Physicians May Be Held Liable for Accidental Harm Done to Others by Their Patients in the Course of Treatment
In Coombes v. Florio, 877 N.E.2d 567 (Mass. 2007), the Supreme Judicial Court of Massachusetts considered whether physicians have a duty to parties put at risk by their patients in the course of treatment. Lyn-Ann Coombes sued Dr. Roland Florio for negligence when her son Kevin was killed by Dr. Florio's patient in an automobile accident.
Facts of the Case
In 2002, 10-year-old Kevin Coombes died after being struck by an automobile driven by David Sacca. Mr. Sacca was a 75-year-old man with numerous medical problems including asbestosis, chronic bronchitis, emphysema, high blood pressure, and metastatic lung cancer. He had never before been in an accident or received a traffic ticket.
Mr. Sacca was under the primary care of Dr. Florio, who coordinated his specialists and was responsible for his medication. Dr. Florio told him that it would be unsafe to drive during his treatment for cancer. Following his recommendations, Mr. Sacca did not drive again until the fall of 2001 when his cancer treatment concluded, and Dr. Florio said that he could drive. Dr. Florio's last visit with Mr. Sacca before the accident was on January 4, 2002.
On March 22, 2002, Mr. Sacca lost consciousness while driving and killed Kevin Coombes as he stood on a sidewalk. Mr. Sacca was taken to a hospital but left against medical advice. The cause of the accident was never determined. Mr. Sacca died four months later.
At the time of the accident, Mr. Sacca had the following prescriptions from Dr. Florio: oxycodone, metolazone, prednisone, tamsulosin, potassium, paroxetine, oxazepam, and furosemide. Mr. Sacca reported neither side effects nor trouble driving anytime before the accident. Ms. Coombes sued Dr. Florio for negligence.
Ruling
A Massachusetts trial court granted summary judgment in favor of Dr. Florio finding that he owed “no duty of care to anyone other than his own patient.” Ms. Coombes appealed, and the case was heard by the Supreme Judicial Court of Massachusetts. In a four-to-two decision, the court reversed and remanded the trial court decision for summary judgment for further proceedings.
Reasoning
In their discussion, the justices focused on three arguments made by Ms. Coombes. First, Dr. Florio was negligent under ordinary common law principles in prescribing medication to Mr. Sacca without warning him of side effects, and his negligence extended to Kevin Coombes because, in an automobile accident, foreseeable risk is not just to the patient but to third parties. Second, when Dr. Florio told Mr. Sacca that is was safe for him to drive, he assumed a future duty to warn him of the dangers of driving when he prescribed medication. Third, the special physician-patient relationship creates a duty of reasonable care toward all those who may be put at risk by the medical care provided.
Majority Decision
The majority agreed that Dr. Florio owed a duty of reasonable care to Kevin Coombes under ordinary negligence principles instead of malpractice, but they did not agree that there was an assumed duty or special relationship. In support, they referred to several nonmedical and medical cases in which parties were held liable for foreseeable consequences caused by the conduct of an intermediary. For example, a liquor store was found negligent for selling alcohol to a minor who later injured a bicyclist. A mother was found liable for a police officer's death when her son, who had a history of violence and psychiatric treatment, killed the officer with a gun that she had improperly stored. A doctor was held liable for a person's death in an automobile accident caused by his patient who was prescribed an eye patch for the treatment of an eye abrasion. In this case, the court ruled that “the general requirement [is] that when a doctor knows, or reasonably should know that his patient's ability to drive has been affected, he has a duty to the driving public as well as to the patient to warn his patient of that fact” (Coombes, p 572, quoting Joy v. Eastern Me. Med. Ctr., 529 A.2d 1364 (Me. 1987)).
They found that an accident was foreseeable, given the number of drugs Dr. Florio had prescribed, Mr. Sacca's age, and Dr. Florio's telling Mr. Sacca that he could safely resume driving. The significant length of time between prescribing the medications and the accident and the fact that Mr. Sacca had been taking them without complaint are irrelevant, because the breach of duty occurred precisely when Dr. Florio failed to warn Mr. Sacca of dangerous side effects.
The majority concluded that this duty of reasonable care is good policy because doctors are already required to warn patients of adverse side effects of medication, and so nothing more is required of physicians. Furthermore, the benefits to the public are clear.
Dissent
The dissenting justices argued that the doctor's failure to warn Mr. Sacca did not extend any duty to the victim; therefore, summary judgment was correctly granted.
They identified two main factors in the discussion: the need for a patient to know and the autonomy of the physician to make judgments about treatment. Physicians are required “to inform their patients of the side effects they determine are necessary and relevant for patients to know in making an informed decision” (Coombes, pp 570–1). This was designed to protect patients and avoid judicial meddling in physician-patient relationships.
By extending a duty of reasonable care to third parties such as Kevin Coombes, physicians would no longer be able to use professional judgment because they would be bogged down by discussing every possible adverse side effect of treatment. Instead of being concerned about patients, they would be forced to deal with “an amorphous, but widespread, group of third parties whom a jury might one day determine to be ‘foreseeable’ plaintiffs” (Coombes, p 581). Furthermore, one cannot compare a physician's professional judgment with the unreasonably dangerous situations of a bar selling alcohol to a minor or a homeowner's failure to store a weapon properly. A physician's duty is to the patient first, not to third parties in the community with whom they have no relationship.
The justices also argued that by extending this duty, confidentiality would be threatened by third parties demanding to know what is discussed between doctors and their patients. It raises questions about how physicians should respond in such circumstances, considering that the duty may conflict with some statutes and professional codes of ethics.
Finally, they feared that it would dramatically increase already high health care costs by inviting a flood of litigation.
Discussion
This case has some similarities to prominent landmark cases studied in psychiatry and the law. In the famous case Tarasoff v. The Regents of the University of California, 551 P.2d 334 (Cal. 1976), a psychologist was sued (along with the university and the campus police) when his patient killed a person whom the patient had threatened. The trial court dismissed the case on summary judgment because doctors historically had had a duty to their patients only, not to third parties. The California Supreme Court overturned the lower court's decision by ruling that, in fact, a doctor does have a duty of reasonable care to third parties if there is a foreseeable danger from a patient.
This ruling opened the door to several notorious cases in which physicians were held liable for third parties injured or killed by patients, even when there was no threat or identifiable victim (Lipari v. Sears, Roebuck & Co., 497 F. Supp. 185 (D. Neb. 1980)). Since then, many state legislatures have passed statutes that limit the Tarasoff duty.
About half of state supreme courts have taken the position adopted by the Supreme Judicial Court of Massachusetts. This case presents a good discussion of conflicting public policies supporting confidentially and the duties physicians may have to third parties.
The majority referred to the duty mental health professionals have to protect third parties. They argued that since society has decided it is reasonable for mental health professionals to breach confidentially, it is reasonable for physicians to do the same. In fact, the social repercussions of doing so are likely to be lower with medical illnesses than with psychiatric illnesses. The dissenting justices were concerned that this would generate an unlimited number of potential third parties who could demand access to physician-patient communications.
They argued that it is best that physicians decide what is appropriate to discuss with their patients. Should physicians now focus less on their patients and more on protecting third parties? For example, should they tell every patient when prescribing a potentially sedating medication “Do not drive. Do not hold your grandchild. Do not carry grocery bags to your car?” They suggested that this intrudes on traditional notions of the physician-patient relationship and would force the physician to be “forever looking over his shoulder.” Furthermore, they pointed out that the majority did not clarify what side effects must be included in such warnings and thus left the matter ambiguous.
The majority argued that the cost of imposing this duty is limited, because tort law already requires physicians to warn a patient of side effects, and the public benefits of doing so are great.
This case forces us to rethink our traditional notions of confidentially and the physician-patient relationship. Of interest, the majority suggests that if the public supports more traditional notions, then it is up to the legislature to pass laws upholding them.
- American Academy of Psychiatry and the Law