plaintiff-appellant

Santana-Concepción, a registered nurse, after submitting to a CT

scan of her brain at Rochester General Hospital in Rochester, New

York, was diagnosed with a large arachnoid cyst.1     After further

medical testing, Santana-Concepción's doctors there advised her

that her arachnoid cyst did not require surgery.

     1
       An arachnoid cyst is a membrane-lined fluid sac, located
between the lower brain and spinal cord region of the cranium.
Stedman’s Medical Dictionary 353 (5th ed. 1982).

                                  -3-
             While in Puerto Rico during the fall of that year,

Santana-Concepción     experienced    extreme    pain   and   went   to     the

emergency room at HIMA-San Pablo Hospital on November 15.                   The

emergency room physician referred her to neurosurgeon Dr. Julio

Rosado-Sánchez     ("Dr.   Rosado"),       who   diagnosed    her    with     a

"symptomatic arachnoid cyst" and recommended surgery and antiedema

medication to help release the increased intracranial pressure.

Dr. Rosado explained to Santana-Concepción that she needed an

operation as soon as possible and that it could be a life-or-death

situation.     Santana-Concepción replied, "Good, not a problem.            Do

as you see fit, as far as you take away this pain.             I just need

this pain to go away."     Dr. Rosado operated on Santana-Concepción

on November 17, 2006, performing exploratory brain surgery around

the cyst and placing a shunt to relieve pressure created by the

cyst.

             Santana-Concepción returned to Rochester that winter and

visited her physician there on January 2, 2007.               Her physician

recorded the details of that visit as follows:

                    This is a 46-year-old female with
             history of an arachnoid cyst, who comes in
             today in follow-up. She actually apparently
             had a VP shunt placed in Puerto Rico when she
             was seen in the ER [and] the cyst was
             evaluated there.   This was in mid-November.
             She states that she has no further depressive
             symptoms.   She has however, had symptoms of
             decreased vision, difficulty with gait and
             balance, and she has noticed that her voice
             is much louder than previously and her sons

                                     -4-
          need to have to point out to her that she is
          talking loudly.

                 She has had no seizure activity. She
          was started on Dilantin at that point. She
          did not bring her records today for me to look
          at.

          . . .

                 We will look at her records and then
          try to get her referred back to Dr. Maxwell
          for neurosurgery to follow the shunt as well
          as Dr. Honch. Will continue the Dilantin and
          Depakote for now and check levels of those as
          a CBC and complete metabolic panel and come up
          with a treatment plan after we see her
          records.

Her son, who spoke fluent English, accompanied her on that visit.

          On February 20, 2007, Santana-Concepción was hospitalized

at Rochester General Hospital with symptoms of headache, dizziness,

and visual changes.     A CT scan and an MRI revealed that she had a

shunt   within    her     arachnoid     cyst.    Two   days   later,

Santana-Concepción again met with her treating physician.        Her

physician recorded the details of that visit as follows:

                 This is a 46-year-old female with
          history of arachnoid cyst, S/P VP shunt
          placement in Puerto Rico who comes in today in
          follow-up from a hospital stay. She had what
          appears to be as a final diagnosis benign
          positional vertigo.   However, she did see a
          neurologist in consult who recommended that
          she might consider getting the shunt taken out
          as it is not decreasing the size of the cyst
          and has seemed to result in some behavior
          changes.

                 She also complains of intermittent pain
          at the shunt site behind the left ear.

                                  -5-
             On April 19, 2007, Santana-Concepción visited her doctor

in Rochester yet another time complaining of pain.                 During this

visit her physician allegedly made the comment that whoever did

this to her (meaning the shunt surgery) was a "butcher."

             Santana-Concepción, along with her husband and four

children,2 filed this suit against Dr. Rosado and HIMA-San Pablo

Hospital on March 3, 2008, a little more than a year after

Santana-Concepción's second hospitalization in New York.                      They

claimed that Dr. Rosado failed to adequately inform Santana-

Concepción of the risks associated with the shunt surgery before

obtaining    her   consent,   and     that   he   failed   to    abide   by   the

prevailing    medical   standards      applicable    to    the   treatment      he

provided (i.e., engaged in malpractice).            The alleged malpractice

concerned the treatment decision to operate on the cyst, rather

than the adequacy of Dr. Rosado's surgical technique in the

operating room.      The plaintiffs contended that the hospital was

vicariously liable for Dr. Rosado's conduct.

             The   district   court    granted    summary    judgment to the

defendants on all claims.           The court held that the claims of

Santana-Concepción and her adult children were all time-barred. It

further held that the medical malpractice claim of her minor

children was foreclosed by the "error of judgment" defense and the

     2
       Santana-Concepción's husband has since passed away.                    She
represents his heirs' interests in this litigation.

                                      -6-
informed consent claim failed on the element of causation.3                 This

appeal followed.

                                      II.

             We review the district court's summary judgment decisions

de novo.     Domínguez-Cruz v. Suttle Caribe, Inc., 202 F.3d 424, 428

(1st Cir. 2000).        Summary judgment is properly granted when "the

movant shows that there is no genuine dispute as to any material

fact and the movant is entitled to judgment as a matter of law."

Fed. R. Civ. P. 56(a).           When considering the summary judgment

record, "[a]ll reasonable inferences are to be drawn in favor of

the party opposing summary judgment, in this case appellant[s],

just as all disputed facts are viewed in the light most favorable

to [them]."     O'Connor, 994 F.2d at 907.          In assessing claims that

genuine material issues exist, we must decide whether "the evidence

is   such   that   a    reasonable   jury   could    return   a   verdict   for

[Santana-Concepción or her children]."          Anderson v. Liberty Lobby,

Inc., 477 U.S. 242, 248 (1986).

             Federal jurisdiction in this case is based on diversity

of citizenship.        See 28 U.S.C. § 1332.4   We apply the law of Puerto

Rico to the medical malpractice and informed consent claims in this

      3
          The district court's reasoning is explained in more detail
infra.     We largely track the court's analysis.
      4
       Plaintiffs are residents of New York.                  Defendants are
residents of Puerto Rico.

                                      -7-
case because that is where the medical treatment at issue took

place.

A.   Santana-Concepción and Adult Childrens' Claims

           1.   Statute of Limitations

           The plaintiffs filed suit on March 8, 2008.      For the

claims to survive the statute of limitations on summary judgment,

there must be a genuine issue of material fact as to whether they

were filed within the limitations period.

                   a.     Application to Malpractice Claims      of
                   Santana-Concepción and Adult Children

           Puerto Rico law affords one year to file suit for medical

malpractice after "the aggrieved person ha[s] knowledge thereof."

P.R. Laws Ann. tit. 31, § 5298 (2008); see also Ortiz v. Municipio

De Orocovis, 13 P.R. Offic. Trans. 619, 621 (1982).    Although the

running of the statute of limitations does not wait for the injury

to "reach its final degree of development," it does not begin to

run until there is "knowledge" of the malpractice.    Ortiz, 13 P.R.

Offic. Trans. at 621.   Such knowledge must include both the injury

and the causal link between the injury and the allegedly negligent

medical procedure. Guzman-Camacho v. State Ins. Fund Corp., 418 F.

Supp. 2d 3, 8 (D.P.R. 2006); Rivera-Encarnación v. Estado Libre

Asociado de P.R., 13 P.R. Offic. Trans. 498, 502 (1982).5

      5
       By statute Puerto Rico has established that the limitations
period for medical malpractice begins not when the injury occurs,
but when the patient first has knowledge of the injury. P.R. Laws
Ann. tit. 31, § 5298 ("The following prescribe in one (1) year:

                                 -8-
           Under the law of torts in Puerto Rico, including medical

malpractice and lack of informed consent, relatives are entitled to

"compensation for the sufferings, emotional distress, or mental

anguish experienced as a consequence of the material or other

damages caused directly to their relatives."          Santini-Rivera v.

Serv Air, Inc., 137 P.R. Dec. 1, 10-12 (1994).                  The period

available to exercise such an action is one year, and begins to run

when the plaintiffs learn about the damages suffered by the

relative-victim.      Id.

           With regard to the medical malpractice claims of the

plaintiff and her adult children, the statutory clock began ticking

soon   after    the   onset   of   Santana-Concepción's     first   negative

post-operation symptoms.       Santana-Concepción sought treatment for

these symptoms in early 2007.         The symptoms were first documented

on January 2, 2007, and then on her subsequent visits to the

hospital   in    February     2007.     The   neurologist    who    examined

Santana-Concepción in February recommended "getting the shunt taken

out as it [was] not decreasing the size of the cyst and ha[d]

seemed to result in some behavior changes."

           Santana-Concepción nonetheless contends that because she

did not understand English, and therefore could not read the notes

. . . (2) Actions to demand civil liability for grave insults or
calumny, and for obligations arising from the fault or negligence
mentioned in § 5141 of this title [which includes medical
malpractice], from the time the aggrieved person had knowledge
thereof.").

                                      -9-
from her hospital visits, she did not learn that her symptoms were

related to the shunt surgery until April 2007 when a doctor told

her about the problem.    This version of events ignores multiple

undisputed facts in the record.       First, Santana-Concepción was

accompanied by her English-speaking son when she visited Rochester

General Hospital on January 2, 2007.    Furthermore, the notes from

that visit include a remark from the doctor that "[s]he actually

apparently had a VP shunt placed in Puerto Rico when she was seen

in the ER [and] the cyst was evaluated there.     This was in mid-

November." Indeed, at that visit the doctor apparently recommended

that she consider having the shunt removed because it was not

decreasing the size of the cyst and may be causing some of the

behavioral issues. However, the notes also reveal that she did not

bring her medical records with her to the exam.    Thus, the doctor

could have known about the shunt procedure only if she informed him

of it during the visit.   No reasonable jury, confronted with this

undisputed evidence, could conclude that Santana-Concepción, or her

adult children, were not aware of any adverse consequences of her

surgery by January 2, 2007.      Accordingly, the district court

properly granted summary judgment on the medical malpractice claims

of Santana-Concepción and her adult children.

                 b. Application to the Informed Consent Claims of
                 Santana-Concepción and Adult Children

          The statute of limitations for a physician's failure to

obtain the patient's informed consent for surgery, a cause of

                               -10-
action separate from a medical malpractice claim, begins to run

when the aggrieved learns that she was subjected to an unauthorized

medical procedure.    Villarini-Garcia v. Hosp. Del Maestro, Inc., 8

F.3d 81, 84-85 (1st Cir. 1993) (citing P.R. Laws Ann. tit. 31,

§ 5298).   A claim, such as the one here, premised on the alleged

failure of the physician to adequately inform the patient of

potential negative consequences, is akin to a failure-to-warn claim

in the medical context.    We have said that the statute begins to

run for those claims at the point when "a reasonable person [would]

conclude that a warning of such possible consequences should have

been given before the operation."        Id. at 85.

           With regard to the informed consent claims of Santana-

Concepción and her adult children, the cause of action accrued when

they learned that she was experiencing negative side effects of the

shunt operation performed by Dr. Rosado.       The presence of a shunt

in Santana-Concepción's cyst was documented in the treatment notes

from her January 2, 2007 consultation with her doctor, the CT and

MRI records from her hospitalization on February 20, 2007, and the

treatment notes from her follow-up consultation on February 22,

2007. At those consultations, Santana-Concepción discussed various

symptoms that she had been experiencing since the shunt was put in

place,   including   "decreased   vision,   difficulty   with   gait   and

balance," and pain at the shunt site.       In addition, the notes from

Santana-Concepción's February 22 follow-up visit show that she

                                  -11-
discussed the potential removal of the shunt to alleviate her

symptoms with the neurologist who tended to her while she was

hospitalized.        A reasonable jury, confronted with this undisputed

evidence, would be compelled to find that, at least by February 22,

2007, a reasonable person would have concluded that she should have

been       warned   of   the   previously    undisclosed   potential   negative

consequences of shunt surgery.              Accordingly, the district court

properly granted summary judgment on Santana-Concepción's informed

consent claim.

               At    least     one   of     the   other    adult   plaintiffs,

Santana-Concepción's sons Herminino and Carlos Manuel, was present

at each of her consultations with doctors in January and February

2007 in New York to translate their mother's interactions with her

doctors.       Hence, the brothers received contemporaneous indications

that Santana-Concepción's shunt surgery had negative consequences,

the risks of which should have previously been disclosed to her.6

Accordingly, the district court properly dismissed the informed

consent claims of the adult children.

       6
       This is not a case where the informed consent claims of a
patient's relatives potentially accrue later than the patient's own
claims because the relatives did not contemporaneously learn the
details of a particular medical procedure and its effects.

                                          -12-
B.   Minor Plaintiffs' Claims7

           "In Puerto Rico, statutes of limitations do not run

against minors until they reach the legal age of 21."             Ocasio-

Berios v. Bristol Myers Squibb, 73 F. Supp. 2d 171, 174 (D.P.R.

1999); P.R. Laws Ann. tit. 32, § 254(1) ("If a person entitled to

bring an action, other than the recovery of real property, be at

the time the cause of action accrued . . . [w]ithin the age of

majority . . . the time of such disability is not a part of the

time limited for the commencement of the action.").         Hence, the

minor plaintiffs' claims cannot be defeated by the statute of

limitations     at   summary   judgment.     Recognizing   this    legal

proposition, the district court addressed the claims of the minor

children on the merits.

           1.   Medical Malpractice

           In Puerto Rico a medical malpractice plaintiff must

establish three elements:      "(1) the basic norms ('normas minimas')

of knowledge and medical care applicable to general practitioners

      7
       Puerto Rico courts have "recognized the right of a person to
receive compensation when his or her spouse or other relative
suffers harm in the most diverse situations [including] in cases of
. . . medical malpractice." Santini-Rivera, 137 P.R. Dec. at 8;
see P.R. Laws Ann. tit. 31, § 5141 (providing a cause of action
against a tortfeasor who "causes damage to another through fault or
negligence" (emphasis added)). Acknowledging that "the Puerto Rico
Supreme Court consistently has referred to relatives' causes of
action as 'separate' or 'independent' from the principal
plaintiff's claim," we have analyzed the application of the statute
of limitations to them as standalone claims. González Figueroa v.
J.C. Penney P.R., Inc., 568 F.3d 313, 321 (1st Cir. 2009).

                                   -13-
or specialists; (2) proof that the medical personnel failed to

follow these basic norms in the treatment of a patient; and (3) a

causal relation between the act or the omission of the physician

and the injury by the patient."            Santiago v. Hosp. Cayetano Coll y

Toste, 260 F. Supp. 2d 373, 381 (D.P.R. 2003) (collecting cases).

            Puerto Rico courts have long recognized a defense of

"error of judgment," which defeats the second element of the tort.

Under that doctrine, when the evidence shows that different courses

of    treatment    existed   for     the   injured   party's    condition,   and

legitimate debate existed between medical experts as to which

treatment would be appropriate, a physician's judgment call cannot

be the basis for a medical malpractice claim.                  Lozada v. Estado

Libre Asociado de P.R., 16 P.R. Offic. Trans. 250, 267 (1985);

Oliveros v. Abréu, 1 P.R. Offic. Trans. 293, 315 (1973) ("[A

physician] is not liable of malpractice when he is faced with a

situation where educated and reasonable doubt about what should be

the    course     to   follow   is    present.").       "It     is,   therefore,

insufficient for a plaintiff in a malpractice case merely to show

that another doctor would have chosen to treat the patient in a

manner different from the manner in which the attending physicians

treated him."      Rolon-Alvarado v. Municipality of San Juan, 1 F.3d

74, 78 (1st Cir. 1993).            The district court found that defense

applicable here.

                                       -14-
             The medical malpractice alleged here is the decision of

Dr. Rosado to perform the shunt placement operation on Santana-

Concepción.       Specifically at issue was whether her cyst warranted

surgical or pharmacological treatment.8        Santana-Concepción argued

that because her cyst did not cause hydrocephalus,9 a fact that is

undisputed, it was not "symptomatic" and surgery would never be

indicated.

             The summary judgment record includes the deposition

testimony of plaintiffs' expert, Dr. Ravi Tikoo.         When asked about

the shunt procedure performed on Santana-Concepción, Dr. Tikoo

testified as follows:

             Q [defense counsel]. Doctor, would you agree
             with this statement: Treatment for arachnoid
             cysts is symptomatic?

             A.     Depending on      how     you're   defining
             symptomatic; yes.

             Q.    How are you defining it.

             A. When someone has significant hydrocephalus
             or severe symptoms and exam findings from the
             cyst.

             Q. But it doesn't have to be hydrocephalus
             only; is that correct?

     8
      There is no evidence in the record that a surgical treatment
option, other than placing a shunt, existed.
     9
        Hydrocephalus is "a condition in which the primary
characteristic is excessive accumulation of fluid in the brain."
National Institute of Neurological Disorders and Stroke,
"Hydrocephalus         Fact      Sheet,"      available        at
http://www.ninds.nih.gov/disorders/hydrocephalus/detail_hydroceph
alus.htm (last visited August 22, 2014).

                                   -15-
A.   Correct.

Q. Would you agree with this: When symptoms
warrant, the surgical placement of a shunt
may be required to decompress the cyst?

A.   Can you repeat that?

[question repeated]

A.   Yes.

Q. Doctor, would you agree that the decision
of when it is that the symptoms warrant
shunting is a clinical judgment call?

A.   To a certain extent, yes.

Q. And that call, you have never taken it in
your life?

A.   Correct.

Q.     Doctor, would you agree with the
following:    Untreated arachnoid cysts may
cause permanent severe neurological damage due
to the progressive expansion of the cyst or
hemorrhage?

A.   In the appropriate circumstance, yes.

Q. Would you agree with the following
statement: With treatment, most individuals
with symptomatic arachnoid cysts do well?

A.   Many, yes.

Q. Doctor, would you agree with the following:
Controversy   surrounds   the   treatment   of
arachnoid cysts?

A.   Yes.

Q.   Some clinicians advocate treating only
patients with symptomatic cysts whereas others
believe that even [a]symptomatic cyst[s]
should be decompressed to avoid future
complications?

                      -16-
          A. I would - my opinion is that doctors that
          recommend   asymptomatic   -   treatment  of
          asymptomatic cysts are not in the majority,
          they are probably in the minority.

          Q. But there are some authorities that state
          that also?

          A. In my opinion, those authorities are not
          reasonable or credible.

          Q. But those authorities or school of thought
          exist?

          A.   Yes.

          Q. And you don't agree with that, but others
          don't agree with you; is that correct?

          A.   I guess so; yes.

          Q. Would you agree with the following: The
          most effective surgical treatment appears to
          be excision of the outer cyst membrane and
          cystoperitoneal [sic] shunting?

          A.   In the appropriate circumstance; yes.

In addition, Santana-Concepción's responses to interrogatories

indicated that she "felt [her] eyes were going to fall [sic] of

their socket" when she saw Dr. Rosado for the first time.   It was

at the conclusion of that examination that Dr. Rosado recommended

surgery to place a shunt and relieve intracranial pressure.

          On this record, a reasonable jury would be compelled to

conclude that legitimate debate existed among medical experts as to

which treatment would be appropriate for Santana-Concepción's

arachnoid cyst, which, though not causing hydrocephalus, did cause

significant pain. Lozada, 16 P.R. Offic. Trans. at 267. Given the

                                  -17-
testimony of the plaintiffs' own expert, they were unable to

generate a genuine issue of material fact as to the application of

the "error of judgment" defense.             Hence, the district court was

correct to grant summary judgment to the minor plaintiffs on their

medical malpractice claims.

             2.    Informed Consent

             The remaining claim of the minor plaintiffs is based on

the doctrine of informed consent, which "imposes on physicians the

duty to inform their patients about the nature and risks of the

proposed medical treatment in order to place the patients in a

position to reach an intelligent and informed decision."           Lozada-

Tirado v. Tirado-Flecha, 177 P.R. Dec. 893 (2010).              The minor

plaintiffs claim that Dr. Rosado performed the shunt placement

surgery on Santana-Concepción without obtaining her fully informed

consent.

             The scope of the duty to inform does not reach every

remote, hypothetical risk posed by a medical procedure.            Indeed,

the scope of the duty varies with the nature of the proposed

treatment.        Sepúlveda de Arrieta v. Barreto, No. RE-90-41, 1994 WL

908876 (P.R. Dec. 23, 1994). "'If [the medical intervention] is to

save a life, the surgeon should, above all, create a favorable

atmosphere.       If the intervention is simply useful, he must then be

more precise in his disclosure.'"        Id. (emphasis omitted) (quoting

J. Ataz López, Los médicos y la responsabilidad civil 74 (1985)).

                                      -18-
             In order to prevail on a claim for lack of informed

consent, a plaintiff must prove that the complained-of injury

resulted from the failure of the physician to fully inform the

patient (i.e., causation).        Sepulveda de Arrieta, No. RE-90-41,

1994 WL 908876. One might expect that such causation can be proved

by showing that the plaintiff would not have consented to the

medical treatment at issue if fully informed of the risks.              The

debate in most U.S. jurisdictions is generally over whether that

fact must be shown subjectively (i.e., from the perspective of the

specific patient) or objectively (i.e., from the perspective of the

reasonable patient). Id.

             "Contrary to the United States model -- that focuses on

the decision-making process of the injured party, whether objective

or subjective -- civil law tradition focuses on the alleged

aggravating circumstance."         Id.     Hence, in Puerto Rico, the

question of proximate causation is viewed from the perspective of

the physician.       In other words, the analysis does not turn on

whether the patient would have declined to consent if provided with

the allegedly absent information.        See id. ("[I]t is not necessary

to determine if she, as a patient -- subjectively or objectively --

would   or   would   have   not   consented   to   the   proposed   medical

treatment.").    Instead, the pertinent question is "whether in the

normal course of events [the physician] had to foresee that the

lack of pertinent information would lead [the] patient . . . to

                                    -19-
take a different decision than the one she would have taken if she

had been suitably informed."                Id.   The district court held that it

would not have been foreseeable that any further disclosure would

have changed Santana-Concepción's decision to undergo surgery. The

court granted summary judgment on that basis.

            Here, the minor plaintiffs claim that Santana-Concepción

was never fully informed of the risks of surgery and was never told

that foregoing surgery was a viable option. The record includes an

informed        consent       form     signed        by    Santana-Concepción,          the

authenticity of which is not dispute.                         The minor plaintiffs

nonetheless argue that Santana-Concepción was not fully informed

because    four       terms    on     the     form    (arachnoid      cyst,       drainage,

fenestration, and shunt) were in English rather than Spanish (which

was the language of the rest of the document).                        They also argue

that Dr. Rosado did not tell Santana-Concepción that her condition

was manageable without surgery, instead implying that the shunt

surgery was a life-saving necessity.

            Both of these arguments focus on the wrong perspective,

however.        As explained above, we must examine the question of

foreseeability         from    Dr.      Rosado's      perspective,         not     Santana-

Concepción's.         The district court was correct in explaining that

"to     create    a    genuine        issue     of   fact    under        the    applicable

foreseeability standard, plaintiffs needed to direct the Court to

facts     Dr.    Rosado       could     have      relied    upon     to     foresee    that

                                              -20-
Santana–Concepción was likely to behave different than most people

under the circumstances.   [However,] [p]laintiffs have provided no

evidence whatsoever in this regard."         Dr. Rosado was confronted

with a patient who had a cyst on her brain that was causing her

debilitating pain. He understood it to be a possible life-or-death

situation   and   communicated   that   to   her.   Santana-Concepción

indicated a willingness to entertain any treatment option that

would take away her pain.         Doing nothing was simply not an

acceptable option, even if Dr. Rosado had suggested it. Dr. Rosado

ultimately suggested a surgical procedure to relieve some of the

pressure.     However, before performing the surgery, Dr. Rosado

informed Santana-Concepción and her family of the major risks of

surgery and obtained written consent.

            As the district court put it, "[t]he conclusion that Dr.

Rosado could have foreseen a decision to forego surgery by Santana-

Concepción is inconceivable under these circumstances."       In other

words, the minor plaintiffs failed to generate a genuine issue of

material fact on the proposition that Dr. Rosado could have

foreseen that providing Spanish translations for the four English

terms, or further discussing some of the possible side effects of

surgery as reasons for not undergoing it, would have changed

Sanatana-Concepción's decision to consent to surgery. Accordingly,

                                 -21-
the district court was correct to grant summary judgment to the

defendants on the informed consent claims of the minor plaintiffs.10

Affirmed.

     10
        Because, as explained supra, the hospital and related
entities were sued on the basis of vicarious liability for Dr.
Rosado's actions, all claims against those corporate defendants
fail with the claims against him.

                               -22-