Court Opinion

ID: 3043563
Source: CourtListenerOpinion
Date Created: 2015-10-13 23:11:41.944038+00
Date Added: 2024-06-11T11:49:02.886213
License: Public Domain

Case: 13-13067      Date Filed: 11/10/2014     Page: 1 of 63

                                                                               [PUBLISH]

                 IN THE UNITED STATES COURT OF APPEALS

                           FOR THE ELEVENTH CIRCUIT
                             ________________________

                                   No. 13-13067
                             ________________________

                         D.C. Docket No. 1:13-cv-20090-JAL

PATRICIA FRANZA,
as Personal Representative of the Estate of
Pasquale F. Vaglio,

                                                                     Plaintiff - Appellant,

                                          versus

ROYAL CARIBBEAN CRUISES, LTD.,
a Liberian corporation,

                                                                    Defendant - Appellee.

                             ________________________

                     Appeal from the United States District Court
                         for the Southern District of Florida
                           ________________________

                                  (November 10, 2014)

Before MARCUS and ANDERSON, Circuit Judges, and GOLDBERG, * Judge.

*
  Honorable Richard W. Goldberg, United States Court of International Trade Judge, sitting by
designation.
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MARCUS, Circuit Judge:

      In this maritime negligence dispute, an elderly cruise ship passenger fell and

bashed his head while the vessel, the “Explorer of the Seas,” was docked at port in

Bermuda. The injured traveler, Pasquale Vaglio, was wheeled back onto the ship,

where he sought treatment from the onboard medical staff in the ship’s designated

medical center. Over the next few hours, Vaglio allegedly received such negligent

medical attention that his life could not be saved. In particular, the ship’s nurse

purportedly failed to assess his cranial trauma, neglected to conduct any diagnostic

scans, and released him with no treatment to speak of. The onboard doctor, for his

part, failed even to meet with Vaglio for nearly four hours. Tragically, Vaglio died

about a week later. Now, Vaglio’s daughter, appellant Patricia Franza, seeks to

hold the cruise line, Royal Caribbean Cruises, Ltd. (“Royal Caribbean”),

vicariously liable for the purported negligence of two of its employees, the ship’s

doctor and its nurse, under one of two theories: actual agency (also termed

respondeat superior) or apparent agency.

      Franza commenced this suit against Royal Caribbean in the United States

District Court for the Southern District of Florida under 28 U.S.C. § 1333 and the

general maritime law, but the district court dismissed her complaint in its entirety.

First, in disposing of Franza’s actual agency claim, the trial court applied a

longstanding rule set forth most prominently in Barbetta v. S/S Bermuda Star, 848

                                           2
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F.2d 1364 (5th Cir. 1988). Although the general maritime law of the United States

has long embraced the principles of agency law, the so-called “Barbetta rule”

immunizes a shipowner from respondeat superior liability whenever a ship’s

employees render negligent medical care to its passengers. The rule confers this

broad immunity no matter how clear the shipowner’s control over its medical staff

or how egregious the claimed acts of negligence. Separately, the trial court

dismissed Franza’s apparent agency claim as inadequately pled.

      On appeal, Franza raises two questions of first impression. No binding

precedent in this Court or in its predecessor, the former Fifth Circuit Court of

Appeals, decided whether a passenger might invoke the principles of actual

agency, or those of apparent agency, to impute to a cruise line liability for the

medical negligence of its onboard nurse and doctor. After thorough review, we

hold that both theories are available in this case. We have repeatedly emphasized

that vicarious liability raises fact-bound questions, and we can discern no sound

reason in law to carve out a special exemption for all acts of onboard medical

negligence. Much has changed in the quarter-century since Barbetta. As we see it,

the evolution of legal norms, the rise of a complex cruise industry, and the

progression of modern technology have erased whatever utility the Barbetta rule

once may have had. We thus decline to adopt the Barbetta rule, and find that the

complaint in this case plausibly establishes a claim against Royal Caribbean under

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the doctrine of actual agency, as well as a claim under the principles of apparent

agency. Accordingly, we reverse and remand for further proceedings consistent

with this opinion.

                                          I.

      When we review a dismissal granted under Federal Rule of Civil Procedure

12(b)(6) for failure to state a claim, we accept the well-pled allegations in the

complaint and construe them in the light most favorable to the plaintiff. Chaparro

v. Carnival Corp., 693 F.3d 1333, 1335 (11th Cir. 2012) (per curiam). Viewed

through this lens, the facts as pled and the procedural history are straightforward.

      On July 23, 2011, Pasquale Vaglio was a passenger aboard the “Explorer of

the Seas,” a cruise ship owned and operated by Royal Caribbean. Compl. ¶¶ 9; 8.

Together with his wife and family, id. ¶¶ 11, 13, Vaglio traveled with Royal

Caribbean to a port-of-call in Bermuda. After the ship docked in Bermuda early in

the morning, Vaglio fell while boarding a trolley “at or near the dock” and suffered

a severe blow to the head. Id. ¶ 10. Although Vaglio “could have easily been

referred ashore for . . . examination, evaluation and treatment,” id. ¶ 44, he was

instead “taken in a wheelchair to the ship’s infirmary,” id. ¶ 11. In fact,

notwithstanding other treatment options, Vaglio allegedly “was required to go to

the ship’s medical center to be seen for his injuries.” Id. ¶ 35 (emphasis added).

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      Vaglio first entered the ship’s infirmary at about 10:00 a.m. Id. ¶ 11. No

physician examined him at that time; rather, Racquel Y. Garcia, a nurse allegedly

employed full-time by Royal Caribbean, performed the first relevant medical

evaluation. Id. Nurse Garcia knew about the trolley accident, and indeed she

observed a lump and an abrasion on Vaglio’s head. Id. Nevertheless, without

administering or even recommending any diagnostic scans, Nurse Garcia advised

Vaglio and his wife that Vaglio “was fine to return to his cabin.” Id. ¶ 11.

Cautioning only “that [Vaglio] might have a concussion,” the nurse instructed

Vaglio’s wife to keep an eye on her husband’s condition. Id. Vaglio received no

“further care or treatment” during this first visit to the ship’s infirmary. Id.

Instead, “relying on the advice of the ship’s medical personnel,” the Vaglios

returned to their cabin at around 10:45 a.m. Id. ¶ 12.

      Ninety minutes later, at about 12:15 p.m., Vaglio’s son and daughter-in-law

“noted a deterioration in [Vaglio’s] status.” Id. ¶ 13. Concerned, his daughter-in-

law called 911, but it took approximately twenty minutes for “someone [to]

arrive[ ] with a wheelchair to transport Mr. Vaglio to the infirmary.” Id.

According to the complaint, Vaglio then encountered another delay: the onboard

medical staff would not examine Vaglio until the ship’s personnel obtained credit

card information. Id. ¶ 14.

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       At about 1:45 p.m., nearly four hours after his first visit to the ship’s

infirmary, Vaglio was finally evaluated by the “ship’s physician,” Dr. Rogelio

Gonzales.      Id. ¶¶ 7, 15.       Like Nurse Garcia, Dr. Gonzales was allegedly an

employee of Royal Caribbean. Id. ¶ 7. During his examination, Dr. Gonzales

started a Mannitol drip and ordered that Vaglio be transferred to King Edward

Memorial Hospital in Bermuda “for further care and treatment.” Id. ¶ 15. Vaglio

arrived at the Bermudian hospital at approximately 4:22 p.m., about two-and-a-half

hours after his only meeting with Dr. Gonzales, and more than six hours after he

was first examined by Nurse Garcia. Id. ¶ 16. By that time, Vaglio’s life was

beyond saving. Id. On July 24, 2011, the day after his deadly fall, Vaglio was

airlifted to Winthrop-University Hospital in Mineola, New York. Id. ¶ 17. There

he remained in intensive care until he died one week later.

       On January 10, 2013, Patricia Franza, Vaglio’s daughter and the personal

representative of his estate, initiated this suit under 28 U.S.C. § 1333 and the

general maritime laws of the United States. 1 Notably, Franza did not attempt to

sue any of the relevant medical personnel directly. Instead, she filed a three-count

complaint solely against Royal Caribbean, and she continues to press two of her

1
 In relevant part, 28 U.S.C. § 1333 provides: “The district courts shall have original jurisdiction,
exclusive of the courts of the States, of . . . [a]ny civil case of admiralty or maritime jurisdiction,
saving to suitors in all cases all other remedies to which they are otherwise entitled.”

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three claims on appeal. 2 Both remaining counts charge Royal Caribbean with the

negligence of its onboard medical personnel, and both counts arise from the same

nine categories of allegedly negligent conduct: (1) “failing to properly assess

[Vaglio’s] condition”; (2) “allowing a nurse to make the initial assessment”; (3)

“failing to have a doctor assess [Vaglio]”; (4) “failing to timely diagnose and

appropriately treat [Vaglio]”; (5) “failing to order appropriate diagnostic scans to

further assess the degree of injury”; (6) “failing to obtain consultations with

appropriate specialists”; (7) “failing to properly monitor [Vaglio]”; (8) “failing to

evacuate [Vaglio] from the vessel for further care in a timely manner”; and (9)

“deviating from the standard of care for patients in Mr. Vaglio’s circumstances

who had suffered a significant blow to the head.” Id. ¶ 20.

       Franza ascribed this misconduct to Royal Caribbean in two ways. First,

Franza invoked the doctrine of actual agency, alleging that Royal Caribbean was

negligent “by and through the acts of its employees or agents.” Id. In the

alternative, she argued that Royal Caribbean was liable “under the theory of

apparent agency,” id. ¶ 40, because the cruise line purportedly “manifested to

[Vaglio] . . . that its medical staff . . . were acting as its employees and/or actual

agents,” id. ¶ 28, and Vaglio, in turn, “relied to his detriment on his belief that the

2
  Franza’s complaint contained one count of “negligent hiring, retention[,] and training by [Royal
Caribbean].” Compl. ¶¶ 41-46. On appeal, however, Franza has specifically abandoned that
claim.
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physician and nurse were direct employees or actual agents of [Royal Caribbean].”

Id. ¶ 38.

       On May 30, 2013, the district court granted Royal Caribbean’s motion to

dismiss. Franza v. Royal Caribbean Cruises, Ltd., 948 F. Supp 2d 1327 (S.D. Fla.

2013). The trial court addressed Franza’s actual agency claim separately from the

one based on apparent agency. The court dismissed the actual agency count as a

matter of law and with prejudice. Specifically, the district court applied the

Barbetta rule to conclude that Franza’s actual agency claim was “predicated on

duties of care which are not recognized under maritime law.” Id. at 1331. Next,

although acknowledging that some courts had applied the doctrine of apparent

agency in similar cases, the district court dismissed Franza’s apparent agency

claim as inadequately pled. In particular, the trial court determined that Franza had

not plausibly claimed that Vaglio ever relied on the appearance of an agency

relationship. Id. at 1332-33.3 Following the holding in Barbetta, the district court

had no occasion to address whether Franza had sufficiently alleged the fact of

negligence, and did not consider whether Franza had plausibly pled the requisite

indicia of control that might have justified imputing liability to Royal Caribbean

for its employees’ wrongful acts. Franza timely appealed.

                                              II.

3
 Though the district court gave Franza leave to amend her allegations of apparent agency,
Franza elected not to do so.
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       We review de novo the district court’s dismissal for failure to state a claim

under Rule 12(b)(6), examining Franza’s allegations in the light most favorable to

the plaintiff. Hill v. White, 321 F.3d 1334, 1335 (11th Cir. 2003) (per curiam).

“To survive a motion to dismiss, a complaint must contain sufficient factual

matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’”

Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S. Ct. 1937, 1949 (2009) (quoting Bell

Atlantic Corp. v. Twombly, 550 U.S. 544, 570, 127 S. Ct. 1955, 1974 (2007)).

This standard is met “where the facts alleged enable ‘the court to draw the

reasonable inference that the defendant is liable for the misconduct alleged.’”

Simpson v. Sanderson Farms, Inc., 744 F.3d 702, 708 (11th Cir. 2014) (quoting

Iqbal, 556 U.S. at 678, 129 S. Ct. at 1949). Put differently, “[i]t is sufficient if the

complaint succeeds in ‘identifying facts that are suggestive enough to render [each

required element] plausible.’” Rivell v. Private Health Care Sys., Inc., 520 F.3d
1308, 1310 (11th Cir. 2008) (per curiam) (quoting Watts v. Fla. Int’l Univ., 495
F.3d 1289, 1296 (11th Cir. 2007)).

                                           III.

       On appeal, Franza first challenges the dismissal of her actual agency claim.

Neither the Supreme Court nor this Court has ever decided, in binding precedent,

whether a passenger may hold a shipowner vicariously liable for the medical

negligence of the ship’s employees. In De Zon v. American President Lines, Ltd.,

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the Supreme Court held that a “shipowner was liable in damages for harm suffered

as the result of any negligence on the part of the ship’s doctor.” 318 U.S. 660, 669,

63 S. Ct. 814, 819 (1943). However, the De Zon Court cabined this holding to

apply only where a ship’s doctor breached a shipowner’s special duty to a seaman

-- not a passenger -- under the Jones Act. See id. at 668 (declining to consider

question of liability “in the absence of the Jones Act”).4 Separately, pursuant to

repealed Eleventh Circuit Rule 36-1, this Court once affirmed without opinion a

dismissal order resembling the order at issue here. See Nanz v. Costa Cruises, Inc.,

932 F.2d 977 (11th Cir. 1991) (Table). We are not bound, however, by a table

disposition. See, e.g., U.S. Steel, LLC, v. Tieco, Inc., 261 F.3d 1275, 1280 n.3

(11th Cir. 2001) (“An affirmance pursuant to Rule 36-1 has no precedential

value.”).

                                               A.

       We begin with these basic principles. Federal admiralty jurisdiction flows

from the Constitution itself, see U.S. Const. art. III, § 2 (“The judicial Power shall

extend . . . to all Cases of admiralty and maritime Jurisdiction . . . .”), and “[w]ith

admiralty jurisdiction comes the application of substantive admiralty law.” E.

4
 Although De Zon’s holding clearly applies only to cases involving injuries to seamen, arising
under the Jones Act, Royal Caribbean suggests the Supreme Court implicitly approved the
principles elaborated in Barbetta, since the Court observed that the rule barring suits by
passengers had been developed by “judges of great learning, for courts of last resort of states
having much to do with maritime pursuits.” De Zon v. Am. Pres. Lines, 318 U.S. 660, 666 n.2,
63 S. Ct. 814, 818 (1943). This dicta in no way expressed any view about the wisdom or
efficacy of the Barbetta rule.
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River S.S. Corp. v. Transamerica Delaval Inc., 476 U.S. 858, 864, 106 S. Ct. 2295,

2298-99 (1986). “Absent a relevant statute, the general maritime law, as

developed by the judiciary, applies.” Id. at 2299. Indeed, the Supreme Court has

repeatedly explained in maritime suits that the “Judiciary has traditionally taken

the lead in formulating flexible and fair remedies in the law maritime, and

‘Congress ha[s] largely left to [the Supreme] Court the responsibility for

fashioning the controlling rules of admiralty law.” United States v. Reliable

Transfer Co., 421 U.S. 397, 409, 95 S. Ct. 1708, 1715 (1975) (quoting Fitzgerald

v. U.S. Lines Co., 374 U.S. 16, 20, 83 S. Ct. 1646, 1650 (1963)); see Moragne v.

States Marine Lines, Inc., 398 U.S. 375, 405 n.17, 90 S. Ct. 1772, 1790 (1970)

(noting that courts are not barred from announcing maritime rules simply because

Congress has “not legislat[ed] on [the] subject”); Romero v. Int’l Terminal

Operating Co., 358 U.S. 354, 361, 79 S. Ct. 468, 474 (1959) (explaining that courts

are best equipped “to draw on the substantive law ‘inherent in the admiralty and

maritime jurisdiction’” (quoting Crowell v. Benson, 285 U.S. 22, 55, 52 S. Ct. 285,

294 (1932))); see also 1 Benedict on Admiralty, Ch. VII, § 110 (2014) (stating that

Congress’s maritime authority “is impliedly inherent in or derived from the grant

of the judicial power”).

      The Supreme Court has likewise authorized and directed the lower federal

courts to shape this law, explaining that the Constitution “empowered the federal

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courts,” including “the Tribunals inferior to the Supreme Court,” to “develop[ ]”

the general maritime law. Romero, 358 U.S. at 360-61, 79 S. Ct. at 474 (internal

quotation marks omitted); see, e.g., Transamerica, 476 U.S. at 865, 106 S. Ct. at

2299 (endorsing maritime theory of products liability first adopted by several

circuits); see also Exxon Shipping Co. v. Baker, 554 U.S. 471, 508 n.21, 128 S. Ct.
2605, 2630 (2008) (observing that “modern-day maritime cases . . . support

judicial action to modify a common law landscape largely of [the courts’] own

making”); Edmonds v. Compagnie Generale Transatlantique, 443 U.S. 256, 259,

99 S. Ct. 2753, 2756 (1979) (“Admiralty law is judge-made law to a great extent

. . . .”). In short, we enjoy considerable latitude in maritime cases because, under

the constitutional grant, the “[b]oundaries” of maritime law generally “were to be

determined in the exercise of the judicial power.” The Thomas Barlum, 293 U.S.
21, 43, 55 S. Ct. 31, 38 (1934).

       Congress has not imposed vicarious liability where, as here, a passenger

seeks recovery from a shipowner for the medical negligence of the ship’s

employees.5 Nor has Congress barred the application of vicarious liability in this

5
  In 1882, Congress passed legislation requiring certain passenger ships to carry medical
personnel and to furnish “surgical instruments, medical comforts, and medicines proper and
necessary for diseases and accidents incident to sea-voyages, and for the proper medical
treatment of such passengers during the voyage.” Pub. L. No. 47-374, § 5, 22 Stat. 188 (1882)
(codified at 46 U.S.C. § 155 (1982)). “[T]he services of such surgeon or medical practitioner
[were required to] be promptly given, in any case of sickness or disease, to any of the
passengers . . . who . . . need[ed] his services.” Id. The “master of the vessel” was liable for any
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context. 6 Thus, in addressing Franza’s claims, we are obliged to exercise our

broad discretion in admiralty and maritime to develop this law, just as the Fifth

Circuit did in Barbetta.

       Under the general maritime law, a shipowner traditionally has owed no duty

to practice medicine or to carry a physician on board. See De Zon, 318 U.S. at

668, 63 S. Ct. at 819 (acknowledging that “there may be no duty to the seaman to

carry a physician”).7 Therefore, the shipowner is only liable to its passengers for

medical negligence if its conduct breaches the carrier’s more general duty to

violation of this statute. Id. However, Congress repealed this act in 1983, see Pub. L. No. 98-89,
§ 4(b), 97 Stat. 600 (1983), without ever enacting substitute legislation.
6
  In a few areas of maritime law, Congress has specifically limited the application of agency
principles. See, e.g., 33 U.S.C. § 905(b) (2012) (forbidding third-party suits against shipowners
under Longshore and Harbor Workers’ Compensation Act where injured person was “employed
by the vessel to provide stevedoring services” and “the injury was caused by the negligence of
persons engaged in providing stevedoring services to the vessel”); Hurst v. Triad Shipping Co.,
554 F.2d 1237 (3d Cir. 1977) (tracing Congress’s policy rationale for § 905(b) exception); 46
U.S.C. § 30505(b) (2012) (capping certain maritime liability where shipowner lacks “privity or
knowledge”); Paradise Divers, Inc. v. Upmal, 402 F.3d 1087, 1089-90 (11th Cir. 2005) (per
curiam) (explaining Congress’s policy rationale for § 30505 limitation). As we have observed,
however, no such legislation protects a maritime principal from all vicarious liability in a case
like this one.
7
  Franza suggests, however, that new laws now require cruise ships to carry medical personnel.
She points specifically to one statute, 46 U.S.C. § 3507 (2012), which mandates that cruise ships
provide “medical staff” who possess either a “current physician’s or registered nurse’s license”
to render “medical treatment” to victims of sexual assault. Id. § 3507(d). We do not read this
codification as creating a broad based obligation that ships carry medical personnel onboard in
order to meet the general health needs of their passengers. Franza also argues that many cruise
ships are flagged in the Bahamas, where cruise ships must carry a “duly qualified medical
practitioner.” See Bahamian Merchant Shipping Act § 124. But Franza’s complaint alleges that
Royal Caribbean is a Liberian corporation, Compl. ¶ 5, and does not specify where the “Explorer
of the Seas” is flagged. Nor, finally, is it otherwise clear what impact a Bahamian statute would
have on a cruise ship’s obligations arising under the general maritime law of the United States.
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exercise “reasonable care under the circumstances.” Kermarec v. Compagnie

Generale Transatlantique, 358 U.S. 625, 632, 79 S. Ct. 406, 410 (1959). Franza

does not argue that Royal Caribbean violated this duty directly. Rather, she asks

us to hold Royal Caribbean vicariously liable under the doctrine of respondeat

superior, precisely because the ship’s medical employees allegedly failed to treat

her father with appropriate care.

      Though we have never examined whether the principles of vicarious liability

apply to a passenger’s claim for onboard medical negligence, the federal courts

have been especially active in the general area of maritime torts. See Exxon, 554
U.S. at 508 n.21, 128 S. Ct. at 2630 (highlighting “the large part [that courts] have

taken in working out the governing maritime tort principles”). In maritime tort

cases, the federal courts often have: (1) adopted new theories of tort liability, see,

e.g., Transamerica, 476 U.S. at 865, 106 S. Ct. at 2299 (“join[ing] [several circuits]

in recognizing products liability, including strict liability, as part of the general

maritime law”); (2) introduced new causes of action, see, e.g., Am. Export Lines,

Inc. v. Alvez, 446 U.S. 274, 284-86, 100 S. Ct. 1673, 1679-80 (1980) (recognizing

claim for loss of consortium under general maritime law), and Moragne, 398 U.S.
375, 90 S. Ct. 1772 (recognizing cause of action for wrongful death under general

maritime law); and (3) promulgated new remedial rules, see, e.g., McDermott, Inc.

v. AmClyde, 511 U.S. 202, 114 S. Ct. 1461 (1994) (adopting proportionate-fault

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rule for calculation of nonsettling maritime tort defendants’ compensatory

liability).

       Moreover, across well over a century of maritime tort precedent, the

Supreme Court has required maritime principals to answer for the negligence of

their onboard agents. See, e.g., The Kensington, 183 U.S. 263, 268, 22 S. Ct. 102,

104 (1902) (characterizing as “unjust and unreasonable” any attempt by carriers to

contract around “responsibility for the negligence of . . . their servants”); The J.P.

Donaldson, 167 U.S. 599, 603, 17 S. Ct. 951, 953 (1897) (holding shipowner

“responsible for injuries caused to third persons by [the] negligence” of ship’s

captain). These teachings now permeate the general maritime law. See, e.g.,

Langfitt v. Fed. Marine Terminals, Inc., 647 F.3d 1116, 1121 (11th Cir. 2011)

(“[A]n otherwise non-faulty employer [is] vicariously liable for the negligent acts

of its employee acting within the scope of employment.”); Archer v.

Trans/American Servs., Ltd., 834 F.2d 1570, 1573 (11th Cir. 1988) (“Federal

maritime law embraces the principles of agency.”).

       That maritime law has long incorporated the concept of respondeat superior

should come as no surprise. Shipowners, like other principals, exercise real control

over their agents. See, e.g., Barrios v. La. Const. Materials Co., 465 F.2d 1157,

1164 (5th Cir. 1972) (detailing maritime principal’s “control over the operations

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which resulted in the injury to [plaintiff]”). 8 In maritime cases, as elsewhere, we

therefore think it “manifestly just” to hold principals responsible for the conduct

they command from their employees. Sony Corp. of Am. v. Universal City

Studios, Inc., 464 U.S. 417, 437, 104 S. Ct. 774, 786 (1984); see Restatement

(Second) of Agency § 219 cmt. a (“[F]rom [the acknowledgment of a principal’s

right of control], the idea of responsibility for the harm done by the servant’s

activities follow[s] naturally.”).

       Thus, we have regularly permitted passengers to invoke respondeat superior

in maritime negligence suits.9 In Suzuki of Orange Park, Inc. v. Shubert, for

example, a passenger in a watercraft was struck by another recreational vessel on a

slalom course. 86 F.3d 1060, 1061-62 (11th Cir. 1996). In addressing the question

of liability, we observed that the corporate owner of the watercraft could be

“vicariously liable under principles of respondeat superior” if the passenger’s

injury were negligently inflicted by a driver “acting on [the owner’s] behalf.” Id.

at 1066 & n.5 (emphasis omitted). In Gibboney v. Wright, two minor passengers

8
 In Bonner v. City of Prichard, 661 F.2d 1206, 1209 (11th Cir. 1981) (en banc), we adopted as
binding precedent all Fifth Circuit decisions issued before October 1, 1981.
9
 Additionally, our admiralty precedent is rife with cases holding principals vicariously liable
under respondeat superior for injuries negligently inflicted by agents to agents. See, e.g., In re
Dearborn Marine Serv., Inc., 499 F.2d 263, 284-86 (5th Cir. 1974); Barrios, 465 F.2d at 1164;
Tri-State Oil Tool Indus., Inc. v. Delta Marine Drilling Co., 410 F.2d 178, 187 (5th Cir. 1969).
Because liability is sometimes complicated by statutory concerns in this related context,
however, we separately collect these cases only to demonstrate the broad salience of respondeat
superior in our admiralty precedent.
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aboard a borrowed racing sloop were injured in a flash fire caused by an

improperly secured fuel tank. 517 F.2d 1054, 1055-56 (5th Cir. 1975). There, the

former Fifth Circuit discerned “ample basis under familiar maritime principles to

impute [the] negligence [of both the vessel’s manufacturer and a marine surveyor]

to [the shipowner,] so far as liability [for injury to the passengers] [was]

concerned.” Id. at 1059. And in Ramjak v. Austro-American S.S. Co., the former

Fifth Circuit found a shipowner vicariously liable where a seaman -- “in a spirit of

ostentation and bravado” -- negligently climbed the ship’s mast and fell onto a

passenger. 186 F. 417, 418 (5th Cir. 1911); see also Doe v. Celebrity Cruises, Inc.,

394 F.3d 891, 908, 913 (11th Cir. 2004) (citing Restatement (Second) of Agency

and holding cruise line strictly liable for crew member assaults on passengers).

Quite simply, our precedent has long allowed passengers to invoke the doctrine of

respondeat superior in a diverse medley of maritime tort disputes.

      We do not stand alone in this. Our sister circuits, too, have generally applied

agency principles to impute liability in maritime tort cases. See Matheny v. Tenn.

Valley Auth., 557 F.3d 311, 315 (6th Cir. 2009) (accepting concession that tugboat

owner was liable for third-party death caused by tugboat captain’s negligence);

CEH, Inc. v. F/V Seafarer, 70 F.3d 694, 705 (1st Cir. 1995) (holding shipowner

“vicarious[ly] liabl[e]” where captain was shipowner’s “agent” who sabotaged

third-party lobstering operation); McDonough v. Royal Caribbean Cruises, Ltd., 48

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F.3d 256, 258 (7th Cir. 1995) (holding cruise line vicariously liable where steward

pushed dolly over passenger’s foot); Jackson Marine Corp. v. Blue Fox, 845 F.2d
1307, 1310 (5th Cir. 1988) (applying “general agency principles” to impute

captain’s fraud on third-party to shipowner); De Los Santos v. Scindia Steam

Navigation Co. Ltd., 598 F.2d 480, 489 (9th Cir. 1979) (explaining that shipowner

could incur liability under respondeat superior if crewmembers knew of allegedly

defective condition that injured plaintiff); Pritchett v. Kimberling Cove, Inc., 568
F.2d 570, 579 (8th Cir. 1977) (holding boat owner “vicariously” liable where

owner’s “agent” negligently entrusted boat to minor who injured passengers in

second boat); Ira S. Bushey & Sons, Inc. v. United States, 398 F.2d 167, 171-72

(2d Cir. 1968) (holding United States vicariously liable to third-party dry-dock

owner after Coast Guardsman negligently caused dry-dock to sink); see also

Landstar Express Am., Inc. v. Fed. Mar. Comm’n, 569 F.3d 493, 498 (D.C. Cir.

2009) (using “common law agency principles” to interpret Shipping Act of 1984);

Servis v. Hiller Sys. Inc., 54 F.3d 203, 207 (4th Cir. 1995) (interpreting Suits in

Admiralty Act in light of “basic principles of agency law” and Restatement

(Second) of Agency); Peter v. Hess Oil Virgin Islands Corp., 903 F.2d 935, 940

(3d Cir. 1990) (construing Longshore and Harbor Workers’ Compensation Act to

incorporate “borrowed servant doctrine”); Bartlett-Collins Co. v. Surinam

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Navigation Co., 381 F.2d 546, 550 (10th Cir. 1967) (commenting in admiralty case

that “existence of an agency is a question to be decided by the trier of the fact”).

          Thus, even absent any statutory mandate, the Supreme Court and all of the

federal circuits have for many years generally applied agency rules across a rich

array of maritime cases. Against this dynamic backdrop, Franza makes only a

modest request. We can see nothing inherent in onboard medical negligence, when

committed by full-time employees acting within the course and scope of their

employment, that justifies suspending the accepted principles of agency.

Certainly, nothing in our case law creates -- or even suggests -- a bright-line zone

of immunity for the onboard negligence of a cruise ship’s medical employees.

          We acknowledge, however, that other circuits have long barred vicarious

liability in this particular context. See Barbetta, 848 F.2d at 1372 (“[G]eneral

maritime law does not impose liability under the doctrine of respondeat superior

upon a carrier or ship owner for the negligence of a ship’s doctor who treats the

ship’s passengers.”); accord The Great Northern, 251 F. 826, 832 (9th Cir. 1918);

The Korea Maru, 254 F. 397, 399 (9th Cir. 1918); cf. Cummiskey v. Chandris,

S.A., 895 F.2d 107, 108 (2d Cir. 1990) (per curiam) (citing Barbetta and

“declin[ing] the invitation to break with maritime precedent” “on the facts before

[the court]”). 10 In effect, these cases stand for the sweeping proposition that no

10
     Several district courts within this Circuit have extended this principle to protect carriers from
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conceivable set of facts could ever justify holding a shipowner vicariously liable

when a passenger receives negligent medical care aboard its ship. We remain

unpersuaded.

       Instead, we think it more accurate to say that, absent any statutory mandate

to the contrary, the existence of an agency relationship is a question of fact under

the general maritime law. See Naviera Neptuno S.A. v. All Int’l Freight

Forwarders, Inc., 709 F.2d 663, 665 (11th Cir. 1983) (“[T]he existence of an

agency relationship is a question of fact.”); accord Garanti Finansal Kiralama A.S.

v. Aqua Marine & Trading Inc., 697 F.3d 59, 71 (2d Cir. 2012) (same); Hawkspere

Shipping Co., Ltd. v. Intamex, S.A., 330 F.3d 225, 236 (4th Cir. 2003) (observing

that existence of agency relationship presents “triable issue of fact”); Chan v.

Soc’y Expeditions, Inc., 39 F.3d 1398, 1406 (9th Cir. 1994) (noting that existence

of agency relationship “is a question of fact”); Equilease Corp. v. M/V Sampson,

756 F.2d 357, 363 (5th Cir. 1985) (“The existence of any agency relationship is a

question of fact . . . .” (emphasis added)); Bartlett-Collins, 381 F.2d at 550 (“[T]he

existence of an agency is a question to be decided by the trier of the fact.”). Thus,

as we see it, at the pleading stage, a passenger must allege “sufficient facts to

render it facially plausible that . . . an agency relationship [is] . . . present.” Bamert

liability for the actions of ships’ nurses, as well as their doctors. See, e.g., Hajtman v. NCL
(Bahamas) Ltd., 526 F. Supp. 2d 1324, 1327-28 (S.D. Fla. 2007); Jackson v. Carnival Cruise
Lines, Inc., 203 F. Supp. 2d 1367, 1374-76 (S.D. Fla. 2002); Stires v. Carnival Corp., 243 F.
Supp. 2d 1313, 1318 (M.D. Fla. 2002).
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v. Pulte Home Corp., 445 F. App’x 256, 265 (11th Cir. 2011) (citing Davila v.

Delta Air Lines, Inc., 326 F.3d 1183, 1185 (11th Cir. 2003)). In cases of medical

malpractice, as in other maritime respondeat superior cases, the essential element

of the relationship is the principal’s control over its agents.

      Plainly, under the ordinary rules of agency, the allegations in Franza’s

complaint support a finding that Nurse Garcia and Dr. Gonzales were agents of

Royal Caribbean. According to our unambiguous precedent, an agency

relationship requires: “(1) the principal to acknowledge that the agent will act for

it; (2) the agent to manifest an acceptance of the undertaking; and (3) control by

the principal over the actions of the agent.” Whetstone Candy Co. v. Kraft Foods,

Inc., 351 F.3d 1067, 1077 (11th Cir. 2003). Franza adequately alleged each of

these elements.

      For starters, Franza’s complaint plausibly established: (1) that Royal

Caribbean “acknowledged” that Nurse Garcia and Dr. Gonzales would act on its

behalf, and (2) that each “accepted” the undertaking. Most importantly, Franza

specifically asserted that both medical professionals were “employed by” Royal

Caribbean, were “its employees or agents,” and were “at all times material acting

within the scope and course of [their] employment.” Compl. ¶¶ 6, 7, 20.

Furthermore, the cruise line directly paid the ship’s nurse and doctor for their work

in the ship’s medical center. Id. ¶ 28. Third, the medical facility was created,

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owned, and operated by Royal Caribbean, id., whose own marketing materials

described the infirmary in proprietary language, see id. (“[T]he doctor and nurse

both worked at what [Royal Caribbean] describes in its advertising as its medical

centers[.]” (emphasis added and internal quotation marks omitted)). Fourth, the

cruise line knowingly provided, and its medical personnel knowingly wore,

uniforms bearing Royal Caribbean’s name and logo. Id. ¶ 29. And, finally, Royal

Caribbean allegedly represented to immigration authorities and passengers that

Nurse Garcia and Dr. Gonzales were “members of the ship’s crew,” id. ¶¶ 31, 33,

and even introduced the doctor “as one of the ship’s Officers,” id. ¶ 30. Taken as

true, these allegations are more than enough to satisfy the first two elements of

actual agency liability.

      Moreover, the facts alleged in Franza’s complaint plausibly demonstrate that

Royal Caribbean exercised “control” over the ship’s medical personnel. See

Whetstone, 351 F.3d at 1077. As we have explained, control is the fulcrum of

respondeat superior. We have recognized the following considerations as

“probative” of control in the maritime context: “(1) direct evidence of the

principal’s right to or actual exercise of control; (2) the method of payment for an

agent’s services, whether by time or by the job; (3) whether or not the equipment

necessary to perform the work is furnished by the principal; and (4) whether the

principal had the right to fire the agent.” Langfitt, 647 F.3d at 1121. Franza’s

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complaint plausibly supports a finding of control under at least three of these four

factors.

      To begin with, Franza alleged substantial “direct evidence” of Royal

Caribbean’s “right to control” Nurse Garcia and Dr. Gonzales. Id. The onboard

medical personnel were: (1) “employed by” Royal Caribbean, Compl. ¶¶ 6, 7; (2)

hired to work in a facility that the cruise line “owned and operated,” id. ¶ 28; (3)

paid directly by the cruise line, id.; (4) considered to be members of the ship’s

“crew,” id. ¶ 31, 33; and (5) “required” to wear uniforms furnished by Royal

Caribbean, id. ¶ 29. Additionally, the cruise line “put the ship’s physician and

nurse under the command of the ship’s superior officers.” Id. ¶ 32 (emphasis

added). At the pleading stage, these allegations offer considerable “direct

evidence” of the cruise line’s “right to control” its medical staff.

      Franza’s specific assertions about the ship’s “method of payment” bolster

her claim that Royal Caribbean controlled its onboard medical personnel. See

Langfitt, 647 F.3d at 1121. Franza alleged that Royal Caribbean paid “salaries” to

the ship’s medical staff. Compl. ¶ 28. This compensation structure normally

suggests an agency relationship, since payment is “by time” and not “by the job.”

Langfitt, 648 F.3d at 1121; see Restatement (Second) of Agency § 220 cmt. h

(observing that “payment by hour or month” indicates “the relation of master and

servant”). Additionally, onboard passengers are allegedly “billed directly by

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[Royal Caribbean] through the passengers’ Sign and Sail Card.” Compl. ¶ 28.

Thus, the cruise line exercises complete control over any funds that might

otherwise have flowed directly from the passengers to the medical professionals in

consideration of treatment rendered.

      Finally, Royal Caribbean allegedly “pays to stock the ‘medical centers’ with

all supplies, various medicines and equipment,” id. ¶ 28, which lends further

support to a finding of control by the cruise line. See Langfitt, 648 F.3d at 1121

(finding agency more likely where “the equipment necessary to perform the work

is furnished by the principal”). Franza did not specifically allege whether Royal

Caribbean had the “right to fire” its onboard medical personnel, and thus her

complaint does not directly address the fourth factor indicating control under

Langfitt. Nevertheless, as we have seen, Franza did assert that Nurse Garcia and

Dr. Gonzales were “member[s] of the crew,” Compl. ¶ 31, 33, who were “under

the command of the ship’s superior officers,” id. ¶ 32. Presumably, the company

maintains the authority to fire crewmembers. See Robert D. Peltz, Has Time

Passed Barbetta by?, 24 U.S.F. Mar. L.J. 1, 31 (2012) (noting that “[t]ypical

employment agreements give the cruise line the right to terminate the shipboard

doctor’s employment”) [hereinafter Peltz, Has Time Passed Barbetta by?].

      Royal Caribbean urges us to look beyond the complaint, to Vaglio’s

passenger ticket contract, which the cruise line attached to its motion to dismiss

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and which purports to limit the ship’s liability for onboard medical services.

According to Royal Caribbean, the contract makes clear that onboard medical

personnel are independent contractors, not employees or agents. At this early stage

in the proceedings, however, we decline to consider the passenger ticket contract

for three reasons. First, Franza did not attach the ticket contract to the complaint.

Second, the complaint makes no mention of the contract. See Bickley v. Caremark

Rx, Inc., 461 F.3d 1325, 1329 n.7 (11th Cir. 2006) (permitting court to consider

defendant’s exhibits only if “the plaintiff refers to certain documents in the

complaint and those documents are central to the plaintiff’s claim” (internal

quotation marks and citation omitted)); Hoffman-Pugh v. Ramsey, 312 F.3d 1222,

1225 (11th Cir. 2002) (same); see also Fin. Sec. Assurance, Inc. v. Stephens, Inc.,

500 F.3d 1276, 1284 (11th Cir. 2007) (considering materials beyond complaint and

its exhibits where plaintiff referred to document in complaint, document was

central to claim, contents were undisputed, and defendant attached document to

motion to dismiss). Finally, even if we were to look to the contract at this stage,

we would not consider the nurse and doctor to be independent contractors simply

because that is what the cruise line calls them. See, e.g., Cantor v. Cochran, 184
So. 2d 173, 174 (Fla. 1966) (“While the obvious purpose to be accomplished by

this document was to evince an independent contractor status, such status depends

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not on the statements of the parties but upon all the circumstances of their dealings

with each other.”).11

       On balance, then, Franza’s complaint unambiguously establishes an agency

relationship between the employer, Royal Caribbean Cruises, Ltd., and its full-time

employees, Nurse Garcia and Dr. Gonzales. Nothing in the complaint suggests

that these medical professionals somehow acted outside the scope and course of

their employment or that the requisite control was missing. Thus, applying the

standard principles of agency, we are compelled to hold that Franza’s complaint

sets out a plausible basis for imputing to Royal Caribbean the allegedly negligent

conduct of its onboard medical employees.

                                                B.

       We decline to adopt the rule explicated in Barbetta, because we can no

longer discern a sound basis in law for ignoring the facts alleged in individual

medical malpractice complaints and wholly discarding the same rules of agency

that we have applied so often in other maritime tort cases.12 No decision of the

11
  Additionally, we note that the ticket contract arguably is internally inconsistent: at one point
the contract actually discusses medical personnel and independent contractors in the alternative,
see Mot. to Dismiss Ex. A, Franza v. Royal Caribbean Cruises, Ltd., 13-20090-CIV (S.D. Fla.
Feb. 4, 2013), at 2 (“To the extent Passengers retain the services of medical personnel or
Independent contractors . . . .” (emphasis added)), seemingly suggesting that medical personnel
are not independent contractors.
12
  Several courts have already rejected or cast doubt upon the majority rule enunciated by the
Fifth Circuit in Barbetta. See, e.g., Huntley v. Carnival Corp., 307 F. Supp. 2d 1372, 1374-75
(S.D. Fla. 2004) (declining to apply majority rule); Nietes v. Am. President Lines, Ltd., 188 F.
26
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Supreme Court or this Court binds us to the strictures of Barbetta, and though we

do not lightly deviate from a rule applied widely and for many years by other

federal courts, we are now reluctant to endorse the approach taken by the Fifth,

Ninth, and Second Circuits. As Justice Holmes famously put it, we should not

follow a rule of law simply because “it was laid down in the time of Henry IV,”

particularly where “the grounds upon which it was laid down have vanished long

since, and the rule simply persists from blind imitation of the past.” Oliver

Wendell Holmes, The Path of the Law, 10 Harv. L. Rev. 457, 469 (1897).13

       When we exercise our broad admiralty jurisdiction, “our experience and new

conditions [sometimes] give rise to new conceptions of maritime concerns.” The

Thomas Barlum, 293 U.S. at 52, 55 S. Ct. at 41-42. Here, the roots of the Barbetta

rule snake back into a wholly different world. Instead of nineteenth-century

Supp. 219, 220-21 (N.D. Cal. 1959) (same); Mack v. Royal Caribbean Cruises, Ltd., 838 N.E.2d
80, 91(Ill. App. Ct. 2005) (same); see also Lobegeiger v. Celebrity Cruises, Inc., 11-21620-CIV,
2011 WL 3703329 at *9 n.8 (S.D. Fla. Aug. 23, 2011) (noting weakness in majority rule);
Fairley v. Royal Cruise Line, Ltd., 1993 A.M.C. 1633 (S.D. Fla. 1993) (same); Carnival Corp. v.
Carlisle, 953 So. 2d 461, 469-70 (Fla. 2007) (same).
13
  Royal Caribbean argues that we must follow Barbetta in order to preserve the uniformity of
maritime law. See Appellee’s Br. at 20-24. Uniformity is a powerful and motivating concern in
federal admiralty jurisdiction. See, e.g., So. Pac. Co. v. Jensen, 244 U.S. 205, 216, 37 S. Ct. 524,
529 (1917), superceded by statute, 69 Pub. L. 803, 44 Stat. 1424 (1927), codified as amended at
33 U.S.C. § 901 et seq., (highlighting “the proper harmony and uniformity of” maritime law).
However, the federal admiralty interest in uniformity is not a stare decisis command. Moreover,
the Supreme Court introduced the principles of uniformity and harmony specifically to prevent
undue encroachment upon national maritime law by the several states. See, e.g., Romero, 358
U.S. at 373, 79 S. Ct. at 480 (“[S]tate law must yield to the needs of a uniform federal maritime
law when this Court finds inroads on a harmonious system.”); see also Mink v. Genmar Indus.,
Inc., 29 F.3d 1543, 1548 (11th Cir. 1994) (characterizing “federal [maritime] interest in
uniformity” as “a reverse-Erie doctrine”).
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steamships, see, e.g., Barbetta, 848 F.2d at 1369 (citing O’Brien v. Cunard S.S.

Co., 28 N.E. 266, 267 (Mass. 1891)), we now confront state-of-the-art cruise ships

that house thousands of people and operate as floating cities, complete with well-

stocked modern infirmaries and urgent care centers. In place of truly independent

doctors and nurses, we must now acknowledge that medical professionals routinely

work for corporate masters. And whereas ships historically went “off the grid”

when they set sail, modern technology enables distant ships to communicate

instantaneously with the mainland in meaningful ways. In short, despite its

prominence, the Barbetta rule now seems to prevail more by the strength of inertia

than by the strength of its reasoning. See United States v. Reliable Transfer Co.,

421 U.S. 397, 410, 95 S. Ct. 1708, 1715 (1975). In our view, “[t]he reasons that

originally led” other courts to adopt “the rule have long since disappeared.” See

id. The rule rests on three basic arguments that a shipowner cannot exercise

meaningful control over its medical staff. But as we see it, none withstands close

scrutiny. We address each in turn.

                                          1.

      The first pillar is the claim that any doctor-patient (or nurse-patient)

relationship, whether on land or at sea, precludes vicarious liability by its very

“nature.” Barbetta, 848 F.2d at 1369. Historically, courts have offered two

separate arguments to explain why no third-party principal could ever

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meaningfully control the conduct of a medical professional and, therefore, no

liability could be vicariously imposed. Nowadays, however, the great majority of

American common law courts have disavowed this categorical liability exception

and each of the rationales that once compelled it.

                                          a.

      Traditionally, courts insulated medical professionals from vicarious liability

simply because of the professionals’ special skills and independent judgment.

Essentially, these courts reasoned that, as a policy matter, highly trained medical

practitioners would and should freely use their own best judgment. Thus, the

courts decided as a matter of law that employers could not exercise control over

doctors to the extent necessary to establish an agency relationship. See, e.g.,

Parsons v. Yolande Coal & Coke Co., 91 So. 493, 495 (Ala. 1921) (barring

vicarious liability because doctor “renders services requiring such training, skill,

and experience, the exercise of which must be in accordance with his best

judgment and without interference”); Schloendorff v. Soc’y of N.Y. Hosp., 105
N.E. 92, 94 (N.Y. 1914) (Cardozo, J.) (precluding vicarious liability because

medicine was “an independent calling . . . sanctioned by a solemn oath”); Pearl v.

W. End St. Ry. Co., 57 N.E. 339, 339 (Mass. 1900) (Holmes, C.J.) (finding “no

more distinct calling than that of the doctor, and none in which the employ[ee] is

more distinctly free from the control or direction of his employer”); see also Eads

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v. Borman, 277 P.3d 503, 511 (Or. 2012) (en banc) (noting historical view that

medical professionals, “because of the skill and judgment they exercised,” were

not subject to employer’s “control”).

      Contemporary common law courts, however, have overwhelmingly

abandoned this approach. As a fundamental matter, “[t]he rules for determining

the liability of the employer for the conduct of both superior servants and the

humblest employees are the same,” Restatement (Second) of Agency § 220 cmt. a,

and employers routinely answer for the misconduct of their skilled employees, see,

e.g., Bing v. Thunig, 143 N.E.2d 3, 6 (N.Y. 1957) (objecting that “the special skill

of other employees (such as airplane pilots, locomotive engineers, chemists, to

mention but a few) has never been the basis for denying the application of

respondeat superior”). Informed by this general rule, the courts have come to

recognize that no principled distinction separates medical skill from other

categories of expertise or requires universal immunization from oversight. As one

court observed, “consistent application of the proposition [barring vicarious

liability for medical negligence based on the degree of skill involved] . . . would

require that virtually every professional who is expected to exercise independent

judgment . . . would have to be deemed an independent contractor.” McDonald v.

Hampton Training Sch. for Nurses, 486 S.E.2d 299, 303 (Va. 1997). Such

wholesale immunity has never been the rule.

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      Moreover, as the medical profession has developed, many courts have come

to acknowledge that “an obligation to maintain control of their medical judgment

does not . . . prevent a physician or nurse from becoming a[n] . . . employee.”

Arango v. Reyka, 507 So. 2d 1211, 1214 (Fla. Dist Ct. App. 1987). Unlike

“physicians of the past,” who often functioned as “distinct independent entities and

independent centers of occupation and profession,” today’s medical practitioners

routinely work for major conglomerates, corporations, and other large associations.

Villazon v. Prudential Health Care Plan, Inc., 843 So. 2d 842, 854 (Fla. 2003). As

the Florida Supreme Court has remarked, “[t]he thought of visiting a private and

independent office of a totally independent physician may now be one more of

history and cultural conditioning than current reality.” Id.

      The fact is that modern healthcare professionals often participate in diverse

agency relationships. They are employed, for example, by hospitals, universities,

clinics, other practitioners, and corporations of all kinds. Such principals may

powerfully influence the medical judgment and conduct of their employees in

many different ways. They might, for instance, restrict the practice of medicine

“through hiring criteria, training, formal practice guidelines, hierarchical

supervision structures, peer review groups[,] and disciplinary measures.” Harris v.

Miller, 438 S.E.2d 731, 737 (N.C. 1994) (footnote omitted). Even subtler

constraints may be enough to establish agency relationships in certain cases. See,

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e.g., Hodges v. Doctors Hosp., 234 S.E.2d 116, 118 (Ga. Ct. App. 1977) (finding

jury question on issue of agency because hospital required staff physician to

perform rotations in emergency room and paid him $100 per day); Newton Cnty.

Hosp. v. Nickolson, 207 S.E.2d 659, 661-63 (Ga. Ct. App. 1974) (finding jury

question on issue of agency because hospital paid physician on hourly basis and set

physician’s work schedule).

      Amidst these broad networks of control, it should come as no surprise that

the courts overwhelmingly recognize and apply the principles of vicarious liability

in the world of modern medicine. See, e.g., Univ. of Ala. Health Servs. Found.,

P.C. v. Bush ex rel. Bush, 638 So. 2d 794, 799 (Ala. 1994) (recognizing vicarious

liability for medical negligence under Alabama law); Villazon, 843 So. 2d at 854-

55 (same under Florida law); Allrid v. Emory Univ., 285 S.E.2d 521, 525-26 (Ga.

1982) (same under Georgia law); see also Eads, 277 P.3d at 511-12 (“[M]ost

jurisdictions now hold that an entity that employs a physician is subject to

vicarious liability for that physician-employee’s malpractice if the negligent act

was committed in the course and scope of the employment.”).

      This does not mean, of course, that every medical practitioner is someone

else’s agent. The application of the doctrine is plainly fact-specific, and no bright-

line rule could fit every circumstance. Again, control of the agent by the principal

remains the touchstone of the analysis. Thus, the courts have considered agency

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relationships on a case by case basis, and a wide variety of employers have faced

vicarious liability for the medical negligence of their employees. See, e.g., Univ.

of Ala. Health Servs., 638 So. 2d at 801-02 (university foundation); Villazon, 843
So. 2d at 854 (health maintenance organization); Allrid, 285 S.E.2d at 525-26

(hospital); see also TransCare Md., Inc. v. Murray, 64 A.3d 887, 889 (Md. 2013)

(ambulance transport company); Cox v. M.A. Primary & Urgent Care Clinic, 313
S.W.3d 240, 254 (Tenn. 2010) (urgent care clinic); Rannard v. Lockheed Aircraft

Corp., 157 P.2d 1, 6 (Cal. 1945) (en banc) (aerospace corporation); Jones v. Tri-

State Telephone & Telegraph Co., 136 N.W. 741, 741-42 (Minn. 1912) (telephone

company); Mrachek v. Sunshine Biscuit, Inc., 283 A.D. 105, 107-08 (N.Y. App.

Div. 1953) (corporate bakery). As a matter of law, we are hard-pressed to see why

the principal-agent relationship between a shipowner and a medical professional

should be treated any differently -- particularly where the shipowner employs a

large medical staff, wholly outfits the clinics where its medical employees work,

and exercises sufficient control over those personnel.

                                         b.

      Separately, we are told that shipowners cannot control onboard medical

personnel because the doctor-patient (or nurse-patient) relationship is “under the

control of the passengers themselves.” Barbetta, 848 F.2d at 1369 (quoting

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O’Brien, 28 N.E. at 267). The Supreme Judicial Court of Massachusetts put it this

way, in a nineteenth-century opinion cited heavily in Barbetta:

      [The passengers] may employ the ship’s surgeon, or some other
      physician or surgeon who happens to be on board, or they may treat
      themselves if they are sick, or may go without treatment if they prefer;
      and, if they employ the surgeon, they may determine how far they will
      submit themselves to his directions, and what of his medicines they
      will take and what reject, and whether they will submit to a surgical
      operation or take the risk of going without it. The master or owners of
      the ship cannot interfere in the treatment of the medical officer when
      he attends a passenger. He is not their servant, engaged in their
      business, and subject to their control as to his mode of treatment.

O’Brien, 28 N.E. at 267; accord The Great Northern, 251 F. at 831-32. Under this

rule, the passenger -- as patient -- always calls the shots.

      There are a number of problems with this load-bearing Barbetta principle.

Most basically, we remain unimpressed by the assumption that a patient always

controls his medical relationships as a matter of law. Again, the facts are critical.

It makes little sense, for example, to suggest that an unconscious trauma patient

meaningfully chooses the emergency treatment he receives. What’s more, for

some time, the courts have imputed vicarious liability where employers have

required their employees or prospective employees to submit to a company

doctor’s care. See, e.g., Lockheed Aircraft Corp., 157 P.2d at 6; Tri-State

Telephone, 136 N.W. at 741; Beadling v. Sirotta, 176 A.2d 546, 549-50 (N.J.

Super. Ct. Law Div. 1961); Mrachek, 283 A.D. 105 at 107-08. In such cases,

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vicarious liability attaches in part because the treated person “ha[s] no [medical]

choice.” Id. at 108.

      More to the point, we are particularly skeptical of the view that the patient

always holds the critical reins in this particular context. With no land on the

horizon, a passenger who falls ill aboard a cruise ship has precious little choice but

to submit to onboard care. The hard reality is that, at least in the short term, he

may have literally nowhere else to go. See, e.g., Fairley v. Royal Cruise Line Ltd.,

1993 A.M.C. 1633, 1638 (S.D. Fla. 1993) (characterizing injured or sick

passengers as “captive audience” whose “only resort” is onboard medical staff);

Carlisle v. Carnival Corp., 864 So. 2d 1, 5 (Fla. Dist. Ct. App. 2003) (rejecting “the

unrealistic suggestion that an ailing cruise passenger at sea has some meaningful

opportunity to simply forego treatment by the ship’s doctor”), decision quashed

953 So. 2d 461, 469-70 (Fla. 2007) (“find[ing] merit” in intermediate appellate

court’s holding but applying Barbetta rule because “federal principles of harmony

and uniformity” constrain state courts in maritime cases). Moreover, even where

resources exist to evacuate passengers to land-based medical facilities, afflicted

persons may reasonably be reluctant to seek treatment from an unknown doctor or

medical facility in a foreign land. Franza’s complaint only underscores these

problems, to the extent she claims that Vaglio “was required to go to the ship’s

medical center to be seen for his injuries.” Compl. ¶ 35 (emphasis added).

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      In any case, even if we were to assume that a patient always controls the

treatment he receives, we would not be required to conclude that a patient

exclusively controls the doctor-patient relationship. As we have recognized

elsewhere, “courts have found that a [physician’s employer] may be vicariously

liable for the negligent acts of physicians even where the [employer] does not

control the manner and method of the physician’s work.” Johns v. Jarrard, 927
F.2d 551, 556 (11th Cir. 1991) (applying Georgia law) (emphasis added). Modern

courts widely acknowledge that a principal “both can, and in fact do[es],

significantly control the overall delivery of medical services . . . even if the

[principal] does not direct a professional’s discrete actions in treating individual

patients.” Eads, 277 P.3d at 511. Notwithstanding a patient’s right to opt in or out

of treatment, an employer can influence a doctor’s (or nurse’s) practice of

medicine in countless other ways. See, e.g., Harris, 438 S.E.2d at 737 (hiring

criteria, training, practice guidelines, supervision, peer review, and disciplinary

measures); see also Hodges, 234 S.E.2d at 118 (scheduling and compensation);

Newton Cnty. Hosp., 207 S.E.2d at 661-63 (same).

      Again, these mechanisms of control will not always yield a finding of

agency. But agency is a question of fact, and we see no sound reason for refusing

to apply its principles in this context. The long and the short of it is that, outside

the maritime realm, the doctor-patient relationship no longer ineluctably, and as a

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matter of law, bars application of respondeat superior. One by one, American

common law courts have responded to seismic shifts in the medical industry by

holding principals responsible for the medical negligence of their agents. Given

the “wholesale abandonment of the rule in most of the area where it once held

sway,” Moragne, 398 U.S. at 388, 90 S. Ct. at 1781, we are reluctant to cling to

these arguments under the general maritime law.

                                          2.

       The second pillar on which Barbetta rests is the claim that the scope and

nature of a cruise line’s expertise renders it unable to supervise a medical

professional. As many courts have observed, with a note of finality, “[a] ship is

not a floating hospital.” Barbetta, 848 F.2d at 1369 (quoting Amdur v. Zim Israel

Navigation Co., 310 F. Supp. 1033, 1042 (S.D.N.Y. 1969)). In other words, since

a shipowner is “not in the business of providing medical services to passengers,”

we are told that no cruise line could “possess the expertise requisite to supervise” -

- and, by extension, to control -- the ship’s medical personnel. Id. (internal

quotation marks omitted). Even if some entities might be vicariously liable for

medical negligence, the argument goes, a cruise line is no such entity as a matter of

law.

       Again, we are unpersuaded by the breadth of this immunity-yielding rule of

law. In the first place, it seems to us disingenuous for large cruise lines to disclaim

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any medical expertise when they routinely provide access to extensive medical

care in the infirmaries they have constructed for this very purpose. Viewing

Franza’s complaint in a light most favorable to the plaintiff, Royal Caribbean is

sufficiently involved in the business of providing medical care to yield the

possibility of liability. Thus, for example, the cruise line allegedly owns and

operates onboard medical centers, Compl. ¶ 28, which are staffed by doctors and

nurses whom the cruise line has hired, trained, outfitted, paid, and controlled, id. ¶¶

6, 7. Moreover, if we credit Franza’s claim that Royal Caribbean “pays to stock

the ‘medical centers’ with all supplies, various medicines and equipment,” id. ¶ 28,

we also presume the cruise line knows at least something about its purchases.

Taken at face value, these allegations evince at least some institutional knowledge

of medicine. In fact, courts recognize the medical knowledge of hospitals on

largely the same basis. See Bing, 143 N.E.2d at 11 (concluding that hospitals

directly “undertake to treat the patient” because they “employ on a salary basis a

large staff of physicians, nurses and internes” and “charge patients for medical care

and treatment”); accord Harris, 438 S.E.2d at 736-37; Eads, 277 P.3d at 511. 14

14
   What’s more, we suspect that Franza’s allegations only scratch the surface. We have no
difficulty imagining other cases in which additional evidence could demonstrate a cruise line’s
medical expertise -- particularly since, in the public domain, cruise lines routinely claim to
possess such knowledge. See, e.g., Peltz, Has Time Passed Barbetta by?, at 19 (quoting
statement by Director of Princess Cruise Lines Medical Department claiming that “major cruise
lines have designed modern medical facilities comprising several ICUs, computerized radiology,
and sophisticated laboratories” and “have achieved accreditation to international health care
standards and ISO 9001 certification”); id. at 14-16 (noting that sixteen major cruise lines
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       There can be no dispute, however, that a cruise ship is different from a

hospital. Undeniably, the practice of medicine is far more central to hospital

operations than to the business of cruising. But under basic agency principles, the

scope of an employer’s vicarious liability is not limited to negligence arising from

its primary business. Instead, common law courts regularly have imputed liability

for actions taken “in the scope of [the agent’s] authority or employment,” Meyer v.

Holley, 537 U.S. 280, 285, 123 S. Ct. 824, 829 (2003), without further requiring

that any such conduct implicate the principal’s core business. Therefore, when a

person is “employed” to perform medical services, Compl. ¶¶ 6, 7, and where any

negligence occurs “within the scope and course of [that] employment,” id.,

vicarious liability is sometimes appropriate -- even if the employer is not a

primarily medical enterprise. See, e.g., Lockheed Aircraft Corp., 157 P.2d 1

cooperated with American College of Emergency Physicians to develop and adopt “industry-
wide guidelines” addressing “unique needs and limitations of shipboard medical infirmaries”);
Adam Goldstein, Medical Tranquility and Peace of Mind, Royal Caribbean (Sept. 27, 2010),
http://www.royalcaribbean.com/connect/medical-tranquility-and-peace-of-mind (touting cruise
line’s onboard lab equipment, x-ray units, and clot-busting thrombolytics); Press Release,
Princess Cruises, Princess Cruises’ Medical Departments Earn Unique Distinction with
Prestigious Quality Certification and Accreditation (May 6, 2010),
http://www.princess.com/news/press_releases/ 2010/05/Princess-Cruises’-Medical-Departments-
Earn-Unique-Distinction-with-Prestigious-Quality-Certification-and-Accreditation.html (“[O]ur
medical centers achieve similar quality standards to medical facilities ashore[.]”); Royal
Caribbean Cruises Ltd., 2012 Stewardship Report, 17 (2012),
http://media.royalcaribbean.com/content/en_US/pdf/13034530_RCL_2012StwrdshpTwoPgrs_v4
.pdf (noting that shipowners supply equipment and provide training to enable onboard blood
transfusions). We do not credit as fact any information not pled in the complaint, but we note
that another plaintiff could have cited any of this information to rebut the basic assumption that
cruise ships are not in the business of providing medical services.

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(aerospace corporation); Chi. Rock Island & Pac. Ry. Co. v. Britt, 74 S.W.2d 398,

403 (Ark. 1934) (railroad); Tri-State Telephone, 136 N.W. 741 (telephone

company); Mrachek, 283 A.D. 105 (corporate bakery); Ebert v. Emerson Elec.

Mfg. Co., 264 S.W. 453, 458 (Mo. Ct. App. 1924) (manufacturing plant); see also

Gen. Elec. Co. v. Rees, 217 F.2d 595, 599 (9th Cir. 1954) (suggesting that

malpractice of employee-doctor “might have bound” General Electric); Hawksby

v. DePietro, 754 A.2d 1168, 1171-2 (N.J. 2000) (explaining that newspaper

company might have been liable for employee-doctor’s negligence absent workers’

compensation scheme). Against this authority, Barbetta stands for the proposition

that cruise lines peculiarly lack all medical expertise -- so much so that a

shipowner, unlike every other class of employer that employs medical staff, can

never be held vicariously liable for medical malpractice as a matter of law.

      In particular, where the provision of some medical services is incidental to

the principal’s core business, courts have not hesitated to entertain the possibility

of vicarious liability. See, e.g., Blackburn v. Blue Mountain Women’s Clinic, 286
Mont. 60, 79-80 (Mont. 1997) (reversing district court’s dismissal of family

planning clinic in suit concerning counselor’s negligence); Speed v. Iowa, 240
N.W.2d 901 (Iowa 1976) (affirming judgment against state for medical

malpractice occurring at University of Iowa’s Student Health Infirmary); cf.

Kleinknecht v. Gettysburg College, 989 F.2d 1360, 1374-75 (3d Cir. 1993)

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(suggesting college might be vicariously liable for negligence of athletic program

trainers during medical emergency); Santiago v. Archer, 136 A.D.2d 690, 692

(N.Y. App. Div. 1988) (reversing district court’s grant of summary judgment

because union might be vicariously liable for medical malpractice occurring at its

clinic).

       One example that strikes us as particularly salient is case law addressing

whether universities should be exempt from medical malpractice when they choose

to open medical clinics that serve their student bodies and members of the

community. University clinics are in many ways similar to cruise ship medical

centers. Both types of facilities provide an abbreviated menu of treatment and

procedure options as compared to a hospital or private physician’s office. Emory

Univ. v. Porubiansky, 282 S.E.2d 903, 903, 904 (Ga. 1981) (noting that clinic

patients agree to treatment that “proceed[s] more slowly” and may not be able to

“insist on complete treatment”); Ash v. N.Y. Univ. Dental Ctr, 164 A.D.2d 366,

369 (N.Y. App. Div. 1990) (noting that a clinic might “limit[] itself to certain types

of care or refus[e] to perform certain procedures”). Moreover, neither a cruise line

nor a university is in the primary business of providing medical services. Finally,

each entity claims to have constructed and maintained its facilities, not for the

purpose of entering the medical service business, but as a supplement to its

primary business. For the universities, clinics provide basic services to students

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and community members and serve as educational and research tools for their

students and professors. See Tunkl v. Regents of the Univ. of Cali., 383 P.2d 441,

442 (Cal. 1963); Emory Univ., 282 S.E. at 905. And for the cruise lines, medical

centers allegedly are provided as a convenience to passengers who may become ill

at sea.

          In the university clinical program context, courts have declined to create

sweeping immunity from medical malpractice liability, explaining that these

characteristics of clinics do not justify “an exemption from the duty to exercise

reasonable care.” Emory Univ., 282 S.E.2d at 905. As the Georgia Supreme Court

has observed, clinics, and thus the universities that run them, “engage in the

practice of [medicine]” by “offering services.” Id. This fact, rather than the

university’s core business or underlying purposes for deciding to provide medical

care, is of primary importance when determining whether an exemption from

liability is appropriate. See id. (“The status of Emory University School of

Dentistry as primarily a training institution does not allow for an exemption from

the duty to exercise reasonable care.”). Additionally, in reponse to a university’s

argument that it should be immune from vicarious, though not direct, negligence,

the California Supreme Court has noted that no feature of clinical programs

justified such a departure from general principles of agency. The court observed

that “a legion of decisions . . . have drawn no distinction between the corporation’s

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own liability and vicarious liability resulting from the negligence of agents,” Tunkl

v. Regents of the Univ. of Cali., 383 P.2d 441, 448 (Cal. 1963), and that no

rationale supported adopting a different rule in the case of university clinics. In

our view, blanket immunity from vicarious liability is similarly unwarranted when

cruise ships choose to create, stock, and operate onboard medical centers with their

own physicians and nurses. Taking Franza’s allegations at face value, Royal

Caribbean employed medical personnel who rendered negligent services in the

course and scope of their medical employment, onboard a ship outfitted by the

principal with a medical infirmary or urgent care center. This seems to us to be

sufficient medical knowledge to at least withstand a motion to dismiss for failure to

state a claim.

      Moreover, no principle from maritime tort law justifies treating shipowners

so differently from ordinary employers. On the contrary, shipowners have been

held vicariously liable for misconduct that falls at least this far outside the

heartland of the cruising business. In Muratore v. M/S Scotia Prince, for example,

a shipowner’s subcontractor’s photographer-employees tortiously photographed

and harassed a passenger. 845 F.2d 347, 349-50 (1st Cir. 1988). The First Circuit

affirmed the shipowner’s vicarious liability because the tortfeasors were “part of

[the ship’s] crew,” even though the shipowner was not primarily in the business of

photography. Id. at 353. If shipowners could be held liable for the photography of

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a subcontractor’s employee, we see little reason to suppose they could not be

called to answer for the medical negligence of the practitioners they directly

employ and control. Cf. Rogers v. Allis-Chalmers Mfg. Co., 92 N.E.2d 677, 683

(Ohio 1950) (acknowledging possibility that machinery manufacturer could be

vicariously liable for negligence by employees “engaged in athletic activities,”

though manufacturer was “not in the business of athletics”); Strait v. Hale Constr.

Co., 26 Cal. App. 3d 941, 950 (Cal. Dist. Ct. App. 1972) (affirming farmer’s

vicarious liability for highway collision caused by on-loan employee-operator of

farmer’s loaned machine, though farmer was avowedly “not in the business of

renting heavy equipment and furnishing an operator”).

      There are also important policy reasons that inform against broad immunity

for cruise lines against any liability for their medical staff’s malpractice. Carriers

owe their ailing passengers “a duty to exercise reasonable care to furnish such aid

and assistance as ordinarily prudent persons would render under similar

circumstances.” Barbetta, 848 F.2d at 1371 (internal quotation marks omitted).

By investing in medical infrastructure and hiring skilled medical employees, cruise

ships avoid the potentially high cost of providing reasonable care in more

expensive ways. See, e.g., The Iroquois, 194 U.S. 240, 243 (1904) (explaining that

reasonable care depends on, inter alia, “the proximity of an intermediate port”).

The shipowner, by providing onboard medical resources, will often “avoid[ ] [its]

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sometimes inconvenient and costly duty to change course for the benefit of an

ailing passenger.” Nietes, 188 F. Supp. at 221. Under the Barbetta rule,

shipowners have access to a liability free method of discharging their duty of care

to passengers that is outside the realm of meaningful judicial review. Additionally,

beyond any potential for cost avoidance, cruise lines may even profit affirmatively

from onboard medical care. For instance, they might charge passengers for

treatment rendered. See Compl. ¶ 28. And, surely, for at least some ticket-buying

customers, the availability of onboard medical facilities is a deal-maker. 15 In short,

cruise lines have chosen quite deliberately to enter the business of medicine, often

in a large way, and they reap the tangible benefits of this business strategy. Thus,

it seems hardly anomalous to require cruise lines to bear the burden of this choice.

See generally Gregory C. Keating, The Idea of Fairness in the Law of Enterprise

Liability, 95 Mich. L. Rev. 1266, 1269 (1997).16

15
   Indeed, in one study, persons over sixty represented nearly thirty percent of all respondents
who had ever taken a cruise vacation. Taylor Nelson Sofres, 2011 Cruise Market Profile Study,
Cruise Lines Int’l Assoc., 32 (June 2011), http://www.cruising.org/sites/default/files/pressroom/
Market_Profile_2011.pdf. Considering the likely preferences of this key demographic, we think
it very unlikely that cruise lines will respond to their new liability by eliminating onboard
medical care.
16
   Several other policy arguments suggest setting aside the Barbetta rule. First, as compared with
an employee-doctor, a resource-rich cruise line can more readily bear the cost of a plaintiff’s
injury. See generally Prosser & Keeton, The Law of Torts 500-01 (5th ed. 1984) (noting that
employer is better able to “absorb,” “distribute,” and “shift” losses caused by employee torts)
[hereinafter Prosser & Keeton, The Law of Torts]; Guido Calabresi, Some Thoughts on Risk
Distribution and the Law of Torts, 70 Yale L.J. 499, 527 (1961) (describing “deep pocket”
justification for imposing liability on principals).Second, by imposing vicarious liability for
employee torts, we encourage profit-seeking employers to minimize the risk of costly tortious
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         All told, Barbetta’s assumption that cruise lines lack any medical expertise is

difficult to accept in light of the industry’s decision to construct, outfit, and staff

medical centers onboard its ships. Moreover, no feature peculiar to cruise lines

distinguishes them from other corporate principals which must ordinarily answer

for the medical negligence of their employees. Again, we are loath to adopt a

principle of law that always immunizes a shipowner without regard to any of the

facts.

                                                 3.

         The final pillar on which Barbetta rests is the notion that shipowners never

exercise “sufficiently immediate” control over their onboard medical personnel to

warrant vicarious liability. Barbetta, 848 F.2d at 1371 (quoting Amdur, 310 F.

Supp. at 1042). At its core, this argument assumes that no shipowner may ever be

close enough to control its onboard medical staff, whether the ship is

geographically near or distant from the principal’s home base. The glaring

problem we see with this conclusion is its fact-dependent premise. Put simply,

shipowners and their vessels (and their onboard medical staff) are not always far

apart. Thus, for example, whenever onboard treatment occurs before a ship

conduct. See generally Richard A. Posner, A Theory of Negligence, 1 J. Legal Stud. 29, 43
(1973) (describing respondeat superior as mechanism encouraging employers to “invest until the
last cent of [their] investment . . . saves one cent in . . . costs”); Prosser & Keeton, The Law of
Torts, at 500 (identifying “modern justification for vicarious liability” as “deliberate allocation of
risk” (footnote omitted)).
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departs, the owner of the vessel may be very close at hand. Moreover, a ship that

has already set sail may still be near its harbor of origin, or a ship may hug the

coastline and remain close to land-based medical facilities. And some ships may

even be owned by physical persons, whose supervision would certainly be

“immediate” whenever they traveled onboard. In short, principals and onboard

agents may be physically close together. To the extent that physical separation

vitiates control, the relevant questions are fact-based and ill-suited to resolution by

a per se rule of law.

      Furthermore, as a general rule, the mere fact of physical separation between

principals and agents does not inevitably defeat respondeat superior -- in medical

malpractice cases or elsewhere. Again, the facts are everything. See, e.g., Scott v.

SSM Healthcare St. Louis, 70 S.W.3d 560, 568 (Mo. Ct. App. 2002) (“reject[ing]

the notion that [an agency] relationship cannot be found merely because the

hospital does not have the right to stand over the doctor’s shoulder”); see also

TransCare Md., 64 A.3d at 889-90, 903 (suggesting that ambulance company could

be vicariously liable for employee-paramedic’s negligence aboard helicopter);

Sigmon v. Tompkins Cnty., 449 N.Y.S.2d 621, 623 (N.Y. Sup. Ct. 1982)

(suggesting that ambulance company could be vicariously liable for medical

malpractice rendered by employee nurse traveling in ambulance); Restatement

(Second) of Agency § 220 cmt. d (“[T]he control or right to control needed to

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establish the relation of master and servant may be very attenuated.” (emphasis

added)); cf. Grigsby v. Coastal Marine Serv. of Tex., Inc., 412 F.2d 1011, 1031

(5th Cir. 1969) (implying unseaworthiness liability of “remote owner” where

“conduct . . . somehow implicates” that owner).

      Even if distance may undercut liability in some cases, we see no need to

adopt a one size fits all rule where advanced technology often enables effective

communication between shore based principals and onboard medics. We do not

have to hypothesize about scenarios to support this point, because cruise lines

proudly advertise their own capabilities. Several cruise lines now purport to staff

extensive land-based medical departments with expert personnel. See Peltz, Has

Time Passed Barbetta by?, at 20 & n.69 (citing examples). By many accounts,

these and other onshore practitioners meaningfully communicate with a ship’s

medical employees even while the ship is at sea. See, e.g., id. at 21-22 (detailing

onboard treatment of passenger’s acute-onset stroke “[w]ith clinical and logistical

assistance” of shore-based medical team). These communications occur through

channels that were unheard of when the Fifth Circuit decided Barbetta, long before

the advent of widespread cellular and satellite communications. See, e.g., Royal

Caribbean Cruises Ltd., 2010 Stewardship Report, 8 (2010),

www.royalcaribbeanpresscenter.com/download-press-release/891/ (highlighting

modern cruise line’s “teledermatology” partnership with shore based university);

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Holland America Line, Onboard Medical Services and Facilities, 1 (2005),

http://www.hollandamerica.com/assets/news/PR_Medical.pdf (explaining that

“[t]he ship is able to access any medical specialist at [University of Texas Medical

Branch] in Galveston” and “radiologists can provide an instant overread of any x-

rays done on board). Because, twenty-six years after Barbetta, we now think a

shipowner could plausibly supervise a ship’s medical employees in places near and

far, we reject the sweep of the rule’s final rationale.

      In short, we do not find that the arguments set forth in Barbetta justify its

broad grant of immunity from vicarious liability in all claims of medical

malpractice. Rather, we think we are obliged to follow our own maritime

precedent, which demands fact-intensive treatment of agency questions. We

cannot accept a legal principle that would erect a categorical exception from this

settled practice, and we see no reason to follow an outdated rule that serves no

useful purpose in modern maritime law. Thus, we hold that Franza’s allegations

established a plausible agency relationship between the employer, Royal Caribbean

Cruise Lines, Ltd., and its employees, Nurse Garcia and Dr. Gonzales, and that the

district court improvidently granted the Rule 12(b)(6) motion to dismiss.

                                          IV.

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       Franza also appeals the dismissal of her claim brought under the alternative

theory of apparent agency. 17 We are the first circuit to address whether a

passenger may use apparent agency principles to hold a cruise line vicariously

liable for the onboard medical negligence of its employees. Like the district court,

we conclude that a passenger may sue a shipowner for medical negligence if he

can properly plead and prove detrimental, justifiable reliance on the apparent

agency of a ship’s medical staff-member. However, we part ways with the district

court’s conclusion that Franza’s apparent agency claim was pled inadequately. As

we see it, Franza has plausibly alleged all of the elements of apparent agency.

                                                A.

       Plainly, actual agency and apparent agency are distinct theories of liability.

Unlike actual agency, the doctrine of apparent agency allows a plaintiff to sue a

principal for the misconduct of an independent contractor who only reasonably

appeared to be an agent of the principal. See, e.g., Borg-Warner Leasing, 733 F.2d
17
  Many courts use the terms apparent agency, apparent authority, ostensible agency, and agency
by estoppel interchangeably. Though some courts have distinguished apparent agency and
apparent authority as theories of liability that require no reliance, we have never recognized that
distinction. See, e.g., Borg-Warner Leasing v. Doyle Elec. Co., 733 F.2d 833, 836 (11th Cir.
1984) (requiring “detrimental reliance” to establish “apparent authority” under Florida law);
Arceneaux v. Texaco, Inc., 623 F.2d 924, 926-27 (5th Cir. 1980) (requiring “reliance” to
establish “apparent authority in tort cases” under Louisiana law); Crowe v. Hertz Corp., 382 F.2d
681, 688 (5th Cir. 1967) (equating “apparent agency” with “agency by estoppel” and requiring
“reliance” under Georgia law). In any case, even if we were to acknowledge the possibility of
“apparent agency” liability without reliance, Franza’s complaint did not allege vicarious liability
on any such theory. Accordingly, we intend the term “apparent agency” in the ordinary sense.
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at 836 (Florida law); Crowe, 382 F.2d at 688 (Georgia law); see also Restatement

(Second) of Agency § 267.

      These separate doctrines have been applied for quite different reasons and

under very different circumstances. While respondeat superior derives from a

principal’s right to control the conduct of its agents, liability under apparent agency

flows from equitable concerns. See Brown ex rel. Brown v. St. Vincent’s Hosp.,

899 So. 2d 227, 236 (Ala. 2004) (equating apparent agency with agency by

estoppel under Alabama law); Jackson Hewitt, Inc. v. Kaman, 100 So. 3d 19, 31

(Fla. Dist. Ct. App. 2011) (“[L]iability based on apparent authority is a form of

estoppel.”); Capital Color Printing, Inc. v. Ahern, 661 S.E.2d 578, 585 (Ga. Ct.

App. 2008) (noting that “doctrine of apparent agency is predicated on principles of

estoppel” (internal quotation marks and alteration omitted)); accord Primeaux v.

United States, 181 F.3d 876, 879 (8th Cir. 1999) (“[O]stensible agency is no

agency at all; it is in reality based entirely on an estoppel.” (internal quotation

marks and citation omitted)); Drexel v. Union Prescription Ctrs., Inc., 582 F.2d
781, 791 (3d Cir. 1978) (equating apparent agency and agency by estoppel under

Pennsylvania law); Sennott v. Rodman & Renshaw, 474 F.2d 32, 38 (7th Cir.

1973) (same under Illinois law); Hill v. St. Clare’s Hosp., 490 N.E.2d 823, 827

(N.Y. 1986) (same under New York law); see also Baptist Mem’l Hosp. Sys. v.

Sampson, 969 S.W.2d 945, 947 (Tex. 1998) (noting doctrine’s equitable

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foundation); Morback v. Young, 113 P. 22, 24 (Or. 1911) (same); Donnelly v. S.F.

Bridge Co., 49 P. 559, 560 (Cal. 1897) (same). Essentially, then, liability may be

appropriate under apparent agency principles when a principal’s conduct could

equitably prevent it from denying the existence of an agency relationship.

       Because apparent agency does not turn on any notion of control, the Barbetta

rule does not directly address the question of apparent agency. 18 Apprehending

this distinction, many district courts within this Circuit have already recognized a

shipowner’s apparent agency liability for onboard medical negligence. See, e.g.,

Aronson v. Celebrity Cruises, Inc., __ F. Supp. 2d ___, No. 12-CV-20129, 2014
WL 3408582, at *12 (S.D. Fla. May 9, 2014); Lobegeiger v. Celebrity Cruises,

Inc., 869 F. Supp. 2d 1356, 1361 (S.D. Fla. 2012); Peavy v. Carnival Corp., No.

1:12-CV-20782, 2012 WL 5306353, at *2 (S.D. Fla. Oct. 26, 2012); Gentry v.

Carnival Corp., No. 11-21580-CIV, 2011 WL 4737062, at *4-5 (S.D. Fla. Oct. 5,

2011); Smolnikar v. Royal Caribbean Cruises Ltd., 787 F. Supp. 2d 1308, 1324

18
   A few courts have suggested that, because of Barbetta’s prominence, no plaintiff could ever
reasonably mistake the agency status of onboard medical personnel “[a]bsent an explicit
manifestation by the ship owner countering the settled principle that medical staff [members] are
not their agents.” Huang v. Carnival Corp., 909 F. Supp. 2d 1356, 1361 (S.D. Fla. 2012); see
also Hajtman, 526 F. Supp. 2d at 1328-29 (holding that Barbetta rule precluded any reasonable
belief that medical staff were agents of shipowner); Warren v. Ajax Navigation Corp., 1995
A.M.C. 2609 (S.D. Fla. 1995) (same). Whatever its merits, this argument does not survive our
departure from the traditional rule. Separately, other courts have concluded that the Barbetta rule
bars apparent agency claims because apparent agency is merely a form of respondeat superior.
See, e.g., Balachander v. NCL (Bahamas) Ltd., 800 F. Supp. 2d 1196, 1204 (S.D. Fla. 2011);
Wajnstat v. Oceania Cruises, Inc., No. 09-21850-CIV, 2011 WL 465340, at *4 (S.D. Fla. Feb. 4,
2011). We think that view misapprehends the analytical distinction between actual and apparent
agency.
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(S.D. Fla. 2011); Peterson v. Celebrity Cruises, Inc., 753 F. Supp. 2d 1245, 1248

(S.D. Fla. 2010); Ridley v. NCL (Bahamas) Ltd., 824 F. Supp. 2d 1355, 1362 (S.D.

Fla. 2010); Rinker v. Carnival Corp., No. 09-23154-CIV, 2010 WL 9530327, at *4

(S.D. Fla. June 18, 2010); Barnett v. Carnival Corp., No. 06-22521-CIV, 2007 WL
1746900, at *2 (S.D. Fla. June 15, 2007); Hajtman v. NCL (Bahamas) Ltd., 526 F.

Supp. 2d 1324, 1328 (S.D. Fla. 2007); Suter v. Carnival Corp., 2007 A.M.C. 2564

(S.D. Fla. 2007); Doonan v. Carnival Corp., 404 F. Supp. 2d 1367, 1371-72 (S.D.

Fla. 2005); Huntley v. Carnival Corp., 307 F. Supp. 2d 1372, 1375 (S.D. Fla.

2004); Fairley v. Royal Cruise Line Ltd., 1993 A.M.C. 1633, 1639-40 (S.D. Fla.

1993).

      We agree with this view. As we have noted at some length, the principles of

agency permeate the general maritime law, see Archer, 834 F.2d at 1573, and

apparent agency is no exception. The great weight of admiralty precedent has long

allowed plaintiffs to sue shipowners based on the apparent authority of third-

parties. See El Amigo v. Houston Marine Eng’g Works, 285 F. 868, 870 (5th Cir.

1923) (upholding claim against shipowner because third-party who ordered

supplies, repairs, and necessities “ha[d] apparent authority to bind the vessel”);

accord Garanti, 697 F.3d at 72 (reversing summary judgment in maritime contract

dispute because of factual question regarding third-party’s “actual or apparent

authority to act on [shipowner’s] behalf” (emphasis added)); Hawkspere, 330 F.3d
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at 236 (affirming shipowner’s maritime lien because no issue of fact existed “as to

whether [third-party] acted as an actual or apparent agent for [shipowner]”

(emphasis added)); Lake Charles Stevedores, Inc. v. Professor Vladimir Popov

MV, 199 F.3d 220, 228 (5th Cir. 1999) (affirming denial of maritime lien on

theory of “apparent authority” because shipowner did not “undert[ake] actions that

caused [plaintiffs] reasonably to believe that [third-party] was its agent”); Cactus

Pipe & Supply Co. v. M/V Montmartre, 756 F.2d 1103, 1111 (5th Cir. 1985)

(absolving shipowner of liability for damaged cargo because third-party did not

have “apparent authority” to issue bills of lading); cf. Marine Transp. Servs. Sea-

Barge Grp., Inc. v. Python High Performance Marine Corp., 16 F.3d 1133, 1138-

39 (11th Cir. 1994) (recognizing doctrine of equitable estoppel in maritime

context).

      The federal circuits have made only passing references to apparent agency

principles in maritime tort cases. See, e.g., Reino de España v. Am. Bureau of

Shipping, Inc., 691 F.3d 461, 474 n.16 (2d Cir. 2012) (suggesting that maritime

principal might have been liable for reckless conduct if alleged agent had

possessed “apparent authority” to receive certain notifications); Kawasaki Kisen

Kaisha, Ltd. v. Plano Molding Co., 696 F.3d 647, 659 (7th Cir. 2012) (implying

that maritime principal might have been liable for negligence under doctrine of

“apparent authority” if plaintiffs had established their “belie[f] that [third-party]

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was acting as [principal’s] agent”). Nonetheless, given the broad salience of

agency rules in maritime law, see Archer, 834 F.2d at 1573, and the important role

the federal courts play in setting the bounds of maritime torts, see Exxon, 554 U.S.

at 508 n.21, 128 S. Ct. at 2630, we think apparent agency principles apply in this

context. Indeed, the equitable foundations of apparent agency are just as important

in tort as in contract. See Arceneaux, 623 F.2d at926 (assuming that Louisiana

courts would apply apparent agency in tort cases because they had done so in

contract); see also Drexel, 582 F.2d 791-92 (concluding under Pennsylvania law

that “policies” and “factual issues” support apparent agency in both contract and

tort).

         Having long applied the principles of apparent agency in maritime cases, we

can discern no sound basis for allowing a special exception for onboard medical

negligence, particularly since we have concluded that actual agency principles

ought to be applied in this setting as well. Outside the maritime realm, many

common law courts -- including the courts found in all three states of this Circuit --

have recognized vicarious liability for the medical negligence of apparent agents.

See, e.g., Brown, 899 So. 2d at 238 (“see[ing] no reason” in medical malpractice

case “to abandon [the Alabama Supreme Court’s] rule” of apparent agency);

Roessler v. Novak, 858 So. 2d 1158, 1162 (Fla. Dist. Ct. App. 2003) (holding

principal “vicariously liable for the acts of physicians, even if they are independent

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contractors, if these physicians act with . . . apparent authority”); Richmond Cnty.

Hosp. Auth. v. Brown, 361 S.E.2d 164, 166-67 (Ga. 1987) (recognizing vicarious

liability where principal “represented to [plaintiff] that its emergency room

physicians were its employees”); see also Eads, 277 P.3d at 514 (“[T]he weight of

authority in other jurisdictions is that, in a proper case, a hospital or other entity

can be held vicariously liable for a physician’s negligence on an apparent authority

theory.”). Medical negligence triggers the same equitable concerns whether it

arises on land or at sea, and, therefore, we think apparent agency liability may be

appropriate in both settings.

                                           B.

      Under the doctrine of apparent agency, just as in the case of actual agency,

vicarious liability turns on the facts presented. When applying the tort and contract

law of several states, we have repeatedly observed that apparent agency liability

requires finding three essential elements: first, a representation by the principal to

the plaintiff, which, second, causes the plaintiff reasonably to believe that the

alleged agent is authorized to act for the principal’s benefit, and which, third,

induces the plaintiff’s detrimental, justifiable reliance upon the appearance of

agency. See Borg-Warner Leasing, 733 F.2d at 836 (Florida law); Arceneaux, 623
F.2d at 927 & n.4 (Louisiana law); Crowe, 382 F.2d at 688 (Georgia law).

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Applying these general principles to the facts alleged in this case, we conclude that

Franza has plausibly and adequately pled all three elements of apparent agency.

       In the first place, Royal Caribbean purportedly made a number of salient

representations to Vaglio. The cruise line: (1) “promote[d] its medical staff and

represent[ed] them as being [cruise line] employees through brochures, internet

advertising, and on the vessel,” Compl. ¶ 26; (2) publicly described the medical

centers in proprietary language, id. ¶ 28; (3) billed passengers directly for onboard

medical services, id. ¶ 28; (4) required its doctors and nurses to wear uniforms

bearing the cruise line’s name and logo, id. ¶ 29; (5) held out Dr. Gonzales and

Nurse Garcia as “members of the ship’s crew” to passengers and immigration

authorities, id. ¶¶ 31, 33; and (6) “introduce[d]” Dr. Gonzales to the ship’s

passengers “as one of the ship’s Officers,” id. ¶ 30.

       Second, based on these allegations, Vaglio reasonably could believe that Dr.

Gonzales and Nurse Garcia were authorized to render medical services for the

cruise line’s benefit. Indeed, according to Franza’s complaint, Royal Caribbean

actually intended that its passengers perceive the ship’s medical staff to be agents

of the cruise line, insofar as the cruise line encouraged “the idea that the medical

staff who work in its ‘medical centers’ are employed by the cruise line as part of a

marketing tool to induce passengers such as [Vaglio] to buy cruises on its ships.”

Id. ¶ 27.

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      Finally, as for the third element, the district court dismissed Franza’s

apparent agency claim because her complaint “d[id] not state how Vaglio relied on,

or changed his position in reliance on, his alleged belief that the doctor and/or

nurse was Royal Caribbean’s agent.” Franza, 948 F. Supp. 2d at 1333. We

disagree. It is true that “apparent agency [cannot] exist for the benefit of the

person injured without reliance upon the apparent holding out of the principal.”

Crowe, 382 F.2d at 688. Moreover, this reliance must be “detrimental,” Borg-

Warner Leasing, 733 F.2d at 836, and “justifiabl[e],” Arceneaux, 623 F.2d at 927

n.4 (quoting Restatement (Second) of Agency § 267); see also Drexel, 582 F.2d at

791; Stone v. Palms W. Hosp., 941 So. 2d 514, 520 (Fla. 4th DCA 2006) (per

curiam). However, the complaint alleged precisely such reliance:

      [Vaglio] relied to his detriment on his belief that the physician and
      nurse were direct employees or actual agents of [Royal Caribbean] in
      that [Vaglio] followed the advice of the nurse and/or physician who
      did not seek any further medical testing or evaluation while the ship
      was in Bermuda, that he relied on the ship’s nurse and/or physician,
      [and] that he did not follow-up with the ship’s medical staff as he was
      told that he did not have any serious injury.

Compl. ¶ 38.

      We are hard-pressed to see how this pleading falls short. Indeed, Franza

explained that Vaglio (1) “relied to his detriment” (2) “on his belief” (3) that Dr.

Gonzales and Nurse Garcia “were direct employees or actual agents of [Royal

Caribbean].” Furthermore, through the specifying phrase, “in that,” she alleged

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precisely how Vaglio relied on the appearance of agency: (1) he “followed the

advice of the nurse and/or physician,” (2) despite the fact that those medical

personnel “did not seek any further medical testing or evaluation while the ship

was in Bermuda,” and (3) the degree of his reliance was so pronounced “that he

did not [even] follow up with the ship’s medical staff.” At this early stage in the

proceeding, one plausible interpretation of Franza’s allegations is that Vaglio

indeed relied to his profound detriment on the appearance of agency, in that he

would not have blindly trusted the advice of unknown medical personnel (who

sought no counsel from other medical professionals while the ship was docked) if

the ship’s doctor and nurse had not borne the imprimatur of a well-known and

trusted cruise line. Under these circumstances, and in light of Royal Caribbean’s

advertised medical expertise, detrimental reliance may have been justifiable.

      Of course, we recognize that Franza could have taken her allegations one

step further. Thus, she could have specifically claimed that Vaglio would not have

followed the advice of the ship’s medical personnel had he suspected they were not

actually the agents of Royal Caribbean. Effectively, however, that sort of

statement would only put Franza’s existing message in the negative. We do not

require plaintiffs to perform such linguistic gymnastics in order to defeat a motion

to dismiss. On these specific allegations, then, we are constrained to reverse the

district court’s dismissal of Franza’s apparent agency claim.

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                                          V.

      Having determined that Franza plausibly alleged two alternative theories of

vicarious liability, we turn to a final question: whether the complaint adequately

supports a claim of negligence in the first place. We think it does. To plead

negligence in a maritime case, “a plaintiff must allege that (1) the defendant had a

duty to protect the plaintiff from a particular injury; (2) the defendant breached that

duty; (3) the breach actually and proximately caused the plaintiff’s injury; and (4)

the plaintiff suffered actual harm.” Chaparro, 693 F.3d at 1336. All four elements

are met here.

      First, Franza alleged that Royal Caribbean was duty-bound to “provide

prompt and appropriate medical care” following Vaglio’s severe head injury.

Compl. ¶ 19. It is indisputable that cruise lines must treat their passengers with

“ordinary reasonable care under the circumstances.” Keefe v. Bahama Cruise

Line, Inc., 867 F.2d 1318, 1322 (11th Cir. 1989) (per curiam). Implicit in this

variable standard is the notion that cruise lines will not always be held to the same

standard of care that would guide treatment onshore. This is as it should be, since

standards of care typically vary among differently situated healthcare providers.

See, e.g., Jackson v. Pleasant Grove Health Care Ctr., 980 F.2d 692, 694 & n.2

(11th Cir. 1993) (recognizing in nursing home negligence case that, under

Alabama law, relevant standard of care governs “similarly situated health care

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provider[s]”), abrogated on other grounds by Weisgram v. Marley Co., 528 U.S.
440, 120 S. Ct. 1011 (2000); see also Cruz-Vázquez v. Mennonite Gen. Hosp.,

Inc., 613 F.3d 54, 56 (1st Cir. 2010) (noting that standard of care depends on

“relevant medical circumstances”); Watson v. United States, 485 F.3d 1100, 1109-

10 & n.7 (10th Cir. 2007) (finding no clear error in determination that ambulatory

care clinic was not required under applicable standard of care to stock Mannitol,

since evidence suggested that “Mannitol was not a medication normally

administered outside of a hospital setting”); cf. Fla. Stat. Ann. § 766.102 (2013)

(defining standard of care in medical malpractice action “in light of all relevant

surrounding circumstances”). Here, the precise contours of Royal Caribbean’s

duty depend on questions of fact that need not and cannot be answered at this

stage. However, Franza’s specific allegations suffice.

      Second, Royal Caribbean, by and through its medical personnel, purportedly

breached its duty in “one or more of the following ways”: (1) “failing to properly

assess the condition” of Vaglio; (2) “allowing a nurse to make the initial

assessment”; (3) “failing to have a doctor assess [Vaglio]”; (4) “failing to timely

diagnose and appropriately treat [Vaglio]”; (5) “failing to order appropriate

diagnostic scans to further assess the degree of injury”; (6) “failing to obtain

consultations with appropriate specialists”; (7) “failing to properly monitor

[Vaglio]”; (8) “failing to evacuate [Vaglio] from the vessel for further care in a

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timely manner”; and (9) “deviating from the standard of care for patients in Mr.

Vaglio’s circumstances who had suffered a significant blow to the head.” Compl.

¶ 20. If proven, these allegations could establish a breach of even a modest duty of

care, framed by the particular circumstances of the case.

      Third, Franza has alleged that, as a “direct and proximate result of [this]

negligence,” Vaglio’s “condition deteriorated to the point that he fell into a coma

and died.” Id. ¶ 22. In fact, had Vaglio “received the appropriate care and

treatment,” the claim is made that, “more likely than not[,] . . . he would have

survived.” Id. ¶ 23. Finally, Vaglio suffered damages as a result of Royal

Caribbean’s alleged negligence. Vaglio’s estate “has become obligated to pay

significant medical bills and other expenses,” id. ¶ 24, and his “widow . . . has lost

his pension, his social security, medical insurance, and the value of his services

and incurred expenses for medical care, funeral services[,] and interment,” id. ¶ 25.

Taken in a light most favorable to Franza, these assertions set forth a prima facie

claim of negligence.

                                         VI.

      In sum, the allegations in Franza’s complaint plausibly support holding

Royal Caribbean Cruises, Ltd., vicariously liable for the medical negligence of its

onboard nurse and doctor. Because Franza adequately pled all of the elements of

both actual and apparent agency, we hold that Franza may press her claims under

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either or both theories. Accordingly, we reverse and remand for further

proceedings consistent with this opinion.

      REVERSED AND REMANDED.

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