Court Opinion

ID: 9537954
Source: CourtListenerOpinion
Date Created: 2023-08-07 07:27:53.832892+00
Date Added: 2024-06-11T14:55:34.118979
License: Public Domain

Dore, J.
(dissenting)—The claims of plaintiff, Elaine McKee, relevant to this appeal, arise from the defendant pharmacists' continual refilling of a prescription of Plegine for a period of 10 years. During 1974 plaintiff, Elaine McKee, believed that she had a weight problem. At that time, Elaine was 20 years of age and otherwise in good health. She went to see her longtime family physician, defendant Dr. Michael Shanahan. Dr. Shanahan prescribed the drug, Plegine and the defendant pharmacy dispensed it to McKee for a period of 10 years. The plaintiff stated in her deposition that during portions of the time these amphetamines were dispensed to her she was well within her target weight range, but felt the drug was saving her life because she felt she was a defective person.
Prior to dispensing Plegine to the plaintiff, the defendant pharmacists elected to remove the manufacturer's warnings from the medication. Defendant Mezistrano testified that he removed the manufacturer's package insert warning instructions in dispensing bottles of 100 Plegine tablets (the quantities dispensed to Elaine). In fact, Mezistrano testified that he had decided that the package warnings were too complicated for the customers to understand them. There was testimony that the druggist could have placed his label on the other side of the capsule container without disturbing the manufacturer's warning.
The nature of the drug, Plegine, is vital to the plaintiff's contentions concerning the duty of the pharmacists. Plegine is an amphetamine. The drug was utilized for weight control, but was potentially addictive and possessed a number of very dangerous side effects.
The majority admits that for 10 years the pharmacists Sidran and Mezistrano removed a label from the Plegine *722prescription sold to McKee, which contained the following warning:
Indications: PLEGINE (phendimetrazine tartrate) is indicated in the management of exogenous obesity as a short term adjunct (a few weeks) in a regimen of weight reduction based on caloric restriction. The limited usefulness of agents of this class should be measured against possible risk factors inherent in their use. (See Actions).
Warnings: DRUG DEPENDENCE: Plegine is related chemically and pharmacologically to the amphetamines. Amphetamines and related stimulant drugs have been extensively abused, and the possibility of abuse of Plegine should be kept in mind when evaluating the desirability of including a drug as part of a weight reduction program . . . Tolerance to the anorectic effect of Plegine (phendimetrazine tartrate) develops within a few weeks. When this occurs, its use should be discontinued; the maximum recommended dose should not be exceeded.
Precautions: . . . The least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of an overdose.
Clerk's Papers, at 115, 749, 756. Majority, at 703. Incredibly, the pharmacists never mentioned the "few weeks" warning and possible side effects to McKee, or the recommendation that the drug should be discontinued after several weeks. Maybe one might understand a delay of such a warning over several months, but not a delay of 10 years.
I would have no difficulty holding that Sidran and Mezistrano were negligent as a matter of law in not warning McKee of Plegine's side effects. But that issue is not presented here. The sole issue is whether McKee presented enough evidence in response to the defendants' motion for summary judgment to take the issue of negligence to a jury. Since McKee did present evidence from which a jury could infer that the pharmacists had failed to exercise the due care required of a reasonably prudent health care provider, the defendant's summary judgment motion should have been denied.
I would reverse the trial court's decision and remand for trial.
*723Pharmacists Owe a Duty of Due Care
There is no question that a pharmacist has a duty of due care. It is established and defined by statute. A pharmacist is defined as a "health care provider" in RCW 7.70.020. RCW 7.70.040 provides in part:
The following shall be necessary elements of proof that injury resulted from the failure of the health care provider to follow the accepted standard of care:
(1) The health care provider failed to exercise that degree of care, skill, and learning expected of a reasonably prudent health care provider at that time in the profession or class to which he belongs, in the state of Washington, acting in tbe same or similar circumstances!.]
The "reasonably prudent practitioner" standard of this statute is distinct from and higher than the "average practitioner" standard of the common law. The question is what the public would expect a reasonably prudent practitioner to do, not what his peers would expect. Harris v. Groth, 99 Wn.2d 438, 444-45, 663 P.2d 113 (1983).
Since the question is what the public judgment of reasonable prudence is, the issue of due care under RCW 7.70-.040 is an issue of fact on which expert testimony will ordinarily be received. This court wrote in Harris:
In general, expert testimony is required when an essential element in tbe case is best established by an opinion which is beyond the expertise of a layperson. Medical facts in particular must be proven by expert testimony unless they are "observable by [a layperson's] senses and describable without medical training". Thus, expert testimony will generally be necessary to establish the standard of care and most aspects of causation.
(Footnote and citations omitted. Italics mine.) Harris, at 449. The court in a footnote stated:
This will remain true even under the reasonable prudence standard of care, since the factual question of whether a particular medical practice is reasonably prudent is generally neither observable by or describable by a layperson. In some exceptional circumstances, laypersons may be capable of balancing the costs and benefits of a particular procedure and deciding whether it was reasonably prudent.
*724(Italics mine.) Harris, at 449 n.6. The issue of a pharmacist's duty of due care is therefore a question of fact for a jury, not an issue of law for the court.
The majority cites several cases for the proposition that the existence of a duty is a question of law. All of these cases consider the existence of a common law duty of due care. None of the cases involved conduct governed by an applicable statute, like RCW 7.70.040, which itself imposes a duty of care. The cases cited by the majority are distinguishable. RCW 7.70.040 supersedes the common law, and whether or not a duty should be imposed is no longer an open question. The only remaining issue is the specific content or application of the duty in the particular case, and that is a question for the jury. Put another way, if the existence of a duty is a question of law, in this case the statute provides a clear answer to that question: yes. The majority's wrestling with the question of whether a duty of due care exists is, at best, unnecessary and, at worst, a usurpation of the Legislature's power.
The majority argues that RCW 18.64.011(11) determines the standard of care for pharmacists, rather than a jury with the assistance of experts under RCW 7.70.040. Majority, at 717. The passage the majority relies on states that:
"Practice of pharmacy" includes the practice of and responsibility for: Interpreting prescription orders; the compounding, dispensing, labeling, administering, and distributing of drugs and devices; . . . the providing of information on legend drugs which may include, but is not limited to, the advising of therapeutic values, hazards, and the uses of drugs and devices.
Stressing the word "may" in this passage, the majority concludes that the pharmacist's duty of due care does not include providing warnings on dangerous drugs because such warnings are optional. This argument has no merit because the passage has been taken out of context. It has nothing whatever to do with the standard of care which governs pharmacists.
RCW 18.64.011(11) is a definition of what constitutes the "practice of pharmacy" for the purposes of RCW 18.64 *725generally. For example, RCW 18.64.020 makes it unlawful for a person "to practice pharmacy" without a license. The passage quoted by the majority, when placed in the proper context, means that one who advises on the therapeutic values and hazards of drugs may be committing an act which is illegal without a license. In drafting RCW 18.64-.011(11) the Legislature was considering an entirely different question from due care, and the majority reads something into the statute which is not there. Furthermore, the proposition that RCW 18.64.011(11) defines the standard of due care is directly contrary to the holding of Harris that the due care of health care providers under RCW 7.70.040 is a question of fact to be decided by the jury with the assistance of expert testimony. Harris, at 449.
Since the majority concludes that the pharmacists owed McKee no duty to warn of the adverse effects of Plegine, it affirms the grant of summary judgment. It is impossible to tell from the majority opinion, however, which of two distinct questions it is attempting to answer. It is clear that neither one is presented here. First, to ask whether a pharmacist owes a duty to warn as a matter of law might mean: Is there a legal duty, distinct from the duty of due care, which the pharmacists owed McKee? Second, to ask whether a pharmacist owes a duty to warn as a matter of law might mean: Was the pharmacists' failure to warn McKee so extreme a failure that it breached their duty of due care as a matter of law? The pharmacists' motion for summary judgment raises neither of these questions. The only issue is whether there is evidence from which a jury could infer that the pharmacists violated their duty of due care.
These distinctions can be illustrated by our prior cases on the duties of health care professionals. In Gates v. Jensen, 92 Wn.2d 246, 595 P.2d 919 (1979) we recognized a duty to warn distinct from the general health care professional's duty of due care. The plaintiff had offered a jury instruction which read in part:
*726"You are instructed that an ophthalmologist has a duty to advise his patient of all relevant, material information concerning the condition of the patient's eyes that the patient will need to make an informed decision respecting the alternative methods of examination for eye disease, of the reasonably foreseeable risks of each alternative, and of no such examination at all. Failure to so advise the patient is negligence.
Gates, at 249 n.2. This duty to warn was not part of the duty of due care, but a separate duty grounded in the physician's status as a fiduciary entrusted with the care of the patient's body. Gates, at 250. The majority at times seems to be discussing a duty to warn distinct from the duty of due care, similar to that recognized in Gates. McKee, however, has never arguéd such a theory. Instead, she contends only that there was evidence of a violation of the duty of due care under RCW 7.70.040 sufficient to preclude summary judgment. Aside from its patently flawed contention that RCW 18.64.011(11) defines the standard of care, the majority ignores that question.
The majority at other times seems to be discussing whether the pharmacist violated the standard of due care as a matter of law. That was the ground of our decision in Helling v. Carey, 83 Wn.2d 514, 519, 519 P.2d 981, 67 A.L.R.3d 175 (1974) in which we recognized that, as a matter of law, failure to test for glaucoma in patients under 40 violated the health care professional's duty to exercise reasonable prudence.
Under the facts of this case reasonable prudence required the timely giving of the pressure test to this plaintiff. The precaution of giving this test to detect the incidence of glaucoma to patients under 40 years of age is so imperative that irrespective of its disregard by the standards of the op/rthalmology profession, it is the duty of the courts to say what is required to protect patients under 40 from the damaging results of glaucoma.
We therefore hold, as a matter of law, that the reasonable standard that should have been followed under the undisputed facts of this case was the timely giving of this simple, harmless pressure test to this plaintiff and that, in failing to do so, the defendants were negligent. . .
In Helling, the judgment appealed from had been entered on a jury verdict for defendants, and so the question *727whether the defendant had been negligent as a matter of law was before the court. That question might also be raised by a plaintiff's motion for summary judgment. However, the issue of negligence as a matter of law is not raised by a defendant's motion for summary judgment, such as the one we have here. Where the defendant moves for summary judgment, the plaintiff need only establish that there is an issue of fact for the jury, not that the defendant violated the standard of due care as a matter of law. McKee established that there was a question of fact for the jury as to whether the pharmacist had breached the ordinary negligence standard of due care.
Washington Statutory Law, Regulation, and Policy Considerations Require Imposition of a Pharmacist's Duty To Advise Customers
Two commentators in 1986 pharmacological literature identified Washington as a state that imposes a statutory duty on pharmacists to advise customers regarding prescriptive drugs. Brushwood & Simonsmeier, Drug Information for Patients, 7 J. Legal Med. 279, 302 (1986); Duckworth, The Potential Liability of Pharmacists Arising From Announcements of New Standards and Codes of Practice, 43 Food Drug Cosm. L.J. 1, 3 (1988). This should not be surprising given the definition of "Practice of pharmacy" as found in RCW 18.64.011(11), which provides:
"Practice of pharmacy" includes the practice of and responsibility for: Interpreting prescription orders; the compounding, dispensing, labeling, administering, and distributing of drugs and devices; the monitoring of drug therapy and use; . . . the providing of information on legend drugs which may include, but is not limited to, the advising of therapeutic values, hazards, and the uses of drugs and devices.
(Italics mine.) The use of the phrase "and responsibility for" indicates this definition is more than merely descriptive, hut also speaks to affirmative duties required of a pharmacist.
*728RCW 18.64.005(H)11 empowers the Washington State Board of Pharmacy to
Promulgate rules for the dispensing, distribution, wholesaling, and manufacturing of drugs and devices and the practice of pharmacy for the protection and promotion of the public health, safety, and welfare. Violation of any such rules shall constitute grounds for refusal, suspension, or revocation of licenses or any other authority to practice issued by the board[.]
(Italics mine.)
The regulations adopted by the board are consistent with recognition of RCW 18.64.011(11) as imposing a duty to advise on the pharmacist.
Summary Judgment Should Have Been Denied
The issue is, analyzing all the evidence in the light most favorable to the nonmoving party, is there a genuine issue of material fact for the jury to resolve? Hartley v. State, 103 Wn.2d 768, 774, 698 P.2d 77 (1985). McKee offered sufficient evidence in response to the defendants' motion to create an issue of fact, precluding summary judgment.
Depositions in the case were filed and published in connection with the summary judgment motion. According to the deposition of Mezistrano, one of the respondent pharmacists, Plegine is distributed in bottles of 100 tablets, with a warning attached to the bottle. The warning was based on the Physicians' Desk Reference (hereafter PDR) entry for Plegine. Clerk's Papers, at 749, 756. The PDR and the attached label both stated the warnings quoted above. Clerk's Papers, at 115.
Mezistrano testified that he filled McKee’s prescriptions for Plegine on numerous occasions between 1981 and 1984. Clerk's Papers, at 765-73. Mezistrano believed it is important for a pharmacist to determine whether a drug he dispenses is potentially addictive, but that at the time he dispensed Plegine to McKee, he did not believe that Plegine had such a potential. Clerk's Papers, at 691-93. *729Mezistrano also testified that, to fill a prescription for 100 tablets of Plegine, such as that submitted by McKee, he dispensed the drug in the manufacturer's bottles of 100. While he did not rebottle the medicine, he removed the warnings attached to the bottles by the manufacturer because he thought consumers might misunderstand the information and be frightened by it. Clerk's Papers, at 755, 756, 757-58, 777-78.
Gerald Sidran, the other respondent pharmacist, testified that he filled McKee's prescriptions for Plegine on numerous occasions between 1977 and 1981, when he sold the pharmacy to Mezistrano. Clerk's Papers, at 563-68. He testified that he was aware that McKee had been receiving Plegine for an extended period of time. Clerk's Papers, at 591. He maintained that it is common practice for a pharmacy to fill repeated prescriptions for drugs which the literature recommends should not be taken over a long period of time. Clerk's Papers, at 588-89. This, of course, would be no justification, since the standard of due care under RCW 7.70.040 is reasonable prudence, not customary practice. Harris v. Groth, 99 Wn.2d 438, 444-45, 663 P.2d 113 (1983).
During the period from 1974 to 1984, McKee never weighed more than 138 pounds. She is 5 feet 4 inches tall. Her weight during the 1982-1983 period dropped at one point to 105 pounds. Clerk's Papers, at 292-93, 331-32.
McKee submitted an affidavit of an expert, Dr. Andrew Weil, who was sharply critical of the defendants' conduct, which was included with her response to defendants' motion for summary judgment. Clerk's Papers, at 117-18. Attached to that affidavit was the Curriculum Vitae of Dr. Weil, which shows that Dr. Weil is currently licensed to practice medicine in seven states: Arizona, California, Maryland, Massachusetts, New York, Oregon and Virginia. Dr. Weil states in his affidavit that during his tenure as professor at the University of Arizona, where he has taught for 10 years, he has lectured on the subject of drug abuse at the pharmacy school of the University of Arizona and has lectured to organizations of professional pharmacists *730regarding the duties and responsibilities of pharmacists to their customers. Additionally, Dr. Weil's affidavit demonstrates that he has written several books on the subject of drug abuse which have received national attention and distribution.
Dr. Weil unequivocally states that he is familiar with the duties and standards of care relative to the duties of pharmacists to their customers during the period involved in this case:
3. . . .1 have lectured to organizations of professional pharmacists. The courses which I have taught deal with the duties and responsibilities of pharmacists to their customers and I am familiar with such duties and the standards of care relative to the duties of pharmacists to their customers during the period involved in this case.
(Italics mine.) Clerk's Papers, at 116. Affidavit of Dr. Weil.
Defendants claim the affidavit of Dr. Weil fails to qualify him as an expert capable of rendering an opinion in the present case. For example, they place significance on the fact Dr. Weil was not licensed to practice medicine in the state of Washington nor was he a pharmacist, but the majority cites no authority which would show that an expert has to be licensed in his particular field in Washington in order to qualify as an expert. To the contrary, an expert, if otherwise qualified, need not be licensed to practice his profession in the state of Washington in order to qualify as an expert witness. Walker v. Bangs, 92 Wn.2d 854, 601 P.2d 1279 (1979), involved the qualification of an attorney who was not licensed to practice law in Washington, but who stated in his affidavit that he was a "specialist" in trial work. This court approved the consideration of his testimony on the standard of care applicable to attorneys in Washington. In reversing the lower court's dismissal of the cause for failure to prove negligence, this court held:
Generally, one who holds himself out as specializing and as possessing greater than ordinary knowledge and skill in a particular field, will be held to the standard of performance of those who hold themselves out as specialists in that area. . . .
*731. . . Brotsky's personal participation in trials in a federal district court of the Ninth Circuit in litigation concerning similar maritime personal injury cases would seem to meet the necessary experiential requirements for qualification as an expert witness in this case, and the exclusion of his testimony was error.
Walker, at 860.
Under Harris, the standard of due care is not what the pharmacists' peers would do, but what the public has a right to expect. Harris, at 444-45. Harris encourages the use of expert testimony for the purpose of aiding the jury in "balancing the costs and benefits of a particular procedure and deciding whether it was reasonably prudent." Harris, at 449 n.6. As to this question, the testimony of a physician from this or any other state is entirely relevant and obviously admissible for the purpose of aiding the jury. Dr. Weil in his affidavit testified:
5. In my opinion the drug plegine which possesses the attributes of an amphetamine should never be prescribed by any physician, or be dispensed by any pharmacist, for a period of more than approximately one month. This drug should never, under any circumstances, be given to any person who is not overweight. In my opinion any pharmacist filling a prescription should be aware of the fact that the drug should not be given for a period of more than one month and should be especially aware that this drug should not be dispensed over a long period of time to anyone and especially to a person who is not overweight.
6. In my opinion it was below the standard of care expected of a reasonable and prudent pharmacist acting under the same or similar circumstances (hereinafter "substandard") for Defendants Mezistrano and Sidran (hereinafter the "pharmacists") to dispense the drug plegine to Elaine McKee for the prolonged periods of time it was dispensed to her, under the circumstances of this case. The prescription and prolonged dispensation of this drug over a period of approximately ten years was grossly substandard and inexcusable. Furthermore, in my opinion, the dispensation of this drug caused very serious long term physical and emotional problems to Elaine McKee and was a cause of two suicide attempts by Ms. McKee. The pharmacists in this case had moral and legal duties to advise the patient of the risks of long term therapy with plegine and to make her aware of the side effects and toxicity of the drug when used over long period [s] of time. Their failure to so *732advise Ms. McKee was also substandard and the drug as dispensed, without appropriate warnings and instructions was, in my opinion, dangerous and defective.
6. [7.] In my opinion the pharmacists had a duty to reasonably inform themselves of the dangers of drugs which they dispensed. This duty included a responsibility to become reasonably acquainted with the risks of addiction and long term toxicity of these drugs. Pharmacists also have a duty to inform patients about these risks and to question Physicians about their continued prescriptions of drugs when there is reasonable question about the appropriateness of their prescription and/or the safety of the use of such drugs. In my opinion, the pharmacists in this case failed to reasonably inform themselves of the dangers of the drug plegine and its prolonged use and the risks of addiction and long term toxicity. In my opinion, it was substandard for the pharmacists in this case to fail to advise Elaine McKee of these risks and/or to provide her with the manufacturer's printed warnings relating to plegine.
Clerk's Papers, at 117-18. Affidavit of Dr. Weil.
The drug Plegine is not recommended for persons who are not overweight. In any event, it is not recommended for a period of more than "a few weeks". Those recommendations were clearly stated by the manufacturer on labels which the pharmacists, at least, were aware of. In addition, those recommendations were made in the PDR, the standard reference work for the profession. McKee was obviously not overweight and the pharmacists dispensed Plegine to her for at least 10 years. A jury could have concluded that a reasonably prudent pharmacist would take some action in these circumstances; that he would not dispense drugs which are clearly contraindicated, would warn the consumer that the drug is contraindicated or would specifically discuss the contraindication with the prescribing physician.
The jury could also conclude that the pharmacists violated their statutory duty of due care when they removed the manufacturer's warnings from bottles intended for consumers. Given that the warnings were actually glued onto the consumer-size bottles, the jury could conclude that the warnings were intended for consumers and that a reasonably prudent health care provider, dispensing an obviously *733powerful drug, would have passed that warning on to the consumer. The majority's argument that some manufacturers' warnings do not accompany individual, consumer-size units, and that requiring pharmacists to pass on such warnings would be a hardship, is completely irrelevant. In this case the warnings did accompany individual bottles; consequently, it could never establish the precedent the majority fears.
The majority's reasoning on the issue of warnings illustrates perfectly why the standard of care is a question of fact and not of law. The majority argues that warnings on drugs "could disturb even the most sophisticated patient." Majority, at 719 (quoting Curran, Package Inserts for Patients: Informed Consent in the 1980's, 305 New Eng. J. Med. 1564, 1565-66 (1981)). In effect the majority accepts Mezistrano's argument that consumers ought to be protected from alarming facts concerning the drugs their physicians have prescribed. I find this sort of paternalism offensive. Is the majority seriously suggesting that a patient has no right to be informed of the dangers of the medication he takes? It may be that the question is a proper one for the Legislature, but the Legislature has determined in RCW 7.70.040 that it is also a question of fact for juries. The warning should be passed on to the consumer if a reasonably prudent health care provider would do so. McKee produced sufficient evidence here to be entitled to a jury's judgment on that issue.
I believe the jury could determine factually that the pharmacist had a duty to warn that this particular drug should be discontinued after several weeks. But for argument sake, assume there was no duty to warn, did the defendants have the right to destroy the warning of the manufacturer? This is a factual issue and the jury might find that the destruction of the manufacturer's warning to the consumer McKee was negligence.
Had the druggist not intervened, the plaintiff would have received the "few weeks" warning and she possibly would have been spared her ordeal. The drug was dispensed *734directly from the druggist to the consumer—in a small 100-pill container and he could have placed his own label on the capsule container on the opposite side from the manufacturer's label without disturbing it. By what authority did the druggist prevent the consumer from knowing that the drug should only be taken for a few weeks at a time? The cases cited by the majority are factually incorrect as the physician here did not act as a "learned intermediary" between the manufacturer and the client.
The majority concludes its opinion with the startling concession: "We agree pharmacists should have a duty to be alert for patent errors in a prescription, for example: obvious lethal dosages, inadequacies in the instructions, known contraindications, or incompatible prescriptions, and to take corrective measures." (Footnotes omitted.) Majority, at 715.
Isn't knowing that Plegine, an amphetamine, should be prescribed only for several weeks rather than 10 years within the definition of the majority's "obvious lethal dosages, inadequacies in the instructions" or "known contraindications"? Aren't there factual issues on these matters which prevent a summary judgment from being granted?
Conclusion
McKee produced evidence from which a jury could conclude that the pharmacists failed to act in a reasonably prudent manner and that they breached their duty of due care under RCW 7.70.040. For 10 years the pharmacists Sidran and Mezistrano removed labels from the Plegine prescription sold to McKee which would have warned her that the medication she was receiving was not necessary and was endangering her health. Not only did they remove the manufacturer's warning, the pharmacists never heeded the warning themselves and never took steps to warn McKee verbally of the drug's possible side effects or the recommendation that the drug should be discontinued after several weeks. Their failure was repeated, not over a few weeks or a few months, but for 10 years. Since McKee's *735evidence was clearly sufficient to go to the jury on the issue of statutory due care, the trial court erred in granting the pharmacists' motion for summary judgment.
I would reverse and remand for trial.
Utter and Brachtenbach, JJ., and Pearson, J. Pro Tern., concur with Dore, J.

In 1989 RCW 18.64.005(11) was amended. There were no textual changes, but that statute now appears as RCW 18.64.005(7).