Court Opinion

ID: 9693919
Source: CourtListenerOpinion
Date Created: 2023-08-25 17:09:44.960936+00
Date Added: 2024-06-11T15:10:54.621256
License: Public Domain

RENDERED: AUGUST 18, 2023; 10:00 A.M.
                        NOT TO BE PUBLISHED

                 Commonwealth of Kentucky
                           Court of Appeals

                              NO. 2022-CA-1324-MR

CHRISSEN MEADE                                                       APPELLANT

                APPEAL FROM FAYETTE CIRCUIT COURT
v.             HONORABLE KIMBERLY N. BUNNELL, JUDGE
                       ACTION NO. 18-CI-04160

STEPHEN A. SCHANTZ, M.D.; AND
WALDMAN SCHANTZ, P.S.C.                                               APPELLEES

                           OPINION
     AFFIRMING IN PART, REVERSING IN PART, AND REMANDING

                                   ** ** ** ** **

BEFORE: CETRULO, ECKERLE, AND GOODWINE, JUDGES.

ECKERLE, JUDGE: A patient seeking a breast augmentation was given the

choice between saline and silicone implants and specifically consented to saline

implants. During surgery on the first breast, it was discovered that the patient

required implants almost 50 percent larger than pre-operative measurements

indicated. Rather than postpone the surgery or implant the largest saline implants
in stock, the doctor elected to place silicone implants inside the patient’s body

without obtaining the patient’s consent. After surgery, the doctor informed the

patient of the material difference, and the patient subsequently sued the surgeon

and his associated medical practice under various theories of liability. The Trial

Court ultimately granted summary judgment in favor of the surgeon and his

associated medical practice, and the patient appealed. Having thoroughly reviewed

the issues and applicable law, we affirm in part, reverse in part, and remand the

grant of summary judgment for additional proceedings.

                                      BACKGROUND

               We present a summary background here, with a more detailed

recitation of the evidence in the ANALYSIS section.

               Appellant, Chrissen Meade (“Meade”), is a licensed practical nurse

who desired to enhance the appearance of her breasts. After seeking

recommendations and looking at reviews, Meade consulted with Appellees, Dr.

Stephen A. Schantz, M.D. (“Dr. Schantz”) at Waldman Schantz, P.S.C.,

(“Waldman Schantz”) for breast augmentation surgery. During the consultation,

Meade reviewed numerous photos of breasts and indicated a desire for DD-sized

breasts.1 To achieve this goal, Meade was presented with four different elective

1
 It appears the sizing of breasts by cup size is not universal; the same breasts may be a size C in
one department store’s brassiere and a DD in another. What was apparent from the photo choice
book was that Meade desired to substantially increase the size of her breasts.

                                                -2-
procedures: a mini-mastopexy2 with silicone implants; a mini-mastopexy with

saline implants; a breast augmentation mammoplexy (“BAM”) with silicone

implants; or a BAM with saline implants. After discussions with Dr. Schantz and a

review of the consent information about the silicone and saline implants, Meade

chose to have Dr. Schantz perform a BAM with saline implants. The BAM with

saline implants had two distinct differences from the BAM with silicone implants:

the former was a cheaper option; and the saline implants carried significantly fewer

cautions in the informed consent than the silicone implants.

                 Pre-operative, external measurements showed that Meade likely

needed a 400 or 500 CC saline implant. Dr. Schantz’s operating room keeps a

stock of different sized implants, both silicone and saline, on consignment from the

manufacturers. The stock is replenished by representatives for the manufacturers

as the products are used and sold. He had the requisite 400 and 500 CC saline

implants in stock prior to the procedure, along with some other sizes of saline

implants.

                 However, once Dr. Schantz made an incision into one of Meade’s

breasts and used a sizer to verify what implant would be necessary, he believed

that to achieve the desired “DD” result Meade would require the largest implants

that are FDA approved, 800 CCs. He did not have any of the 800 CC saline

2
    This procedure is more commonly referred to as a breast lift.

                                                 -3-
implants in stock because it is rare to use saline implants and even rarer to need the

largest sized saline implants. Also, as it is extremely rare that the pre-operative,

external sizing would indicate a much smaller size than was actually needed, Dr.

Schantz did not foresee a need to stock the 800 CC size in saline. He did,

however, have 800 CC silicone implants in stock. Accordingly, Dr. Schantz

admitted that he had three options: (1) abort the procedure, order the proper size,

and perform the procedure again at a later date; (2) use the 500 CC saline implants

and risk Meade not being satisfied with the result; or (3) use the 800 CC silicone

implants and inform Meade that she could have them switched for saline implants

using only local anesthesia if she was not satisfied with the silicone implants.

             Though Meade admits her augmented breasts are “nice and

acceptable” and that Dr. Schantz “did not do a bad job in my opinion,” she

ultimately filed a Complaint against Dr. Schantz and Waldman Schantz alleging:

(1) negligence against Dr. Schantz; (2) vicarious liability against Waldman

Schantz; (3) negligence against Waldman Schantz; (4) battery against both Dr.

Schantz and Waldman Schantz; and (5) “Lack of informed consent/breach of

contract” against Dr. Schantz and Waldman Schantz.

             On August 31, 2020, Meade filed a motion for summary judgment,

arguing that there was a lack of informed consent, and that Dr. Schantz was liable

for breach of contract. Dr. Schantz later filed a motion for partial summary

                                          -4-
judgment on the breach of contract claim. The Trial Court denied Meade’s motion

and granted Dr. Schantz’s partial summary judgment motion. Additionally, the

Trial Court ordered Meade to disclose her expert witness as it related to informed

consent and her negligence claim.

             Meade disclosed her expert, Dr. Leland Deane (“Dr. Deane”). In his

deposition, Dr. Deane opined that Dr. Schantz breached the standard of care by

using silicone implants without the consent of Meade. He further opined that it

was not a breach of the standard of care to need such substantially larger implants

than the external examination showed, nor was it unreasonable to believe he would

not need 800 CC saline implants prior to surgery, nor was it unreasonable to fail to

anticipate a 200 CC or greater difference in the anticipated size needed and the

actual size needed. Likewise, Dr. Deane stated that a supermajority of women

elect to have the silicone implants, and that modern silicone implants are generally

safe.

             Dr. Schantz then filed a motion for summary judgment on all claims,

which the Trial Court granted, leading to the instant appeal. Each of these motions

was thoroughly briefed and orally argued below, and the orders entered resolving

them were summary in nature. Meade now appeals these orders and requests that

we reverse the grant of summary judgment in favor of Dr. Schantz and Waldman

Schantz and remand for further proceedings.

                                        -5-
                                         ANALYSIS

                Meade’s theories of recovery are admittedly both overlapping and, in

some respects, contradictory. Principally her claims involve medical battery,

medical negligence, and breach of contract. As the Trial Court’s Order resolved on

the motions for summary judgment, the following standard applies:

                        The proper standard of review on appeal when a
                trial judge has granted a motion for summary judgment is
                whether the record, when examined in its entirety, shows
                there is “no genuine issue as to any material fact and the
                moving party is entitled to a judgment as a matter of
                law.” CR[3] 56.03. The trial judge must view the
                evidence in a light most favorable to the nonmoving
                party, resolving all doubts in its favor. Spencer v. Estate
                of Spencer, 313 S.W.3d 534, 537 (Ky. 2010) (quoting
                Steelvest, Inc. v. Scansteel Service Center, Inc., 807
                S.W.2d 476 (Ky. 1991)). Because summary judgment
                does not require findings of fact but only an examination
                of the record to determine whether material issues of fact
                exist, we generally review the grant of summary
                judgment without deference to either the trial court’s
                assessment of the record or its legal conclusions. Malone
                v. Kentucky Farm Bureau Mut. Ins. Co., 287 S.W.3d 656,
                658 (Ky. 2009) (citing Schmidt v. Leppert, 214 S.W.3d
                309 (Ky. 2007)).

Hammons v. Hammons, 327 S.W.3d 444, 448 (Ky. 2010). With this precedent in

mind, we now turn to the three claims of liability.

3
    Kentucky Rules of Civil Procedure.

                                            -6-
I.    Battery claim

             Meade first alleges that Dr. Schantz committed battery by performing

a BAM with silicone implants rather than a BAM with saline implants. Dr.

Schantz initially argues that at the trial level Meade stood “mute” and never fairly

presented an argument on the battery claim. Dr. Schantz requests that we review

this issue for palpable error. Dr. Schantz admits, however, that Meade at minimum

made a summary argument that Dr. Schantz committed battery by performing the

BAM with silicone without her informed consent.

      A. Preservation

             We have reviewed the underlying record and find Meade made ample

noise to press her battery claim. Meade argued throughout the summary judgment

proceedings, both in written responses and in oral arguments at hearings, that Dr.

Schantz should be liable for failing to obtain informed consent to perform a BAM

with silicone implants. Throughout these proceedings the concepts of informed

consent, medical negligence, and intentional battery blurred together, as even Dr.

Schantz admits in his brief that the Trial Court concluded the “[c]laim for battery is

really a claim for medical malpractice because it depends on [the physician’s]

professional judgment.” Appellee’s Brief at 12.

             Ultimately, the Trial Court granted summary judgment in favor of Dr.

Schantz on all claims, including the battery claim, rejecting the underlying premise

                                         -7-
of lack of informed consent. But a lack of informed consent is not the tort. As

Justice Leibson has previously summarized:

                    “Lack of informed consent” is not, per se, a tort. It
             is only a term useful in analyzing medical malpractice
             claims involving two different torts: (a) the type of
             assault and battery which occurs when a physician
             performs an unauthorized procedure, i.e., “where a
             patient has not consented to the particular medical
             treatment which was given”; and (b) the type of
             negligence which occurs when a physician has not made
             a “proper disclosure of the risks inherent in a treatment.”

Keel v. St. Elizabeth Medical Center, 842 S.W.2d 860, 862-63 (Ky. 1992)

(Leibson, J., concurring) (citations omitted) (emphasis in original). Hence, a lack

of informed consent in a medical battery claim is really just a lack of consent

claim. See Vitale v. Henchey, 24 S.W.3d 651, 656 (Ky. 2000) (noting the

confusion between a lack of informed consent claim in medical negligence and a

lack of consent claim in medical battery).

             In other words, Meade is not raising a wholly new argument, which

would be unpreserved, see, e.g., Celina Mutual Insurance Co. v. Harbor Insurance

Agency, LLC, 332 S.W.3d 107, 112-13 (Ky. App. 2010), but has fairly presented

her alternative claims for relief based on the same underlying argument – that there

was no consent, informed or otherwise, to perform a BAM with silicone implants.

             However, we do agree with Dr. Schantz that Meade never requested

summary judgment on the battery claim. Indeed, Meade impliedly admits as much

                                         -8-
as her request for relief on appeal is that we reverse and remand the grant of

summary judgment in favor of Dr. Schantz. Notably, she does not request that we

reverse and remand the denial of a summary judgment motion in her favor on the

battery claim. Accordingly, we will review on appeal whether the Trial Court

erred by granting summary judgment in favor of Dr. Schantz on the battery claim.

      B. Consent

             A medical battery claim is an intentional tort and distinguishable from

a medical negligence claim. Vitale, 24 S.W.3d at 657-58. A person may establish

an action for battery “when a physician performs an operation without the consent

of the patient.” Id. at 656. The medical battery action “is different from a

negligence action for medical malpractice because the claim depends on neither

professional judgment nor the physician’s surgical skill.” Id. Accordingly, “[i]n

establishing a battery claim, a plaintiff must prove the absence of consent.”

Andrew v. Begley, 203 S.W.3d 165, 172 (Ky. App. 2006) (citing Vitale, 24 S.W.3d

at 658). Additionally, civil battery in the common law is defined as “any unlawful

touching of the person of another, either by the aggressor himself, or by any

substance set in motion by him[.]” Vitale, 24 S.W.3d at 657 (quoting Sigler v.

Ralph, 417 S.W.2d 239, 241 (Ky. 1967)). Battery is an intentional tort, and the

intention in medical battery is merely the intention to make contact with the

person, not to cause harm, and the harmful contact is simply where the touching

                                         -9-
results in an impairment or alteration of the person’s body. Vitale, 24 S.W.3d at

658.

             Accordingly, to determine the threshold issue of whether Dr. Schantz

was entitled to summary judgment on the battery claim, we must determine

whether there was consent to perform the BAM with silicone implants. Reviewing

the evidence of record, we hold that there exists a genuine issue of material fact as

to whether Meade consented to the BAM with silicone implants; thus the Trial

Court erred by granting summary judgment on the medical battery claim.

             “Kentucky courts have repeatedly recognized that valid consent to

medical treatment is to be gleaned from evidence of the circumstances and

discussions surrounding the consent process.” Kovacs v. Freeman, 957 S.W.2d

251, 255 (Ky. 1997). We must look at the written consent documents, which are

“a component” of the consent process, and also at the discussions had between the

parties. Hoofnel v. Segal, 199 S.W.3d 147, 150 (Ky. 2006).

             Initially, we note that written documentation in this case points to two

main conclusions, which only a jury may decide: a BAM with saline implants is a

different procedure with a different risk profile than a BAM with silicone implants;

and Meade only consented to a BAM with saline implants being performed on her

person.

                                        -10-
             Prior to surgery, Dr. Schantz made it clear to Meade that the two

procedures carried different risks. Meade initialed a lengthy document outlining

specific surgical risks inherent in various breast enhancement procedures. Among

the risks noted were significantly different risks for either saline or silicone

implants:

             DEFLATION: Saline: The valve through which the
             implant is filled can fail and leak over time. The outer
             shell of the implant can develop a small tear or a pinhole
             defect and leak. While neither of these problems occurs
             frequently, when they do, the saline (fluid) leaks out of
             the implant, and is absorbed by the body. The breast size
             becomes smaller. Sometimes, only a portion of the fluid
             leaks out, and the breast does not deflate all the way to
             the preoperative size. Leakage of saline is not dangerous,
             but the only solution is to replace the implant with a new
             one.

             Silicone: The rupture of a silicone gel-filled breast
             implant is most often silent. This means that neither you
             nor Stephen A. Schantz, M.D. will know that your
             implants have a rupture most of the time. Rupture can
             occur at any time after implantation, but they are more
             likely to occur the longer the implant is implanted. The
             following things may cause your implant to rupture.
             Damage by surgical instruments, stressing the implant
             during implantation, and weakening it, folding or
             wrinkling of the implant shell, excessive force to the
             chest (for example, during closed capsulotomy, which is
             contraindicated), trauma, compression during
             mammographic imaging, and severe capsular contracture.
             Breast implants may also simply wear out over time. If
             rupture occurs, silicone gel may either remain within the
             scar tissue capsule surrounding the implant (intracapsular
             rupture), move outside the capsule (extracapsular
             rupture), or gel may move beyond the breast (migrated

                                          -11-
             gel). There is also a possibility that rupture may progress
             from intracapsular to extracapsular and beyond. There
             have also been health consequences reported in the
             literature. In fact, the ability of a physical examination
             by a plastic surgeon who is familiar with breast implants
             to detect silicone breast implant rupture is 30% compared
             to 89% for MRI. You will need regular screening and
             MRI examinations over your lifetime in order to
             determine if silent rupture is present. You should have
             your first MRI at 3 years after your initial implant
             surgery, then every 2 years, thereafter. The cost of MRI
             screening may not be covered by your insurance, and
             should be considered in making your decision. If implant
             rupture is noted on MRI, you should have the implant
             removed, with or without replacement. Sometimes, these
             are symptoms associated with gel implant rupture. These
             symptoms include hard knots or lumps surrounding the
             implant, or in the armpit, change or loss of size or shape
             of the breast or implant, pain, tingling, swelling,
             numbness, burning, or hardening of the breast. You
             should perform an examination of your breasts to watch
             for these symptoms. These should be reported to
             Stephen A. Schantz, M.D., and possibly evaluated with
             an MRI to screen for rupture.

Surgical Risks p. 19. Additionally, a silicone implant carried a caution regarding

connective tissue disorder:

             PRESENCE OF SILICONE RUBBER/CONNECTIVE
             TISSUE DISORDER: Silicone filled implants are made
             of silicone rubber. Silicone rubber, more commonly
             referred to as silicone elastomer, is a synthetic product.
             Concern over the association of silicone in breast
             implants to the development of autoimmune or
             connective tissue diseases, such as lupus, scleroderma, or
             rheumatoid arthritis, was raised because of cases reported
             in the literature of small numbers of women with
             implants. A review of several large epidemiological
             studies of women with and without implants indicates

                                        -12-
             that these diseases are no more common in women with
             implants than those in women without implants.
             However, a lot of women with breast implants believe
             that their implants caused a connective tissue disease.

Surgical Risks p. 20-21. No similar risks were identified for saline implants.

             Moreover, Dr. Schantz had prepared four quotes for services: a mini-

mastopexy with saline implants; a mini-mastopexy with silicone implants; a BAM

with saline implants; and a BAM with silicone implants. Each of these quotes

included three references to the type of implant being used: first, as part of the

heading describing the quote; second, as a line item describing the implant to be

used as part and parcel of the procedure to be performed; and third, as a separate

line item showing the medical device to be implanted (silicone or saline implants)

with its associated cost. For example, the quote for a “BAM-Saline” included a

line item quantity of 1 “Breast Augmentation – Saline” with a corresponding price,

and a separate line item quantity of 1 “Saline implants” with a corresponding price.

In other words, all of the documentation provided indicated a BAM with saline

implants was a different procedure than a BAM with silicone implants.

             Likewise, the documentary evidence shows that Meade elected a

BAM with saline. She signed a “Consent for Surgery” that read as follows:

             I, Chrissen Meade, desire Stephen A. Schantz, M.D. and
             such assistants as may be assigned by him/her, to
             perform the procedure(s) of:

                                         -13-
                   • Surgery – Dr. Schantz Cosmetic – BAM with
                     Saline Implants4 Mini Mastopexy with Saline
                     Implants. Sch with TJT on 12/14/16

             The nature and purpose of the operation(s), possible
             alternative methods of treatment, including no
             treatment/surgery, risks and possible complications have
             been fully explained to me by Stephen A. Schantz, M.D.
             and the physician assistant, during my pre-operative
             consultation. I understand that this operation is not an
             emergency nor is it medically necessary to improve or
             protect my physical health. I have been advised that all
             surgery involves general risks, including but not limited
             to bleeding, infection, nerve or tissue damage, and rarely,
             cardiac arrest, death, or other serious bodily injury. I
             acknowledge that no guarantees or assurances have been
             made as to the results that may be obtained.

             ...

             It has been explained to me that during the course of the
             operation unforeseen conditions may be revealed that
             necessitate an extension of the original procedure, and I
             hereby authorize Stephen A. Schantz, M.D. and/or such
             assistants as may be selected by him/her to perform such
             procedures as necessary and desirable, including but not
             limited to the services of pathologists, radiologists, or
             laboratory. The authority granted in this paragraph shall
             extend to remedying conditions that are not known to
             Stephen A. Schantz, M.D. at the time the operation
             commences.

             ...

             In signing this consent, I hereby certify that I understand
             the risks, benefits, and alternatives to my procedure(s)

4
  “BAM with Saline Implants” was handwritten above “Mini Mastopexy,” which had been struck
through as well.

                                          -14-
             and that I have discussed them with Stephen A. Schantz,
             M.D.

The form was signed and dated on January 18, 2017.

             In addition to the documentary evidence, the depositions submitted by

the parties show that different procedures are involved in the implantation of

silicone versus saline products, and that Meade had only consented to have a BAM

with saline implants to be performed on her person. Initially, in his deposition, Dr.

Schantz made it clear that the choice of implant is one that is determined by the

client:

             Q. All right. Let me just ask you in general, Doctor,
             what – how do you counsel patients about whether they
             choose saline or silicone devices?

             A. When they come for the original consultation, we
             discuss the fact that both saline and silicone implant
             devices are available to the patient. I discuss what I view
             to be the benefits of each and then let [sic] that open to
             the patient as to what she chooses. And it may not be
             done at that time.

             Q. So, is it the patient that decides whether it’s silicone
             or saline implants that are used?

             A. The patient does make the decision as to which
             implants she would like to have placed.

             Q. All right. And do you make sure that that’s in writing
             somewhere and initialed by the patient prior to the
             procedure?

             A. Yes, we do.

                                         -15-
Dr. Schantz Deposition at 8 (emphasis added). And Meade unequivocally made

her election for saline:

             Q. But did Ms. Meade make it crystal clear to you and
             your staff that she only wanted to use saline?

             A. At our initial consultation we discussed both types of
             implants, and at that time it was not – she had not made
             her mind up, which is not unusual unless patients come in
             knowing exactly what they want.

                    When she came back for her planning session, at
             that time is when they make the decision because that’s
             usually when they start – they pay either – I think they
             pay their balance. So at that time it was known to us that
             she wanted saline implants.

Dr. Schantz Deposition at 32-33 (emphasis added).

             Additionally, there was a pre-operative verification protocol to

identify the type of implant to be used. In Meade’s case, at least once, and

possibly twice, it was confirmed prior to surgery that saline implants were the

election. Dr. Schantz admitted that by January 18, 2017, Meade had

communicated that she wanted saline, not silicone, implants.

             Dr. Schantz also noted that one of his staff had written on a consent

for surgery form that Meade was to have “BAM, with saline implants.” Dr.

Schantz Deposition at 51. That form was signed by Meade and a member of Dr.

Schantz’s staff and dated January 18, 2017, the date of surgery.

                                        -16-
             Additionally, the undisputed evidence showed that a BAM with saline

implants is a procedure that carries a different risk than a BAM with silicone

implants. Dr. Schantz stated that he reviews with his patients the “risks of saline

versus silicone.” Dr. Schantz Deposition at 43. The information regarding the

risks of silicone ruptures is roughly three times as long as the information

regarding the risks of saline ruptures. The information noted “hard knots or lumps

surrounding the implant, or in the armpit, change or loss of size or shape of the

breast or implant, pain, tingling, swelling, numbness, burning, or hardening of the

breast” could all be associated with silicone ruptures, but the same were not

denoted as associated with saline ruptures. Dr. Schantz did not feel the need to

explain this information to Meade; “It’s pretty self-explanatory, and I believe she

read that on her own.” Dr. Schantz Deposition at 48.

             Dr. Schantz also admitted that once he realized he did not have a

saline implant that he believed would result in the outcome Meade desired, he had

three options:

             I had choice A, which would be just to abort the
             procedure because we did not have the proper implant,
             come back and put a – order the implant, come back and
             put the proper size to get the patient to her goal. So that
             meant that’s a second surgery.

                   Choice B was to put a smaller implant than she
             desired in the saline realm knowing that she was not
             going to be happy because we did not achieve her goals,

                                         -17-
            according to her pictures, so more than likely coming
            back and putting in a larger implant at a later date.

                   Or choice C, which is to put in a silicone implant,
            which I did have the size proper, felt that it’s a superior
            product, which most women choose, and have her have
            the possibility of not having to have another surgery and
            another anesthetic if she was okay with that. We
            certainly made it known to her that I would more than
            gladly remove the implants and replace them with saline
            which could be done under local if she so desired.

Dr. Schantz Deposition at 54 (emphasis added).

            These options show that Dr. Schantz understood the procedure to

which Meade consented was a BAM with saline implants. Choice “C” shows that

Dr. Schantz viewed silicone versus saline implants as a choice or an election for

the patient. Choice “C” also shows that Dr. Schantz knew what he did not know,

namely that he did not know whether Meade would give her consent to perform a

BAM with silicone implants. Dr. Schantz consciously and intentionally chose not

to perform A or B, both of which aligned with the procedure Meade had elected

and which he had consent to perform. Yet he intentionally chose to perform a

BAM with silicone implants, a procedure to which Meade had not given consent to

perform and for which Dr. Schantz knew he might have to perform another surgery

if Meade truly did not post-surgery elect the BAM with silicone implant procedure.

             In an effort to vitiate the lack of consent, Dr. Schantz now argues that

prior to the operation Meade never specifically objected to silicone implants. This

                                        -18-
argument is unavailing, as the dissent in Vitale utilized the very same type of

argument. 24 S.W.3d at 660 (“Although Henchey did not specifically authorize

Dr. Vitale to perform the surgery, neither did he specifically object to his doing

so.”) (Cooper, J., dissenting). It is thus sufficient to survive summary judgment on

the issue of battery that Meade consented to the use of saline and did not

specifically reject silicone.

             Dr. Schantz also argues that pursuant to Hoofnel v. Segal, 199 S.W.3d

147, 149 (Ky. 2006), the “unforeseen conditions” clause in the consent form

permitted him to perform a BAM with silicone implants after discovering during

the procedure that he would need much larger implants than his pre-operative

measurements indicated. We do not agree. First, Dr. Schantz’s admission in his

deposition indicates that he understood he had two choices that were aligned with

Meade’s consent – to stop the procedure and perform it later with the correct

implants, or to use the saline implants he had available and risk not achieving the

desired “DD” size outcome. He also understood that the third choice, which he

elected to do without obtaining Meade’s consent, was to perform a procedure that

he hoped Meade would later not object to having had performed on her. In other

words, even with the unforeseen conditions that arose, Dr. Schantz acknowledged

that he had options that aligned with the consent; thus, the unforeseen conditions

                                         -19-
did not create a necessity for an extension of the procedure, which is all that the

consent form permitted.

             Second, Meade put forth an expert opinion to rebut this argument.

Her expert, Dr. Deane, testified in his deposition that the consent form did not

authorize Dr. Schantz to use silicone implants:

             Q. The first criticism you have is that Dr. Schantz
             breached the standard of care by inserting silicone
             implants without the informed consent of Ms. Meade,
             correct?

             A. Correct.

             Q. And I guess the second criticism is that he failed to
             wake Ms. Meade up from anesthesia until such a time
             that she could make a decision about whether she wanted
             to go forward with the silicone or wait and get saline?

             A. Yes.

             Q. Why do you believe that he did not have the informed
             consent of Ms. Meade?

             A. Because I saw the informed consent.

             Q. She signed the form, and she wanted saline, and she
             told him that she wanted saline, and therefore, that is a
             lack of informed consent?

             A. Yes. Unless it is documented elsewhere, and I didn’t
             see that.

Deane Deposition at 89.

                                         -20-
             Finally, Hoofnel does not permit so broad a reading of the “unforeseen

conditions” clause as Dr. Schantz argues. In fact, quite the opposite is true, as

Hoofnel found the clause to “authoriz[e] additional procedures that may be

medically necessary[.]” 199 S.W.3d at 149. There, during a scheduled surgery for

colorectal cancer, it became medically necessary to remove a patient’s ovaries and

uterus. Id. at 148. Summary judgment had been granted to the health care

providers on a subsequent battery claim because a written consent form contained

the aforementioned clause along with express consent to perform an anterior

resection of the colon, appendectomy, and possible bilateral oophorectomy. Id. at

148-49. During the surgery, due to the patient having an abnormally large uterus

that two medical professionals viewed and believed to be cancerous, and that also

contained multiple fibroid tumors and was blocking the surgeon’s ability to

perform the colon resection, the surgeon performed a medically necessary

hysterectomy. Id. at 149. Our Supreme Court held that the “unforeseen

conditions” clause permitted a procedure that was medically necessary, to wit,

“[t]he additional surgical procedure to remove the uterus became medically

necessary once the enlarged uterus was observed as it impaired and impeded [the

surgeon’s] ability to resect the lesion in the colon.” Id. at 151.

             Here, there was neither a medical emergency nor a medical necessity

requiring Dr. Schantz to perform a different procedure. We grant to “[e]very

                                         -21-
human being of adult years and sound mind . . . a right to determine what shall be

done with his own body; and a surgeon who performs an operation without his

patient’s consent commits an assault, for which he is liable in damages[.]” Tabor

v. Scobee, 254 S.W.2d 474, 475 (Ky. 1951) (internal quotation marks and citation

omitted). “This is t[ru]e, except in cases of emergency where the patient is

unconscious, and where it is necessary to operate before consent can be obtained.”

Id. (internal quotation marks and citation omitted). Dr. Schantz admitted here

there was no medical emergency, and he further admitted it was his choice to

perform a different procedure. He also admitted that he knew Meade would have

an objection to the different procedure, but hoped it would not be a strong

objection:

                     And then I explained why we had to use – why I
             chose to use the silicone. I further explained that if that
             was something that she had a very strong objection to or
             felt like she did not wish to have silicone that I was more
             than happy to exchange that for her at no cost to her.

Dr. Schantz Deposition at 63-64. Meade’s expert, Dr. Deane, likewise

acknowledged that there was no medical emergency.

             Given that the evidence is undisputed that there was no medical

emergency that required Dr. Schantz to perform the BAM with saline implants, the

unforeseen conditions clause did not permit the use of silicone implants. We liken

this case to Vitale, where an action in battery lay because a patient consented to a

                                         -22-
certain surgery but not to the particular doctor who performed the surgery. 24

S.W.3d at 654 (“Henchey further testified that, based on Dr. Sparrow’s comments

to him about Dr. Vitale, he would not have consented to Dr. Vitale performing the

surgeries on his mother.”). Indeed, “the decision to consent to a particular medical

procedure is not a medical decision. Instead, it ordinarily is a personal and often

difficult decision to be made by the patient[.]” Pauscher v. Iowa Methodist

Medical Center, 408 N.W.2d 355, 360 (Iowa 1987). Here, viewing the evidence in

a light most favorable to Meade, one can conclude that Meade made a personal

decision and consented to saline implants, not silicone, and Dr. Schantz’s decision

to implant silicone was performed without Meade’s consent. Cf. Hershley v.

Brown, 655 S.W.2d 671, 676 (Mo. Ct. App. 1983) (holding a complaint alleged a

battery where patient requested elective sterilization procedure involving burning,

cauterizing, and removing portions of the fallopian tubes, but surgeon instead

performed sterilization procedure by using a Wolfe ring instrument and implanting

a foreign object in patient’s body).

             Though Dr. Schantz may now argue that Meade never specifically

objected to silicone, we note that the dissent in Vitale pointed to the very same type

of argument, which the majority had rejected. 24 S.W.3d at 660 (“Although

Henchey did not specifically authorize Dr. Vitale to perform the surgery, neither

did he specifically object to his doing so.”) (Cooper, J., dissenting). Thus, it is

                                         -23-
sufficient to survive summary judgment on the issue of battery that Meade

consented to the use of saline and did not specifically reject silicone.

              In summary, our holding here is very narrow. This medical battery

claim arose from an elective procedure and circumstances that did not create a

medical necessity for a different procedure. In fact, the surgeon admitted he had

two options that aligned with the procedure to which the patient had consented.5

The surgeon intentionally and knowingly inserted into the patient’s body a foreign

object that the patient had neither expressly nor impliedly chosen to have inserted

into her body. Under these facts, summary judgment should not have been granted

to Dr. Schantz or Waldman Schantz on the battery claim. Accordingly, we reverse

and remand the grant of summary judgment in favor of Dr. Schantz and Waldman

Schantz on the medical battery claim. On remand, we note that on a medical

battery claim a “plaintiff need not prove actual damages . . . because a showing of

actual damages is not an element of battery and, when no actual damages are

shown for a battery, nominal damages may be awarded.” Vitale, 24 S.W.3d at 659

(footnotes and citations omitted).

5
  Dr. Schantz notes that Meade indicated she would have brought a lawsuit against Dr. Schantz
had he chosen any of the three options. Thus Dr. Schantz opined that proceeding with choice C
should be viewed as a reasonable way of potentially avoiding a second surgery. This argument
is a non sequitur; had Dr. Schantz elected choice A or B, Meade’s lawsuit would have no
actionable cause under a medical battery claim.

                                             -24-
II.   Medical negligence

             Meade next argues that the Trial Court erred by granting summary

judgment in favor of Dr. Schantz on the medical negligence claim. We disagree.

             “Generally, ‘the plaintiff in a medical negligence case is required to

present expert testimony that establishes (1) the standard of skill expected of a

reasonably competent medical practitioner and (2) that the alleged negligence

proximately caused the injury.’” Morris v. Boerste, 641 S.W.3d 688, 698 (Ky.

App. 2022) (quoting Andrew v. Begley, 203 S.W.3d 165, 170 (Ky. App. 2006)

(citing Johnson v. Vaughn, 370 S.W.2d 591, 596-97 (Ky. 1963); Reams v. Stutler,

642 S.W.2d 586, 588 (Ky. 1982))). While “under certain factual circumstances,

the claim of battery may arise in addition to a claim for medical malpractice[,]”

Andrew v. Begley, 203 S.W.3d 165, 171 (Ky. App. 2006) (citation omitted), Meade

does not present such a case.

             Meade’s claim is that Dr. Schantz was negligent in failing to have the

largest sized saline implants on hand for the surgery, and thus committed medical

negligence by performing a different procedure and inserting silicone implants into

her body. But Meade’s argument is not that the standard of skill for a BAM with

silicone implants was breached, but that the very act of performing a BAM with

silicone implants is in and of itself a breach of the standard of skill expected of a

reasonably competent, medical practitioner. The argument creates a feedback loop

                                         -25-
of litigation. By performing a non-consented-to procedure, does a doctor ipso

facto breach the standard of skill expected of a reasonably competent, medical

practitioner? If that were the case, every medical battery claim – an intentional tort

– would also constitute medical negligence.

             Meade might have actionable claims under both medical negligence

and battery if she alleged that Dr. Schantz performed some negligent act that

breached the standard of care during the BAM with silicone implant procedure.

For example, had Dr. Schantz used the wrong size or type of stitches, or placed the

implants incorrectly, or ruptured the implants during the surgery, or performed any

number of other, potential, negligent acts, then perhaps Meade might have an

actionable, medical negligence claim.

             However, the evidence here unequivocally shows that Dr. Schantz

intentionally did not perform the procedure to which Meade consented, but it does

not show that Dr. Schantz otherwise breached the standard of care while

performing the BAM with silicone implants procedure. The proper cause of action

in this fact pattern is battery, and the Trial Court did not err by granting summary

judgment on the medical negligence claim.

             Additionally, Meade argues that the Trial Court erred by requiring her

to support her medical negligence claim with expert testimony, specifically that

she must establish that the use of silicone implants was a significant risk for which

                                         -26-
she was not warned. We agree with Meade inasmuch as such testimony was not

necessary to establish a lack of consent on the battery claim. See Vitale, 24 S.W.3d

at 656 (“However, the physicians, as did the trial court, confused the issue of

informed consent, i.e., the failure to disclose a risk or hazard of the surgeries, with

the issue of no consent, or whether any valid consent was obtained prior to . . .

performance of the surgeries.”). However, to proceed on a medical negligence

claim, Meade would likely have had to demonstrate through expert testimony that

Dr. Schantz breached the standard of care while performing the BAM with silicone

implant procedure. Because Meade does not even make a claim that the BAM

with silicone implant procedure was negligently performed, nor does she establish

breach, causation, and damages, the Trial Court appropriately granted summary

judgment in favor of Dr. Schantz and Waldman Schantz on this issue.

III.     Breach of contract

                Finally, Meade argues that the Trial Court erred by granting summary

judgment in favor of Dr. Schantz on the breach of contract claim. Meade claims

that KRS6 304.40-300 does not apply in this case. That statute reads:

                No malpractice liability shall be imposed upon any health
                care provider on the basis of an alleged breach of any
                guaranty, warranty, contract or assurance of results to be
                obtained from any procedure undertaken in the course of
                providing health care, unless such guaranty, warranty,

6
    Kentucky Revised Statutes.

                                          -27-
             contract or assurance is in writing and signed by the
             provider.

             It is undisputed that there exists no written contract between Dr.

Schantz and Meade that is in writing and signed by Dr. Schantz. The statute is

clear and unequivocal. When we engage in statutory interpretation, we must give

effect to the intent of the General Assembly, and “[w]here the words used in a

statute are clear and unambiguous and express the legislative intent, there is no

room for construction and the statute must be accepted as written.” Bell v. Bell,

423 S.W.3d 219, 223 (Ky. 2014) (citation omitted). Here, the statute expressly

states that Meade’s cause of action is unsustainable without a “contract . . . in

writing and signed by the provider.” KRS 304.40-300. Additionally, longstanding

jurisprudence in this state and sister states demonstrates a reluctance to turn

medical consent documents into legally enforceable contractual obligations. See

Kovacs v. Freeman, 957 S.W.2d 251, 256-57 (Ky. 1997). There being no

enforceable contract, we affirm the Trial Court’s order granting summary judgment

on this claim.

                                  CONCLUSION

             Sufficient evidence was presented to survive a motion for summary

judgment on the battery claim, as the evidence viewed in a light most favorable to

Meade shows that she did not consent to the insertion of silicone implants into her

body. However, the same cannot be said of her negligence and breach of contracts

                                         -28-
claims. Accordingly, we REVERSE AND REMAND the Trial Court’s Order

inasmuch as it granted summary judgment in favor of Dr. Schantz on the battery

claim, but otherwise AFFIRM the Order on all other grounds.

            ALL CONCUR.

BRIEFS FOR APPELLANT:                   BRIEF FOR APPELLEES:

J. Dale Golden                          Mark E. Nichols
Laraclay Parker                         Sarah C. Clark
Alexandra DeMoss-Campbell               Lexington, Kentucky
Lexington, Kentucky

                                      -29-