Court Opinion

ID: 9748039
Source: CourtListenerOpinion
Date Created: 2023-08-27 15:49:50.041137+00
Date Added: 2024-06-11T07:25:30.862310
License: Public Domain

*418HANDLER, J.,
concurring.
In this difficult cancer malpractice case the Court has ruled that the trial court, and the Appellate Division affirming, erred in refusing to recognize that plaintiff Merle Evers, victimized by defendant’s failure to make a prompt and effective diagnosis of her malignancy, had proved substantial consequential injuries. The Court has decided that it was error to enter judgment for defendant at the close of plaintiff’s proofs since plaintiff had established sufficient evidence of physical injury. The uncontested evidence that the physical enlargement of plaintiff's malignant breast tumor as well as the infiltration or increased infiltration of the cancerous cells into the duets surrounding the original site of the tumor arguably constitute injuries proximately caused by defendant’s negligence. The Court also recognized that plaintiff was prepared to prove, and should have been permitted to prove, that she suffered anxiety, emotional distress and mental anguish as a result of her realization that defendant’s misdiagnosis and the resulting delay in proper treatment increased the risk that she would suffer a life-threatening recurrence of cancer. I subscribe completely to these conclusions.
It would follow from these determinations alone that plaintiff is entitled to a remand and a retrial with the opportunity to establish these damages. I therefore find great significance in the Court’s additional conclusion concerning another element of damages that will be available to plaintiff on the remand. The Court concludes that plaintiff is entitled to prove that defendant’s alleged negligence in delaying proper treatment resulted in an increased risk of metastasis and that such increased risk was a substantial factor in bringing about plaintiff’s post-trial recurrence of cancer. Since at this time the potential harm attributable in part to defendant’s malpractice has actually occurred in a form of metastasis capable of clinical detection, the Court is willing to permit consideration of the unquantified increased risk of such harm as an element of damages. The Court accepts the application of Restatement (Second) of Torts § 323(a) (1965) *419to this kind of medical malpractice case, reducing plaintiffs burden of proof to a threshold of substantial likelihood, that is lower than the traditional standard of reasonable medical probability (Coll v. Sherry, 29 N.J. 166, 175 (1959)).
I fully endorse these holdings. Actual increased risk of harm, even though not measurable or quantifiable, in the context of medical malpractice is sufficiently demonstrable to justify its recognition as a compensable form of injury. The relaxation of plaintiff’s burden of proof under these circumstances to allow the recognition of and redress for such injury fairly and justly ameliorates the traditional burden of proof that would render establishment of this kind of injury unnecessarily difficult.
Because in this case, as it has unfolded during the pendency of the appeal, the increased risk — the possibility of cancer recurrence — “has now become a reality,” the Court feels it “need not determine whether the unquantified (and unquantifiable) but nevertheless certain increase in the risk standing alone, [i.e., without a recurrence of cancer] is sufficient injury to sustain plaintiff’s cause of action.” Ante at 406; 412 n. 7. Perhaps not. However, when this case was tried, the harm from the increased risk had not yet become a reality. Many cancer patients whose condition has been made worse because of an unreasonable delay in proper diagnosis and treatment may not have suffered an ultimate harm when they realize they have been the victims of malpractice. I think it is therefore entirely appropriate and extremely needful that this issue — whether such an increased risk of an ultimate harm may constitute a compensable injury even though that harm has not yet eventuated — be addressed.
I
At the outset, it is important to point out that even if plaintiff were not otherwise entitled to a remand and retrial, the subsequent recurrence of cancer following the trial itself justifies the grant of a new trial. The Court considers that the question *420raised by plaintiff’s motion for a new trial on the ground of the post-trial recurrence of cancer may be “technically moot” because plaintiff is otherwise entitled to a remand, ante at 412. However, the question of whether this recurrence of cancer standing alone would merit a retrial clearly ought to be resolved. This situation can arise in countless cases involving malpractice. Further, the increased risk of harm complete with the recurrence of cancer is now recognized by the Court as a relevant additional injury on the remand even though it has occurred after the trial.
Mrs. Evers was clinically cancer-free at the time of her trial in May 1981, three and one-half years after she underwent a radical mastectomy in October 1977. However, according to the motion brought by her attorney on this appeal, by July 1983 she had suffered a recurrence of cancer, clinically verified by breast cancer cells found in her lung, some six years after her original surgery and more than two years after trial.
Such evidence, which is the subject of plaintiff’s motion for a new trial, should be regarded as newly discovered evidence. R. 4:50-1(b). Clearly the continued existence or presence of cancerous cells in her body, following corrective surgery, was not discoverable or previously known. Presumably, available scientific and medical technology was incapable of detecting such underlying cancer or micrometastasis. Consequently the recurrence of cancer should be regarded as newly discovered evidence when it is clinically diagnosed. Because the recurrence of cancer is the exact harm that she risked suffering as a result of defendant’s malpractice, it is a significant consequential injury that should be included in an assessment of plaintiff’s total damages. This evidence is unquestionably highly relevant to plaintiff’s cause of action and damages claims. Recognition of such evidence as within the purview of R. 4:50-1(b) would then allow in a single action all relevant and material elements of injury and damages, including those related to the recurrence of *421the cancer and the unquantified enhancement of risk of that harm.
II
I consider that the linchpin of the Court’s explication of the nature and scope of legally cognizable medical injury in a case such as this, involving negligent delay in the proper treatment of cancer, is the actuality of an increased risk of a recurrence of the cancerous condition. The Court recognizes in this case that as a result of the malpractice, Mrs. Evers did in fact suffer an actual increased risk that the cancer would recur, demonstrated wholly apart from the fortuitous circumstance that subsequent to the trial plaintiff again fell victim to the cancer. Ante at 406. However, such enhancement of risk is recognized by the Court as a compensable injury only because plaintiff has experienced a recurrence of cancer. The Court rules that this evidence — the increased risk of harm plus the harm itself — may be proved at a new trial in which the damages issues will have been expanded in light of changed circumstances.
I do not dispute the significance of resultant harm in the overall analysis of medical injury and assessment of damages. I do not believe, however, that such resultant harm constitutes a sine qua non, a condition precedent before there can be recovery for an actual albeit unquantified increase in the risk of such harm. The Court is here troubled by a seeming inability to quantify the risk of future cancer. But, adding the incurrence of future harm as a requirement for the recovery for such increased risk does not resolve the dilemma since the risk still remains unquantified. Yet, insistence that the harm occur as a condition for recovery does unfortunately add greatly to the legal burdens of cancer victims. The inadvertent effect of such a court rule is that those victims, who undeservedly have been put in greater peril in terms of their survival, are not permitted to be compensated for this peril unless they have suffered a resurgence of their cancer.
*422Medical science itself cannot quantify the increased risk of cancer in such victims.1 Nevertheless, medical science does acknowledge the existence of an increased risk. This should be sufficient to satisfy the standard of reasonable medical probability that we generally recognize. Coll v. Sherry, supra, 29 N.J. at 175.
In this case, it was established that, without any negligence on the part of the doctor in treating plaintiff, she was exposed to at least a 25 percent risk or probability that she would again become a cancer victim. Thus, plaintiff should be required to prove only that defendant’s malpractice and the resultant delay in receiving proper treatment increased the probability that she would fall into the 25 percentile of persons who suffer recurrence. Stated somewhat differently, the plaintiff should be required to prove simply that (1) absent defendant’s malpractice she had a 25 percent chance of suffering a recurrence of cancer and (2) because of defendant’s malpractice, there is a probability greater than 25 percent that she will suffer such a recurrence and a concomitant diminishment of her chance of survival.
I approve of the Court’s reliance on the Pennsylvania line of cases recognizing that the complexities of certain medical malpractice actions require a more flexible standard of causation than conventional tort claims. This is appropriate in order to prevent a tortfeasor from being unfairly insulated from the real but elusive consequences of his negligent conduct. A tortfeasor should not be allowed to escape responsibility for causing an increased risk that would not have existed but for his negligence simply because of the statistical uncertainty of the risk.
*423Such cases by their very nature elude the degree of certainty one would prefer and upon which the law normally insists before a person- may be held liable. Nevertheless, in order that an actor is not completely insulated because of uncertainties as to the consequences of his negligent conduct, Section 323(a) [of Restatement (Second) of Torts (1965) ] tacitly acknowledges this difficulty and permits the issue to go to the jury upon a less than normal threshold of proof. [Hamil v. Bashline, 481 Pa. 256, 271, 392 A.2d 1280, 1287-88 (1978) (footnote omitted).]
See also Jones v. Montefiore Hosp., 494 Pa. 410, 431 A.2d 920 (1981); Gradel v. Inouye, 491 Pa. 534, 421 A.2d 674 (1980), applying this principle to cancer medical malpractice cases.
The Pennsylvania court in Hamil held that unquantified increased risk due to defendant’s negligence is an actionable injury once the harm has in fact ensued; if the jury determines that the increased risk was a substantial factor in producing the actual harm, the plaintiff will prevail. While the cited cases relied on by the Court have all involved situations where such future harm in fact occurred, that circumstance should not be regarded as indispensable in demonstrating the existence of medical injury. The significance of these decisions is that once the basic fact that the risk had increased to some degree had been proved to a reasonable medical probability, none required the increased risk of future cancer attributable to a defendant’s malpractice be measured or quantified.
In James v. United States, 483 F.Supp. 581 (N.D.Cal.1980), the court viewed the unquantified loss of the chance of survival caused by delayed treatment as constituting compensable injury in and of itself even while the plaintiff remained alive. In James, plaintiff’s chest x-ray and radiologist’s report disclosing an abnormality were inadvertently filed without being reviewed by the examining physician of plaintiff’s prospective employer. Two years later plaintiff was diagnosed as having lung cancer. Plaintiff’s experts concluded on the basis of the tumor’s size that it had probably metastasized since the negligent oversight and that earlier radiation treatment would have decreased its size and reduced the risk of metastasis. Id. at 587. Although plaintiff continued to live, the court awarded damages for the *424unquantified but actual increased risk of death, as well as the accompanying mental anguish arising from the awareness of this increased risk.
As a proximate result of defendant’s negligence, James was deprived of the opportunity to receive early treatment and the chance of realizing any resulting gain in his life expectancy and physical and mental comfort. No matter how small that chance may have been — and its magnitude cannot be ascertained — no one can say that the chance of prolonging one’s life or decreasing suffering is valueless. [Id. at 587.]
The increased risk of a recurrence of cancer due to delayed treatment is so obvious that it is a cruel irony to insist that a cancer victim again be stricken in order to receive just compensation for medical injuries. In this case, the medical testimony of the increased risk of future cancer was unimpugned. This medical testimony established that plaintiff was at a greater risk of future metastasis on account of the delay in receiving proper treatment. As recapitulated by the Court, both plaintiffs medical experts were of the opinion that defendant’s malpractice — the untimely diagnosis and the delayed treatment of the malignancy — increased the chances that plaintiff would suffer a recurrence of the cancer. Ante at 404-405.
Harm in the form of increased risk of future cancer attributable to delay in diagnosis and treatment has become so widely accepted by the medical community that the existence of such harm could be reasonably inferred from this professional common knowledge. A survey of the medical literature indicates that it is universally agreed within the medical community that delay in cancer diagnosis and treatment usually increases the risk of metastasis.2 Thus, the inference of harm from delayed *425treatment would be permissible, aside from expert testimony explaining the etiology or physiological nature of such harm. See Buckelew v. Grossbard, 87 N.J. 512, 528-29 (1981) (Testimony of plaintiff’s expert witness created a permissible inference of negligence on the basis that his opinion represented the “common knowledge within the medical community that the type of accident that took place in this case does not ordinarily occur in the absence of the surgeon’s negligence” and siich knowledge was based on experience rather than intuition.). Indeed, the Court, pursuant to Evid.R. 9(2)(e), arguably could take judicial notice of this literature and the evidential inferences which it generates. See Calabrese v. Trenton State College, 82 N.J. 321, 325 (1980) (Existence and extent of the risk of harm involved in administering a series of anti-rabies injections could be established by use of medical reports of treating physicians, medical depositions, and use of extensive medical literature pursuant to Evid.R. 9(2)(e), providing for judicial notice of “specific facts and propositions of generalized knowledge which are capable of immediate determination by resort to sources of reasonably indisputable accuracy.”); see also James v. United States, supra, 483 F.Supp. at 586 (“Plaintiff may *426demonstrate the benefit of earlier treatment in his case by relying on general theories of appropriate medical treatment.”).
Further, common knowledge and informed lay testimony can augment the opinion of medical experts concerning the relationship of delayed diagnosis and treatment to the spread of cancer. Information about this causal relationship is widely disseminated.3 The general public accepts the causal relationship between delay in treatment and metastasis; it understands the official and popular vocabulary of urgency stressing the imperative of early detection to prevent metastasis. Indeed, this common knowledge is endorsed and encouraged by the medical profession itself.4 Whether such information is accurately absorbed by the *427average person or not, it can be used by fact-finders in their consideration of the existence and nature of injury. See Klimko v. Rose, 84 N.J. 496, 503-04 (1980).5
In a case such as this, the medical evidence as reflected by the experts at trial and in discovery, as well as that available through published medical literature and the common knowledge of the general public, serves to establish that plaintiff was at a greater risk of future metastasis on account of the delay in receiving proper treatment. This conclusion is strengthened by the evidence in this case of the concomitant growth in the size of the tumor during the time proper treatment was withheld from the plaintiff, which growth alone the Court properly recognizes as a compensable form of injury. Ante at 407-409.
There is clearly a correlation of size and prognosis — between the increase in the size of a malignant tumor and the increased risk of metastasis. The Court acknowledges that this increase in the size of the tumor during the delay in proper treatment attributable to defendant’s malpractice is negatively related to prognosis.6 Ante at 409 n. 4. The same logic and common *428sense that allows an award of damages for unquantified increased risk to cancer victims who exhibit positive lymph nodes at the time of surgery or thereafter (see Jones v. Montefiore Hosp., supra, 494 Pa. 410, 431 A.2d 920) justify damages to plaintiffs who also have established an identical increased risk but whose lymph nodes are negative for metastasis.7
The following observation was made in a somewhat variant context raising similarly perplexing problems in understanding the nature of physical and psychic injury and the appropriate assessment of damages:
Indeed, the collective wisdom of the community on the proper redress for a particular harm, informed by experience, common sense, and a desire to be fair to the parties, seems an acceptable way of arriving at a damage verdict and probably one that is preferable to a more scientific (and sterile) process that *429excludes nonquantifiable elements to achieve an aura of objectivity and precision. [Capron, “Tort Liability in Genetic Counseling,” 79 Colum.L.Rev. 618, 649 (1979) (citing Story Parchment Co. v. Paterson Parchment Paper Co., 282 U.S. 555, 563, 51 S.Ct. 248, 250, 75 L.Ed. 544 (1931)).]
In my opinion there was an ample evidential basis in this case at the time of trial for recognizing the unquantified increased risk of future cancer as a compensable form of medical injury and an element of damages independent of an actual recurrence of cancer. The expert opinion in this case is buttressed by the shared understanding of the medical profession itself and comports with the common knowledge and experience of the public-at-large. The widespread acknowledgement of this unquantified increased risk of future metastasis due to delayed diagnosis and treatment and its critical correlation with growth in size of a malignancy, which is recognized by the Court as an actionable claim, justifies awarding damages notwithstanding the absence of an absolute quantification that is beyond the current capacity of science.
Failure to do otherwise is grossly unfair to cancer patients victimized by medical malpractice. It deprives them of rightful compensation while burdening them with the need to pursue multiple and successive claims. By insisting that the harm be incurred before entitlement to a claim exists, no action for an actual but unquantified enhancement of risk could be brought before that unforeseeable time jvhen a plaintiff experiences a recurrence of disease. Such a rule may very well force a plaintiff to engage in multiple suits in order to recover adequate damages for all injuries proximately attributable to the medical malpractice. No sound policy is served by needlessly encouraging successive actions based upon a single tort, with the consequent potential for complexity of issues, duplication of claims, and confusion in results. Cf. Alfone v. Sarno, 87 N.J. 99 (1981) (Although parties and interests are different in decedent’s own personal injury suit and wrongful death action, defendant should be required to litigate only once the substantive issues *430deriving from a single act of negligence, and elements of damages should not be duplicated.).
For these reasons, I write separately while concurring in the judgment of the Court.
HANDLER, J., concurring in the result.
For reversal and remandment — Justices CLIFFORD, SCHREIBER, HANDLER, POLLOCK, O’HERN and GARIBALDI — 6.
For affirmance —None.

 In this case, for example, plaintiffs cancer cells found first in the original breast tumor have now migrated to the lung, according to the certification annexed to plaintiffs motion for a new trial. Despite a pathology report negative for metastasis at the time of plaintiffs radical mastectomy almost six years earlier, this recurrence accentuates the inadequacy of medical science to detect micrometastasis — the clinically undetectable spread of cancer — and thus statistically assess increased risk, as well as emphasizing that this risk is absolutely real though eluding quantification.

 ExampIes of the acceptance of this knowledge within the medical community are numerous; experts continuously urge vigilant detection as the most realistic means of improving prognosis, viz: Clinical Oncology for Medical Students and Physicians at 33 (P. Rubin 3d ed. 1970-1971) (“The passage of time versus the spread of tumor: Most specialists in clinical cancer feel very strongly that the earlier one makes a diagnosis of cancer, the greater is the chance for cure .... [I]n breast cancer we do know that: 1. The bigger the tumor, the worse the prognosis .... Both of these factors are related to the *425passage of time. This concept of 'the earlier the better' is the basis for attempts at the early diagnosis of cancer.”); Dohrmann, McDermott & Price, “Symptom Duration, Tumor Staging and Survival in Patients with Carcinoma of the Breast,” 154 Surgery, Gynecology, and Obstetrics 707 (1982) (“Earlier treatment is generally believed to improve survival prospects in patients with carcinoma of the breast.”); Id. at 710 (“Cancer specific survival time was better for the total patient series and for those treated by potentially curative operation when symptoms had been present for one week or less as compared with those who had symptom duration of six months or more, p = 0.007. Survival prospects were also better in those patients who had symptoms from one week to one month as compared with those who had six months or more symptom duration, p = 0.005. These results indicate that patients in whom diagnosis is made and operation performed early in the symptomatic phase of carcinoma of the breast have less advanced tumors and better survival prospects.”).

 U.S. Dept. of Health and Human Services, The Breast Cancer Digest 95 (1980) alludes to communication efforts for mass audiences, as well as the results of a study in 1977 comparing the effectiveness of alternative breast cancer public education programs. See also Cancer Control at 60 (I. Kessler ed. 1980) which refers to programs advocating early diagnosis sponsored by the American Cancer Society during the last 25 years. The messages are universal, e.g., “For these reasons cancer research scientists have long looked for methods of detecting or finding breast cancer early in its growth before it has had a chance to spread to other parts of the body.” National Cancer Institute, Breast Exams: What You Should Know 1 (1981); “The real hope for the future is in earlier detection .... At present, the key to saving more lives from breast cancer is earlier detection and treatment.” American Cancer Society, Inc., Facts on Breast Cancer 14 (1982); “At the beginning, cancer cells usually remain at their original site, and the cancer is said to be localized .... If left untreated however, the cancer is likely to spread throughout the body.” Id. at 4; “Because with each stage a case of cancer becomes progressively serious, it is important to detect cancer as early as possible.” Id. at 4; “The therapeutic consequence of the detection of a tumor in Stage I is that, if it can be located, removal would prove truly curative.” Cancer Control, supra at 59; "Until breast cancer can be prevented, the greatest hope for its control is early detection, diagnosis, and treatment.” The Breast Cancer Digest, supra at 17.

 One of plaintiffs experts, Dr. Janis, stated at deposition in this case: “I have to tell you what everybody, including a layman knows, namely, that one can expect a complete cure of cancer with surgery only if the tumor is completely removed before it spreads to distant sites [metastasis]. The longer a malignant tumor remains in the body, the greater the chances of *427metastasis.” (Emphasis added). This testimony was heard by the judge outside the presence of the jury.

 The use of common knowledge may be particularly apt in the cancer field. Radiation therapy for cancer is an example of the expansion of the doctrine of common knowledge. Compare an earlier case, Dietze v. King, 184 F.Supp. 944, 946 (E.D.Va.1960) (effects of radiation therapy not within common knowledge) with a later decision, ZeBarth v. Swedish Medical Center, 81 Wash.2d 12, 20, 499 P.2d 1, 7 (1972) (“high voltage radiation in the treatment of cancer has been widely enough and long enough employed in this country to allow the jury to find that, within the experience and observation of mankind, myelopathy or paralysis ordinarily will not result from its use ____”); Dahlquist, “Common Knowledge in Medical Malpractice Litigation: A Diagnosis and Prescription,” 14 Pac.L.J. 133, 135 n. 4 (1983).

 This correlation is so strong that even patients such as plaintiff whose lymph nodes were negative for metastasis at the time of her mastectomy may have no better chance for survival than patients whose cancer has already metastasized into the lymph nodes. The risk of recurrence is frequently more affected by the size and growth of a malignancy, correlated with delayed *428treatment, than it is to actual metastasis at the time of detection. See, e.g., Fracchia, Rosen & Ashikari, “Carcinoma of Breast Without Axillary Lymph Node Metastasis,” 151 Surgery, Gynecology & Obstetrics 375, 376 (1980) (“Recurrence was more frequent with an increase in size of the primary carcinoma. Usually, the survival rate paralleled the frequency of recurrence, and both were associated with tumor size____”) This is true even as to a person, like plaintiff, whose lymph nodes were negative for metastasis. Id. at 377 (“The likelihood of recurrence among patients with negative [lymph] nodes, was directly related to the size of the primary tumor, being less with smaller carcinomas and more frequent with larger lesions. In this respect, patients with, or without metastasis, in the axillary lymph nodes are similar.”).

 In this case, it is logical that unquantified increased risk of metastasis is also compensable as a future consequence of the existent harm of the enlarged tumor, even without the post-trial recurrence of cancer. Once she has proved actual harm, plaintiffs action for damages for future metastasis is analogous to the Pennsylvania case cited by the Court that awarded damages not only for an unquantified increased risk of harm that was a substantial factor in bringing about the resultant harm, according to Restatement (Second) of Torts § 323(a), but also for unquantified future risk resulting from that harm. “[A] doctor properly may be allowed to explain the possible future effects of an injury, and with less definiteness than is required of opinion testimony on causation. Consequently, it was not improper for the jury to consider the possibility of future metastasis in awarding damages.” Gradel v. Inouye, supra, 491 Pa. at 546, 421 A.2d at 680.