Articles Posted in Medical Malpractice Law in Maryland

The Maryland Court of Appeals has issued a new decision on the law of informed consent in Maryland medical malpractice cases. According to the court, doctors must inform patients not only of the risks of procedures but also the potential consequences of forgoing a medical procedure. The decision is a victory for patient’s rights.

A number of years ago, the Maryland Court of Appeals held that informed consent only applied when there was some physical contact with the patient. The Court’s new decision, however, removed that limitation.

As an experienced Baltimore, Maryland medical malpractice lawyer, I have handled a large number of informed consent cases. In any medical malpractice case, it is always important for a lawyer to ask whether the patient was properly informed of risks, alternatives, probabilities of success and failure and other considerations that bear on what was important to the patient. To see some of the cases I have handled, click here.

Maryland has enacted significant limitations on the ability of Plaintiffs to use expert witnesses in Maryalnd medical malpractice cases. In 1976, the Maryland Health Claims Arbitration Act was enacted to help address a perceived medical malpractice insurance crisis. In 1986, the legislature further amended the Act to include a certificate of qualified expert requirement. As proposed in Senate Bill 559, an expert only would be qualified to sign a certificate if he or she did not receive 50 percent or more income from testimony and other activities related to personal injury claims. That language was amended to become the 20 Percent Rule; i.e., in order to qualify, a certifying expert cannot devote more than 20 percent of his or her professional activities to activities directly involving testimony in personal injury claims. The dichotomy that the General Assembly sought to reconcile was the desire, on the one hand, to exclude certain “professional witnesses” from the “pool of eligible experts” available to sign certificates of merit, while on the other, it did not want to “shrink” the size of that pool so as to “deny the parties the ability to pursue and defend these [malpractice] claims.” This balance was achieved by the aforementioned language changes which “keyed the critical numerical measurement to time, instead of income,” and narrowing the activities described as “related to” personal injury claims to the more circumscribed world of activities “directly involving testimony in personal injury claims.”

In December 2004, a Maryland General Assembly Special Session passed further amendments to the Act, addressing the issues of how much and what kind of experience an expert witness must have to be qualified to execute a certificate of merit or to testify before a panel or court on the issue of a defendant’s compliance with the standards of care. Those amendments require that a certifying or testifying expert witness: “have had clinical experience, provided consultation relating to clinical practice, or taught medicine in the defendant’s specialty or a related field of health care, or in the field of health care in which the defendant provided care or treatment to the plaintiff, within 5 years of the date of the alleged act or omission giving rise to the cause of action . . .”

When most people think of a medical malpractice case, they think about the kind of case in which the plaintiff (the party bringing the case) claims that a doctor of hosptial has acted below the standard of care and caused significnat injury in a patient. Another type of medcial malpractice case, however, inolves what is called “informed consent.” In the seminal case of Sard v. Hardy, the Maryland Court of Appeals held that the doctrine of informed consent follows logically from the universally recognized rule that a physician treating a mentally competent adult under non-emergency circumstances, cannot properly undertake to perform surgery or administer other therapy without the prior consent of his patient. The fountainhead of the doctrine of informed consent is the patient’s right to exercise control of his own body. In order for the patient’s consent to be effective and “informed,” it must have been one that is given after the patient received a fair and reasonable explanation of the contemplated treatment or procedure.

In determining the proper test for measuring the scope of a physician’s duty to disclose risk information, Maryland courts are clear. The appropriate test is not what the physician, in the exercise of his medical judgment thinks a patient should know before acquiescing in a proposed course of treatment, but what the particular patient needs in order to make an intelligent decision. That need is whatever “is material to the patient’s decision. A material risk, in turn, is one which a physician knows or ought to know would be significant to a reasonable person in the patient’s position in deciding whether or not to submit to a particular medical treatment or procedure. In short, whether a physician has fulfilled his duty to disclose, is to be determined by reference to a general standard of reasonable conduct and is not measured by a professional standard of care. Importantly, the law does not allow a physician to substitute his judgment for that of the patient.

From the very beginning, the Maryland Court of Appelas has been clear that there is no bright-line test, or all-inclusive list of items that must be disclosed by a physician in order to procure informed consent. Nevertheless, in Sard, the Court identified five categories of information that generally must be communicated to the patient. (1) the nature of the risks inherent in a particular treatment; (2) the probabilities of therapeutic success; (3) the frequency of the occurrence of particular risks; (4) the nature of available alternatives to treatment; and (5) whether or not disclosure would be detrimental to a patient.

Many of my Maryland medical malpractice clients ask me whether there is any possibility that they can claim or recover punitive damages in their cases. The answer in every case is no. In Maryland, in order to recover puntive damages, the Maryland Court of Appeals (Maryland’s “Supreme Court”) decided in the 1992 case of Owens-Illinois, Inc. v. Zenobia, that a person must prove that the defendant acted with “actual malice.” Actual malice has been defined to mean intent to injury, ill will, or fraud. In a medical malpractice case, I have never seen a case where a physicain intended to injure a patient, or where there was ill will toward a patient that caused injury. Similarly, I have never seen a case of fraud in a medical malpractice case that injure a patient. While I suppose it could happen, it almost never does.

There are, however, times when punitive damages can be claimed in a medical malpractice case involving a defective product. In Zenobia, the Court of Appeals held that in order to prove a claim for punitive damages, a plaintiff must plead and then demonstrate: (1) that the defendant possessed actual knowledge of the product defect; and (2) that the defendant consciously and deliberately disregarded a foreseeable harm that might result from the defect. With respect to a product manufacturer, the Zenobia Court cited with approval academic commentary which stands for the proposition that manufacturer’s requisite level of knowledge “is usually gained through…testing procedures before the marketing or through post-marketing consumer accident reports and complains received by the defendant.” Additionally, actual knowledge also includes the willful refusal to know. Therefore, a defendant cannot shut his eyes or plug his ears when he is presented with evidence of a defect and thereby avoid liability for punitive damages. Id. Simply put, “the test requires a bad faith decision by the defendant to market or distribute the product, knowing of the defect and danger, in conscious disregard of the threat to the safety of those who will be exposed to the product.” While this is not an easy standard to meet, it can be met, and has been met in many cases, where evidence supports such a claim.

Many peole ask what type of damages they can get in a medical malpractice / medical negligenc cases. One type is lost wages. Maryland courts have repeatedly acknowledged the legitimacy of lost wage claims in negligence cases. For instance, in Adams v. Benson, 208 Md. 261, 270-271, 117 A.2d 881, 885 (1955), the Court of Appeals recognized: “That in an action for personal injuries caused by the negligence of the defendant, the plaintiff may recover not only for the consequences which have actually and naturally resulted from the tort, but also for those which may certainly or reasonably and probably result therefrom as proximate consequences, but not for consequences which are speculative or conjectural.” The Court then recognized that in a personal injury action, a plaintiff may claim: “damages for (1) resulting loss of time and loss of earnings; (2) loss or diminution of earning capacity sustained by being temporarily deprived of her capacity to perform her ordinary labor, and (3) loss of future earnings, if shown with reasonable certainty and not merely speculative in character”. Id., 208 Md. at 271, 117 A.2d at 885.

Additionally, in Lumber Terminals Inc. v. Nowakowski, 36 Md. App. 82, 89, 373 A.2d 282, 287 (1977), the Court of Special Appeals held that, “In personal injury cases courts generally, and Maryland particularly, consider among other losses lost wages and earnings suffered by the injured person not only from the time of the injury to trial, but those reasonably certain to occur in the future.” That Court recognized, “In short, the measure of damages, broadly stated, is the amount which will compensate the injured person for all losses he has sustained by reason of the injury.” Id., 36 Md. App. at 92, 373 A.2d at 289; see also Monias v. Endal, 330 Md. 274, 623 A.2d 656 (1993) (“In an action for personal injuries, a plaintiff may recover for loss of future earnings which will reasonably and probably result from the tort.”).

Generally, recovery in Maryland for malpractice against a physician/psychiatrist is allowed only where there is a relationship between the doctor and patient. This relationship may be established by contract, express or implied, and the fact that a physician does not deal directly with a patient does not necessarily preclude the existence of a physician-patient relationship.

Complaints of malpractice and intentional infliction of emotional distress with regard to third parties have been reviewed by Maryland Courts. In the case of Dehn v. Edgecombe, 384 Md. 606 (Md. 2005), Mr. Dehn underwent a vasectomy. According to Mr. Dehn, his primary care physician advised him that he could resume engaging in unprotected intercourse with his wife without fear of pregnancy, despite the fact that requisite tests had yet to be performed. Mrs. Dehn subsequently became pregnant and sued her husband’s primary care physician, claiming that the physician had negligently counseled her husband. The Court held that there was no independent cause of action for a patient’s wife against a doctor who acted negligently while treating her husband because there was no relationship or direct interaction with the wife.

There are exceptions to this rule. For example, when a physician undertakes to act gratuitously or in an emergency situation, a duty may be created, but such exceptions are rare, particularly when the doctor never provided any treatment to the person alleging negligence. Dehn v. Edgecombe, 384 Md. 606 (Md. 2005). Therefore, this case does not appear to fall within one of these exceptions.

“The common law duty of care owed by a health care provider to diagnose, evaluate, and treat its patient ordinarily flows only to the patient, not to third parties. Thus, it has often been said that a malpractice action lies only where a health care provider-patient relationship exists and there has been a breach of a professional duty owing to the patient.” Dehn v. Edgecombe, 384 Md. 606 (Md. 2005).
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A New York trial judge has ordered a new trial on damages in the malpractice case of a businessman left permanently paralyzed after a stroke. The plaintiff was awarded $5 million in April after a jury trial. The judge, however, set aside the verdict last week with respect to damages, finding that the award was too low. The judge then entered judgment for approximately $18.4 million. Specifically, the judge found that the jury’s award of $1 million each for past and future pain and suffering to the plaintiff and his family deviated materially from what would be fair compensation, and thus increased the award to $5 million each. The plaintiff contended in the case that doctors at a hospital failed to diagnose what they called “classic symptoms” of a brain aneurysm that led to the stroke.

In Maryland, whether in medical malpractice cases or otherwise, it is possible for judges to increase or decrease a jury verdict, but it is very rare that judges increase such verdicts. It is practically unheard of for judges to increase a verdict so much.

The Massachusetts Supreme Court issued a written decision yesterday in a medical malpractice case, finding that doctors can be held liable for medical negligence that reduces a patient’s chance of survival, even if the patient’s probability for recovery was already less than 50 percent. The Massachusetts Supreme Court’s ruling came in a closely watched medical malpractice case. In 2004, a jury awarded $1 million to the family of a man whose cancer was overlooked by a doctor. The court upheld the jury’s award in its decision, ruling that Massachusetts law is such that if a doctor’s negligence reduces or eliminates the patient’s chance for recovery, the doctor still is liable for damages. A copy of the article regarding the case can be found here.

In Maryland medical malpractice cases, the law is different than in Massachusetts. In Maryland, in a case where a plaintiff seeks to prove that a doctor or hospital’s negligent failure to diagnose and/or treat cancer case has or will cause them to die, the plaintiff must prove that the doctor or hospital’s conduct caused them to go from having a probability of surviving the cancer (something greater than 50 percent) to having a probability of not surviving the cancer (something less than 50 percent). I have had many such cases. But if a patient only had a 40 percent probability of surviving the cancer before the malpractice, and now due to the malpractice the patient only has a 20 percent chance of surviving the cancer, that is considered a “loss of chance,” which Maryland does not recognize.

Under Maryland Rule 2-501(a), summary judgment is only appropriate where there is no dispute of material fact and the moving party is entitled to judgment as a matter of law. Therefore a motion for summary judgment should be denied where the opposing party has shown that “there is a genuine dispute as to a material fact by proffering facts which would be admissible as evidence.” Beatty v. Trailmasters Products, Inc., 330 Md. 726, 737 (1993). “A material fact is a fact the resolution of which will somehow affect the outcome of the case.” Carter v. Aramark Sports and Entertainment, 153 Md.App. 210, 224 (2003) (quoting Sterling v. Johns Hopkins Hosp., 145 Md.App. 161, 167 (2002), cert. denied, 371 Md. 264 (2002)).

“When ruling on a motion for summary judgment, a court must view the facts, including all inferences drawn therefrom, in the light most favorable to the opposing party.” Carter, 153 Md.App. at 224, (citing Sterling, 145 Md. App. at 168, quoting Jones v. Mid-Atlantic Funding Co., 362 Md. 661, 676 (2001)). “The moving party bears the burden of establishing the absence of a genuine issue of material fact.” Carter, 153 Md.App. at 224, (citing Sterling, 145 Md.App. at 168, citing Adickes v. S.H. Kress & Co., 398 U.S. 144, 157 (1970)), therefore the Defendant must show the absence of disputed facts. Furthermore, the standard is such that the trial court is not to draw inferences in favor of the moving party. Rather, if the facts are undisputed, but these facts “are susceptible of more than one permissible inference, the choice between those inferences should not be made as a matter of law.” Carter, 153 Md.App. at 225, (citing, Porter v. General Boiler Casing Co., 284 Md. 402, 413 (1979), quoting Fenwick Motor Co. v. Fenwick, 258 Md. 134, 138 (1970)).
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Maryland is one of the many states that cap, or limit, certain types of damages in medical malpractice cases. Under current Maryland law, medical malpractice damages for pain, suffering and emotional distress are capped at $650,000. That cap will not change until the end of this year (December 31, 2008), when the cap is scheduled to begin increasing $15,000 per year. A jury can award whatever it wants for pain, suffering and emotional distress, but if it awards more than the cap, the judge is required to reduce the verdict to no more than the cap.

The type of damages that are capped in Maryland medical malpractice cases – pain, suffering and emotional distress – are called non-economic damages. Economic damages, on the other hand, such as past and future lost wages, past and future medical expenses, and lost household services, are uncapped in Maryland.

The Maryland statute that sets forth the cap on medical malpractice cases specifically states that the jury shall not be told about the cap. Thus, everyone in the courtroom knows about the cap except for the jury that is making the decision on damages.