Court Opinion

ID: 6453724
Source: CourtListenerOpinion
Date Created: 2022-06-25 12:37:02.913728+00
Date Added: 2024-06-11T15:53:08.780286
License: Public Domain

Cordy, J.
(dissenting). The opinion of Justice Ireland (and the two Justices who join him) would recognize a new duty vastly expanding the potential liability of a physician to persons with whom the physician has had no contact or relationship. This duty is not compelled by our precedents, nor does it reflect “existing social values and customs and appropriate social policy,” Cremins v. Clancy, 415 Mass. 289, 292 (1993). To the contrary, the duty would interfere with, and distort, the highly personal, confidential physician-patient relationship, recognized since the time of Hippocrates, circa 400 B.C.1 It would alter a physician’s affirmative duty to care for his patient by introducing a new audience to which the physician must attend — everyone who might come in contact with the patient. It would create an unlimited number of third parties who might now demand to know precisely what a doctor and patient have discussed regarding medication and treatment, threatening our strongly held policy of confidentiality with respect to such communication. While Justice Ireland attempts to cast the duty he would impose as limited in scope and mild in effect, it would establish a principle with broad and troubling implications. *207Because I find this to be unwarranted and ill advised, I respectfully dissent.
The plaintiff offers three arguments supporting her claim that the doctor owed the decedent a legal duty: (1) the doctor voluntarily assumed a duty; (2) the doctor has a “special relationship” with his patient thereby creating a duty to third parties; and (3) the doctor created a reasonably foreseeable risk to the decedent (ordinary negligence). I agree with Justice Ireland’s rejection of the first two of these arguments.2,3 I disagree with his acceptance of the third.
Justice Ireland’s reasoning begins with the axiom that a physi*208dan has a duty to warn a patient of potential side effects when prescribing medications. Ante at 188 (Ireland, J., concurring), citing Cottam v. CVS Pharmacy, 436 Mass. 316, 321 (2002) (Cottam).4 He then notes that, when those side effects (such as drowsiness or dizziness) could “diminish a patient’s mental capacity, this warning serves to protect the patient from ... the foreseeable risk of an automobile accident.” Ante at 188 (Ireland, J., concurring). He further points out that in the case of automobile accident, the class of legally foreseeable victims includes “other motorists, bicyclists, and pedestrians.” Id. From this, he would concludes that a physician “owes a duty of care to all those foreseeably put at risk by his failure to warn about the effects of the treatment he provides to his patients.” Ante at 184 (Ireland, J., concurring).
In my view, this reasoning does not adequately address the principal issue in this case, which is not the duty of a doctor to a patient, or the duty of a patient-driver to an accident victim, but the duty of a doctor to the victim of a patient’s negligent conduct. There is no debate that it is foreseeable that the victims of an impaired driver are not only the driver but other drivers, pedestrians, or cyclists. The impaired driver plainly has a duty to all potential (foreseeable) victims. But extending the duty of the driver’s physician, grounded in the doctor-patient relation*209ship, to all those whom the driver encounters is entirely different. Because A has a duty to B, and B has a duty to C, it does not necessarily follow that A has a duty to C. The duty of A to C must be established on its own terms.
That the harm was caused directly by Sacca rather than Dr. Florio is not necessarily fatal to the plaintiff’s argument that Dr. Florio owed a duty to the victim of Sacca’s negligence. As Justice Ireland states, we have in certain limited circumstances recognized a duty where an “unreasonably dangerous condition [created by a defendant] involves the foreseeable criminal or negligent conduct of an intermediary.” Ante at 189 (Ireland, J., concurring), citing Jupin v. Kask, 447 Mass. 141, 147 (2006) (Jupin). In Jupin, we concluded that a homeowner who allowed the storage of dangerous instrumentalities (firearms) in her home, and permitted a person whom she knew to have had a history of violence and mental instability unfettered access to that home, owed a duty of reasonable care (with respect to the storage of those guns) to a police officer who was subsequently shot by that person with one of the guns stolen from an (allegedly) unsecured cabinet in the home. We imposed this duty after careful consideration of the extremely dangerous nature of the instrumentality, a statutory framework that required gun owners to ensure that their firearms were “ ‘secured in a locked container’ when stored” (G. L. c. 140, § 131L [a]), and after concluding that the creation of the duty would not expose homeowners to “endless liability and litigation” over the acts of “innumerable persons.” Id. at 152-154.
I would not equate the “unreasonably dangerous condition” created by the homeowner in Jupin with a doctor’s prescription of medication necessary to the treatment of a patient. But that is in essence what Justice Ireland would do. Moreover, he would justify the imposition of this new duty on the supposition that this is but a minimal step. A physician, after all, he reasons, is already obliged to warn his patient of potential side effects of medications. Cottam, supra at 321. Given that duty, the argument goes, it is inconsequential to extend the duty to others. “The duty described here,” Justice Ireland claims, “requires nothing from a doctor that is not already required by his duty to his patient.” Ante at 191 (Ireland, J., concurring). To accept this *210justification, however, one must presume that the addition of a duty to third parties will have no effect on the nature of the duty of care owed by a doctor to his patient. Such a presumption is not supported by the nature of a physician’s duty to warn his patients about the potential side effects of medications and other treatments.
A duty to warn generally arises in cases involving a product with an inherent danger. See, e.g., Mitchell v. Sky Climber, Inc., 396 Mass. 629, 631 (1986) (manufacturer of product has duty to warn all foreseeable users of dangers in use of that product of which he knows or should have known). This duty does not arise from of any affirmative relationship between a manufacturer and a user, but from a duty a manufacturer has to act reasonably. In the physician-patient context, however, the duty to warn is part of the duty of care the physician has for the patient. Cottam, supra at 322. That duty rarely involves warnings akin to information a manufacturer might give to potential users of its products, such as, “do not insert your finger between the rotating blades.” Rather, it involves a process of communication and decision-making aimed at the well-being of the patient, and the patient alone, in which the advantages and risks of particular treatments are discussed and weighed. See St. Germain v. Pfeifer, 418 Mass. 511, 520 (1994); Restatement (Third) of Torts: Liability for Physical Harm § 41 comment c (Proposed Final Draft No. 1, 2005) (“Unlike most duties, the physician’s duty to the patient is explicitly relational: physicians owe a duty of care to patients” [emphasis in original]).
The special nature of the duty to warn in the context of the doctor-patient relationship (as contrasted with the manufacturer-user context) is evident in this court’s reasoning in Cottam. In that case, we held that the “physician [not the pharmacy] is the appropriate person to perform the duty of warning a patient of the possible side effects of prescription drugs,” Cottam, supra at 322, adopting the rationale that “[p]hysicians, 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,” id. at 321. The court went on to conclude that the physician’s duty to inform of poten*211tial side effects of medication he prescribes is so central to the treatment of a patient that involving others in it (such as the pharmacy) would “interfere with the doctor-patient relationship.” Id. at 321, citing McKee v. American Home Prods. Corp., 113 Wash. 2d 701, 711 (1989).
“Interfere” is a strong word. In using it, the court confirmed a strong policy of maintaining that relationship as autonomous, free from the influence of concerns beyond the patient’s well-being. This reflects long-held norms about the relationship between doctor and patient and the sound social policy that a doctor’s interest be solely in the well-being of his patient. The duty proposed by Justice Ireland today, however, would do exactly what Cottam sought to avoid: it would interfere with and distort the doctor-patient relationship. Claiming that the duty he would impose would require nothing more of a doctor than is already required, a simple duty to warn, Justice Ireland misapprehends the nature of the duty to a patient, and fails to consider the distorting effect of insinuating the doctor’s concerns about third parties into his decisions about the treatment of a patient. Justice Ireland avoids the problem of this distortion by suggesting that it is no distortion at all.
A nuanced communication between doctor and patient works well (and is presumably highly preferable) where a doctor’s concern is focused solely on what, in his or her judgment, the patient’s own situation requires. With his or her attention now, necessarily, also directed elsewhere, however, the doctor may, understandably, become less concerned about the particular requirements of any given patient, and more concerned with protecting himself or herself from lawsuits by the potentially vast number of persons who will interact with and may fall victim to that patient’s conduct outside of the treatment setting. The substance and extent of the doctor’s advice and judgment about “warnings” will necessarily be affected. Is the doctor to tell a patient whenever a medication is prescribed that might in some circumstance cause drowsiness or fainting, “Do not drive. Do not hold your grandchild. Do not carry grocery bags to your car. In fact, do not do anything that involves interacting with another person?” Or will the patient now routinely be handed a printout of all possible side effects of any medication prescribed by *212the doctor and be asked to read and sign it in the physician’s office, as a substitute for a discussion more tailored to the physician’s judgment about what the patient’s situation requires and what the patient needs to know in order to make an informed decision? This is not an alarmist reading of Justice Ireland’s concurring opinion. The natural extension of its logic protrudes beyond the question whether any “warning” regarding side effects was given into the adequacy and completeness of that warning as concerns all possible side effects.
Even were I to accept Justice Ireland’s claim that the duty he would impose would not, in reality, change the treatment decisions and advice of doctors, I would still be concerned by the vast increase in litigation it would invite. Justice Ireland’s concurring opinion uses the most restrained language on this point, admitting only that “[ajilowing a larger number of potential plaintiffs may result in some increase in litigation . . . .” Ante at 192 (Ireland, J., concurring). This is a significant understatement. Almost everyone is, at some point in their lives, under the care of a doctor. This care often involves medication (or treatment) that might conceivably cause some impairment of the patient’s faculties. If there were now a duty owed by doctors to parties injured by their patients, the doctor would be a potential defendant whenever the reaction of the patient to a medication is a possible contributor to an injury. Accordingly, it is hard to imagine a plaintiff’s attorney failing in negligence cases to sue not just the negligent party who caused the injury but also his or her doctor. Even if the majority of these claims eventually did not result in verdicts for plaintiffs, the fact that they could be brought would increase costs and (in my view) modify the behavior of doctors in a way not necessarily helpful to patients.5 Both of these would be undesirable outcomes. They severely undermine the claim that “[sjound public policy . . . *213favors a duty in these circumstances.” Ante at 191 (Ireland, J., concurring).
Allowing such suits against doctors would also threaten the confidentiality inherent in the doctor-patient relationship. Patient privacy is a matter of great public concern. That concern has translated into strong statutory and regulatory protections for the privacy of patient records at both the State and Federal level. See, e.g., Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, 110 Stat. 1936, and privacy regulations promulgated pursuant to its Title II at 45 C.F.R. Parts 160 and 164 (2007). See also G. L. c. Ill, § 70E (patients’ rights). A patient’s decision to sue his doctor in malpractice implies a waiver of that confidentiality for purposes of the suit. In contrast, there is no such implied waiver in cases in which the doctor is sued by an injured party who is not the doctor’s patient. How are doctors to respond when faced with inquiries from third parties about discussions they have had with patients about their treatments? Statutes as well as professional codes of ethics constrain how a doctor can answer such inquiries. Yet if there is now imposed on the doctor a duty to the party making the inquiry, this places doctors in an untenable situation.
Because the duty Justice Ireland (and the Justices who join him) would recognize might fundamentally alter the relationship between doctor and patient, and increase significantly the costs of health care, contrary to sound policy, and because such a duty is plainly not warranted by any existing precedent, I respectfully dissent.6

The Oath of Hippocrates, taken by many physicians, provides in part: “[W]hatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.” 1 Hippocrates 301 (W.H.S. Jones, trans., Harvard Univ. Press 1984).

The first, that the doctor voluntarily assumed a duty to the decedent, clearly fails. Insofar as the doctor voluntarily assumed a duty to anyone, it was to his patient, not to the plaintiff’s decedent. The plaintiff offers no legal support for the proposition that a doctor’s assumption of a duty to a patient constitutes an assumption of a duty to a third party. Moreover, it is not correct to speak of a doctor assuming or not assuming a “duty to warn” his patient about the effects of medications. Ante at 187 n.5 (Ireland, J., concurring). Informing a patient about the risks and effects of medication is not a separate duty a doctor voluntarily assumes; rather, it is part and parcel of the doctor’s duty of care for the patient, grounded in the doctor-patient relationship. See Cottam v. CVS Pharmacy, 436 Mass. 316, 322 (2002) (Cottam).

The plaintiff’s special relationship argument is similarly without merit. A person ordinarily has no duty to protect a third party against the dangerousness or unlawful acts of others, Luoni v. Berube, 431 Mass. 729, 731 (2000), except where there is a “special relationship” between the actor (here the driver) and the person (the doctor) that imposes a duty on the latter to control the former. Restatement (Second) of Torts § 315(a) (1965). In the category of special relationships, we have recognized at common law the duty of a parent to control a minor child, the duty of a master to control the conduct of his servant, and the duty of a possessor of land or chattels to control the conduct of his licensee. See Restatement (Second) of Torts, supra at §§ 316-318; Luoni v. Berube, supra. There is no duty of a physician to control his patient.
This court has also recognized a “special relationship” in situations where the duty to control is premised, at least in part, on a responsibility created by statute. Most prevalent in this category are cases involving the sale and consumption of alcoholic beverages, an area highly regulated by statute. See, e.g., Irwin v. Ware, 392 Mass. 745 (1984) (town liable to injured motorist where police had released intoxicated driver back onto roadway); Adamian v. Three Sons, Inc., 353 Mass. 498 (1968) (bar owner could be held liable to those injured by patron to whom bar negligently served excessive quantities of alcoholic beverages). Cf. Michnik-Zilberman v. Gordon’s Liquor, Inc., 390 Mass. 6, 10-11 (1983), quoting Rappaport v. Nichols, 31 N.J. 188, 201-202 (1959) (finding prohibition on sale of liquor to minors, G. L. c. 138, §§ 34, 69, intended “for the protection of members of the general public as well”). See also Jean W. v. Commonwealth, 414 Mass. 496, 498-499 (1993) (Liacos, *208C.J., concurring) (duty on part of parole officers to ensure parolees not erroneously released).
The physician-patient relationship is not a “special relationship” creating a duty to third parties. The relationship is not one of control, as a parent would have over her child; it is not one of statutory responsibility, as an officer would have for the safety of the public when encountering a drunk driver. Rather, the physician-patient relationship involves an affirmative duty to care, only for the well-being of the patient in the course of treatment. St. Germain v. Pfeifer, 418 Mass. 511, 520 (1994). Cf. Restatement (Third) of Torts: Liability for Physical Harm § 41 comment c (Proposed Final Draft No. 1, 2005) (“Unlike most duties, the physician’s duty to the patient is explicitly relational: physicians owe a duty of care to patients” [emphasis in original]). Premising a physician’s duty to third parties on a “special relationship” with his patient would transform the physician’s duty of care for his patient into an obligation to control the patient. This is not an accurate characterization of the relationship between physician and patient.

Justice Greaney would go further, positing that the physician has a duty to warn not only of the potential side effects of medications (e.g., drowsiness or dizziness), but also whether the patient should drive at all while taking them. Ante at 197-198 (Greaney, J., concurring in part and dissenting in part).

Having expressed little concern that the duty he would impose would spur an increase in litigation, Justice Ireland then “leave[s] to the Legislature the task of determining whether to impose further limits on doctors’ liability.” Ante at 192 (Ireland, J., concurring). This implies that a decision in this area should take little account of the consequences on tort litigation. Yet a decision to impose a duty is at heart a decision about values and social policy, including the value of limiting or expanding the possibility of litigation under given circumstances. See Cremins v. Clancy, 415 Mass. 289, 292 (1993) (existence *213of duty of care decided “by reference to existing social values and customs and appropriate social policy”).

We are not the first State to address the question. In circumstances similar to this case, two States have declined to impose on doctors a duty to third parties harmed by a patient. Kirk v. Michael Reese Hosp. & Med. Ctr., 117 Ill. 2d 507 (1987); Calwell v. Hassan, 260 Kan. 769 (1996). The Supreme Court of Hawai’i, in contrast, did recognize such a duty in similar circumstances. McKenzie v. Hawai’i Permanente Med. Group, Inc., 98 Haw. 296, 307-309 (2002). The Hawai’i court emphasized that it meant to impose only a duty to warn the patient not to drive, a duty which the court proclaimed the doctor already had. Two other cases relied on by Justice Ireland are readily distinguishable. See Hardee v. Bio-Medical Applications of S.C., Inc., 370 S.C. 511, 516 (2006); Joy v. Eastern Me. Med. Ctr., 529 A.2d 1364 (Me. 1987). Both cases involved patients who received treatments and medications administered *214by the doctor in his office. Although the treatments caused impairment, the patients were allowed to leave the office before the impairment subsided, resulting in accidents. The duty in those cases rests squarely on the present control the doctors had over their patients. In contrast, this case presents a patient administering prescription medication to himself, at home, over a course of many months. The elements of present control and temporal proximity, so central to the reasoning of the courts in the South Carolina and Maine cases, are lacking here. This distinction was critical to two decisions by the Supreme Court of New Mexico. Compare Wilschinsky v. Medina, 108 N.M. 511 (1989) (physician owed duty to driving public when administering drugs to patient in office), with Lester v. Hall, 126 N.M. 404 (1998) (no duty where medication taken away from office, injury caused remote in time).