In the Missouri Court of Appeals Eastern District DIVISION TWO
JASON D. DODSON & JASON D. ) DODSON, JR., A MINOR & EVA RAINE ) DODSON-LOHSE, A MINOR AND ) AUGUST WILLIAM DAVIS DODSON, A ) No. ED100952 and ED101143 MINOR, SAID MINORS APPEARING BY ) THE DULY APPOINTED NEXT FRIEND ) JASON D. DODSON, ) ) Plaintiffs/Respondents/Cross-Appellants, ) Appeal from the St. Louis County ) Circuit Court vs. ) ) ROBERT P. FERRARA, M.D., AND MERCY ) Honorable Thea A. Sherry CLINIC HEART AND VASCULAR, L.L.C., ) ) Defendants/Appellants/Cross-Respondents. ) Filed: July 21, 2015
Introduction
Dr. Robert P. Ferrara and his employer, Mercy Clinic Heart and Vascular, LLC
(Defendants) appeal the judgment of the trial court, awarding Jason Dodson and his children
(Plaintiffs) $2,181,155 on their wrongful death action. Defendants challenge (1) Plaintiffs’
counsel’s question to Defendants’ expert regarding St. Louis-based physicians; (2) the
admissibility of evidence that Dr. Ferrara did not speak with the cardiac surgeon following
Shannon Dodson’s death; (3) the trial court’s decision to submit Missouri Approved Instruction
2.07 regarding insurance; (4) the denial of Defendants’ motion for directed verdict on the issue of loss of economic support; and (5) the delayed denial of motion for directed verdict on the
issue of aggravating damages.
Plaintiffs filed a cross-appeal, challenging the constitutionality of § 538.210(1) RSMo,1
which caps noneconomic damages in tort actions against healthcare providers at $350,000.
Plaintiffs argue that the Missouri Supreme Court declared the damage cap unconstitutional in
Watts v. Lester E. Cox Medical Centers, 376 S.W.3d 633 (Mo. banc 2012). Plaintiffs also argue
that the statute is unconstitutional because it violates the equal protection clause and separation
of powers. Finally, Plaintiffs contend that the trial court erred in granting Defendants’ motion
for directed verdict on the issue of aggravating damages. We conclude that we do not have
jurisdiction to hear this appeal, and order the case transferred to the Missouri Supreme Court.
Factual Background
This case arises out of the death of Shannon Dodson (Decedent), wife of Jason Dodson
and mother of three children. In February 2011, Decedent experienced shortness of breath and
went to the emergency room at Mercy Hospital, where she was diagnosed with bronchitis. She
complained of chest pain and an electrocardiogram (EKG) revealed some abnormalities.
Interventional cardiologist Dr. George Kichura treated Decedent that day. After reviewing the
results of her EKG and determining they were abnormal, Dr. Kichura recommended that
Decedent undergo a stress EKG, which did not produce clear images of the heart. Dr. Kichura
then recommended a cardiac catheterization, so that the doctors could conclusively determine
whether Decedent had any heart disease. While Decedent initially expressed some fear, she
decided to undergo the cardiac catheterization. Dr. Kichura scheduled the surgery, to be
performed in the catheterization lab by Dr. Robert Ferrara.
1 All statutory references are to RSMo 2005, unless otherwise indicated.
2 During the catheterization, Decedent suffered a left main coronary artery dissection,
which caused difficulty in blood flow to the heart. Dr. Ferrara called Dr. Kichura to the
catheterization lab to confer about whether to proceed with a stent. Dr. Ferrara also asked a
nurse to call the surgeon to prepare an operating room. When Dr. Kichura arrived, about twenty
minutes later, Dr. Ferrara was preparing to put in an intra-aortic balloon pump. Dr. Kichura
continued with the balloon pump to attempt to restore blood flow, which was only partially
successful. Dr. Blucher, a cardiothoracic surgeon, responded to the earlier call for a surgeon, and
Dr. Ferrara conferred with him. Decedent was transported to surgery. Efforts to restore cardiac
function failed. Decedent was pronounced dead shortly thereafter.
Plaintiffs filed suit against Defendants for wrongful death. Plaintiffs claimed that Dr.
Ferrara was medically negligent and caused Decedent’s death through his negligent performance
in addressing the complications of the cardiac catheterization. Plaintiffs also claimed
aggravating damages. The case proceeded to trial in August 2013.
At the close of the evidence, the trial court granted Defendants’ motion for a directed
verdict on the claim for aggravating damages. Subsequently, the jury returned a verdict for
Plaintiffs on the wrongful death claim, awarding Plaintiffs:
Past economic damages: $305,737
Past noneconomic damages: $1,000,000
Future economic damages: $1,525,418
Future noneconomic damages: $8,000,000
Defendants filed a post-trial motion for a reduction of the noneconomic damages award, pursuant
to § 538.210, which limits noneconomic damages in medical malpractice cases to no more than
3 $350,000. The trial court granted Defendants’ motion and entered an amended judgment of
$2,181,155. Both parties appealed.
Plaintiffs filed their Notice of Appeal and Jurisdictional Statement with the Missouri
Supreme Court. Plaintiffs argued that the Missouri Supreme Court had exclusive jurisdiction
over the appeal because they challenge the constitutional validity of a state statute. Defendants
countered that the case falls within the general jurisdiction of the Court of Appeals. The
Supreme Court ordered the cause transferred to this Court. Plaintiffs’ appeal was consolidated
with Defendants’ appeal previously filed in this Court.
Discussion
In their cross-appeal, Plaintiffs challenge the constitutionality of a state statute, and as a
general rule, questions regarding a statute’s constitutionality are a matter within the exclusive
jurisdiction of the Missouri Supreme Court. MO. CONST. art. V, § 3; Sharp v. Curators of the
Univ. of Mo., 138 S.W.3d 735, 737 (Mo. App. E.D. 2003). However, there are two exceptions to
this rule. Id. at 738. First, if the claim is not properly preserved for review, jurisdiction falls in
this Court, rather than the Supreme Court. Id. “To properly preserve a constitutional issue for
appellate review, the issue must be raised at the earliest opportunity and preserved at each step of
the judicial process.” Id. The trial court must have ruled on the constitutionality of the statute,
and the theory of the argument on appeal must be the same as that raised at the trial court. Id.
Second, this Court has jurisdiction if the claim is not “real and substantial.” Id. A claim is real
and substantial if:
Upon preliminary inquiry, the contention discloses a contested matter of right, involving some fair doubt and reasonable room for controversy; but if such preliminary inquiry discloses the contention is so obviously unsubstantial and insufficient, either in fact or law, as to be plainly without merit or a mere pretense, the claim may be deemed merely colorable.
4 Id. “One clear indication that a constitutional challenge is real and substantial and made in good
faith is that the challenge is one of first impression.” Id.
“Earliest Opportunity”
We must first address the threshold issue whether Plaintiffs timely raised their
constitutional arguments. Defendants argue that Plaintiffs did not timely raise a constitutional
challenge to the application of § 538.210, and that because Plaintiffs did not raise their
constitutional claims at the earliest possible time, those claims are waived. Plaintiffs maintain
that the claims were timely raised.
Claims must be properly preserved “to prevent surprise to the opposing party and to
allow the trial court the opportunity to identify and rule on the issue.” Hill v. Boyer, No.
ED101552, 2015 WL 3759344, at *2 (Mo. App. E.D. 2015). Parties in litigation must have “full
and fair opportunity to litigate significant issues as early and as inexpensively in the litigation
process as possible.” Id. Nonetheless, “the purpose of the rule is not to prevent parties from
litigating issues that arise during the course of a lawsuit if there is no prejudice to the opposing
party.” Id.
Here, Defendants raised the issue of § 538.210 in their answer. Raising an affirmative
defense, Defendants argued:
[I]n the event of an adjudication of the issues in this case whereby this defendant is held liable to respond in damages to any plaintiff, defendant invokes the provisions of § 538.210, RSMo. (2006), which provides, in part, that no plaintiff shall recover more than $350,000, for non-economic damages irrespective of the number of defendants.
Plaintiffs did not raise their constitutional challenges to § 538.210 until after the trial court
entered its judgment and Defendants filed their motion to amend the judgment pursuant to
§ 538.210. The record shows that both Plaintiffs and Defendants submitted memoranda to the
5 trial court with arguments on whether the noneconomic damage cap should apply. The motion
was argued on November 7, 2013. The trial court amended its judgment on December 16, 2013.
It is clear from the record that the parties had the “full and fair opportunity to litigate” the
application of the noneconomic damage cap. Hill, 2015 WL 3759344, at *2.
Defendants argue that Plaintiffs should have addressed the issue after Defendants raised
§ 538.210 as an affirmative defense in their responsive pleadings, and because Plaintiffs failed to
do so, the claims are waived. However, we fail to see how Defendants were prejudiced by
Plaintiffs waiting to file a motion not to reduce noneconomic damages until the jury had returned
a verdict that included noneconomic damages above the amount contained in § 538.210. Hill,
2015 WL 3759344, at *2. Litigating whether the noneconomic damage cap should have been
applied before a judgment including noneconomic damages was entered would have been
inefficient. After the judgment was entered in excess of the cap, the parties were given a full and
fair opportunity to litigate the issue, and the trial court was given the opportunity to, and in fact
did, rule on the motions. See Call v. Heard, 925 S.W.2d 840, 847 (Mo. banc 1996) (“[The
opposing party] had the opportunity to respond and the trial court had the opportunity to address
the issue; thus the purposes of the rule were met”). As a result, we conclude that this issue is
properly preserved. Accordingly, we next determine whether the issues raised are real and
substantial.
Right to a Jury Trial
In Plaintiffs’ first point on appeal, Plaintiffs contend that the trial court erred in applying
§ 538.210 because the cap was found unconstitutional as a violation of the right to trial by jury.
Specifically, Plaintiffs argue that the Missouri Supreme Court held in Watts v. Lester E. Cox
Medical Centers that the noneconomic damage cap is unconstitutional, and that the reasoning in
6 Watts applies to wrongful death claims because wrongful death is a cause of action recognized at
the common law. Further, Plaintiffs maintain that Sanders v. Ahmed, 364 S.W.3d 195 (Mo. banc
2012), does not apply because that case considered a different version of § 538.210,2 and because
Watts is more recent than Sanders. In response, Defendants argue that Sanders does, in fact,
control in this case, that wrongful death is not a cause of action that was recognized at the
common law, and that the different versions of § 538.210 are not relevant to the distinctions
between Watts and Sanders.
The two cases significantly relied on in Plaintiffs’ argument, Sanders and Watts, were
decided by the Missouri Supreme Court within six months of each other in 2012. These two
cases were preceded by Adams By and Through Adams v. Children’s Mercy Hospital, in which
the Missouri Supreme Court upheld the validity of a previous version of the noneconomic
damage cap in regard to common-law medical negligence causes of action. 832 S.W.2d 898,
900 (Mo. banc 1992). The Court held that because § 538.210 RSMo (1986) “establishes the
substantive, legal limits of the plaintiffs’ damage remedy,” it is a matter of law that is beyond the
role of the jury, and therefore it does not infringe upon the right to a jury trial. Id. at 907.
In Sanders, the Court faced another challenge to the noneconomic damage cap. The
plaintiff argued that § 538.210 violated the right to a jury trial. 364 S.W.3d 195, 202 (Mo. banc
2012). However, the Court differentiated the plaintiff’s case from Adams, because the plaintiff
was suing for wrongful death, rather than common-law medical negligence. Id. at 203. The
Court further noted that Missouri does not recognize a common law cause of action for wrongful
death. Id. Because wrongful death is a statutorily created cause of action, the Court found that
“[t]he legislature has the power to define the remedy available if it creates the cause of action.”
2 The previous version of the statute allowed plaintiffs to recover from more than one defendant and also provided for a cost of living increase. § 538.210 RSMo (2000).
7 Id. Accordingly, the Court concluded that the noneconomic damage cap, when applied to
wrongful death actions, does not violate the right to a jury trial. Id. at 204.
Following Sanders, the Court decided Watts, in which the plaintiff asserted that Adams
was wrongly decided.3 376 S.W.3d 633, 637 (Mo. banc 2012). The Watts Court held that
§ 538.210 “is unconstitutional to the extent that it infringes on the jury’s constitutionally
protected purpose of determining the amount of damages sustained by an injured party,” because
limitations on damages were not permitted at common law when Missouri adopted its
constitution in 1820. Id. at 636. In so holding, the Court examined the historical context of
Article I, § 22(a) of the Missouri Constitution. Id. at 637. The Court considered whether a
plaintiff, in 1820, was entitled to a jury determination of her noneconomic damages, and stated
that if so, a cap on noneconomic damages would be unconstitutional. Id. at 638. The Court
found that a claim for medical negligence, including noneconomic damages, did exist in 1820
and therefore, the right to a jury trial, including a jury’s determination of noneconomic damages,
attaches. Id. In finding that § 538.210 violates the right to trial by jury when applied to
common-law medical negligence actions, the Court stated that the cap “operates wholly
independent of the facts of the case” and “directly curtails the jury’s determination of damages.”
Id. at 640. The Court further found that the Court’s previous ruling in Adams violates the right to
a jury determination of damages for four reasons. Id. at 641-44. First, the Court found that
Adams “misconstrued the nature of the right to trial by jury” by focusing on the jury’s role as
fact-finder rather than the individual’s right “to the damages awarded by the jury.” Id. at 642.
3 Judge Michael Wolff authored a concurring opinion in Klotz v. St. Anthony’s Medical Center in which he also advocated for the Court to overturn Adams. 311 S.W.3d 752, 774 (Mo. banc 2010) (Wolff, J., concurring). Judge Wolff extensively reviewed the common law history and concluded that noneconomic damage caps violate the right to a jury trial, as to common law medical negligence. Id. at 780. However, Judge Wolff also noted that some statutory limits on damages are valid because the cause of action did not exist at common law, for example, wrongful death. Id. at 779.
8 The Court also found that Adams “permits legislative limitation of an individual constitutional
right,” disregards longstanding Missouri law that “the jury’s role is precisely to determine both
liability and damages,” and finally, that Adams did not cite to any applicable Missouri law. Id. at
642-44. Noting a general unwillingness to overturn its own precedent, the Court found that
overturning Adams was “necessary to protect the constitutional rights of Missouri’s citizens.” Id.
at 644.
First, we address Plaintiffs’ contention that Watts overruled Sanders, to the extent that
both cases address whether § 538.210 violates the right to a jury trial. We disagree. The Watts
Court limited its holding to common-law medical negligence. Despite the fact that Watts is more
recent in time than Sanders, the Supreme Court’s Sanders holding still stands, because Watts did
not address the applicability of noneconomic damage caps to wrongful death causes of action.
Further, Plaintiffs’ attempt to differentiate the two versions of § 538.210 likewise fails. The
Court’s focus in both Watts and Sanders is whether the damage cap violates the right to a jury
trial, a principle applicable regardless of whether plaintiffs may recover against more than one
defendant or whether there is a cost of living increase written into the statute.
Nonetheless, Plaintiffs maintain that the Watts decision applies to wrongful death causes
of action as well as common law actions. Plaintiffs state that any other interpretation would
sever the statute so that noneconomic damage caps apply to wrongful death but not to
common-law medical negligence. Defendants contend that the Watts Court utilized the doctrine
of severability when it held that § 538.210 is unconstitutional as to common law claims, and as a
result, the cap on noneconomic damages in wrongful death cases still applies post-Watts.
9 Section 538.210 is silent on severability.4 Statutes “should be upheld to the fullest extent
possible.” Gen. Motors Corp. v. Dir. of Revenue, 981 S.W.2d 561, 568 (Mo. banc 1998).
Statutes are presumptively severable. Id. Under § 1.140, which addresses the severability of
statute provisions:
If any provision of a statute is found by a court of competent jurisdiction to be unconstitutional, the remaining provisions of the statute are valid unless the court finds the valid provisions of the statute are so essentially and inseparably connected with, and so dependent upon, the void provision that it cannot be presumed the legislature would have enacted the valid provisions without the void one; or unless the court finds that the valid provisions, standing alone, are incomplete and are incapable of being executed in accordance with the legislative intent.
§ 1.140 RSMo (2000). Because statutes are presumptively severable, we conclude that §
538.210 is severable, and that the trial court did not err in its interpretation of Watts and
Sanders. The noneconomic damage cap on a cause of action for wrongful death is not
“incomplete and … incapable of being executed in accordance with legislative intent”
without the cap on common law causes of action. Because wrongful death is a statutory
cause of action, separate and apart from the common law cause of action for medical
negligence, the provisions of the statute are not “essentially and inseparably connected.”5
As it stands, Sanders’ ruling that § 538.210 is constitutional as to wrongful death causes
of action stands. Watts did not overrule Sanders – it simply held unconstitutional § 538.210 as it
4 This Court recognizes that the legislature passed a new cap on noneconomic damages in 2015 that explicitly addresses severability. S.B. 239, 98th Gen. Assem., Reg. Sess. (Mo. 2015). However, the previous version of the statute did not. 5 Plaintiffs, in arguing that wrongful death is analogous to common law negligence, rely on State ex rel. Diehl v. O’Malley, 95 S.W.3d 82 (Mo. banc 2003). Diehl addresses the right to a jury trial under the Missouri Human Rights Act (MHRA). Id. at 84. However, the issue in Diehl is different from the issue raised here. The Diehl Court ruled on whether an MHRA plaintiff’s right to a jury trial was violated when the trial court denied her motion for a jury trial on her MHRA claim. Id. The Court ruled that the plaintiff did have the right to a jury trial, despite the fact that the MHRA cause of action was statutorily created. Id. at 92. Here, Plaintiffs were granted a jury trial. The issue is whether or not the damage cap violates the right to a jury trial, which Diehl did not address. While the historical common law background in Diehl is relevant to our considerations here, Diehl does not apply in the way Plaintiffs contend.
10 applies to common law medical negligence. The statute is severable, and therefore, we conclude
that Plaintiffs’ arguments regarding the right to a jury trial is merely colorable.
Separation of Powers
Plaintiffs also contend that § 538.210 violates separation of powers. 6 Specifically,
Plaintiffs contend that the statutory cap on noneconomic damages interferes with the judicial
function of remittitur. The Missouri Supreme Court addressed a similar argument in Sanders v.
Ahmed as it relates to actions for wrongful death. 364 S.W.3d at 204. In Sanders, the plaintiff
argued that the cap “interferes with the judiciary’s performance of its constitutionally assigned
power to render judgments in conformity with the jury’s verdict and to enforce judgments upon
the verdict.” Id. at 204. The Missouri Supreme Court reasoned that § 538.210 is the law
“through which the wrongful death cause of action operates,” and that after the jury makes the
factual determination of damages, the judge applies the law to the fact-finder’s determination.
Id. at 205. Accordingly, the Court found that the statutory cap does not violate separation of
powers. Id. Because of the Supreme Court’s holding in Sanders, we do not see any controversy
on the issue of whether § 538.210 violates separation of powers. See Sharp, 138 S.W.3d at 738.
We find that the separation of powers challenge to § 538.210 is merely colorable.
Equal Protection
Finally, we turn to Plaintiffs’ contention that the Missouri Supreme Court’s rulings in
Watts and Sanders violate both the federal and state equal protection guarantees. See U.S.
CONST. amend. XIV, § 1; MO. CONST. art. I, § 2. Plaintiffs argue that § 538.210 as applied
violates equal protection because it treats similarly situated individuals – wrongful death and
6 MO. CONST. art. II, § 1 reads, “The powers of government shall be divided into three distinct departments – the legislative, executive and judicial – each of which shall be confided to a separate magistracy, and no person, or collection of persons, charged with the exercise of powers properly belonging to one of those departments, shall exercise any power properly belonging to either of the others, except in the instances in this constitution expressly direct or permitted.”
11 common-law medical negligence plaintiffs – differently. Plaintiffs contend that this
differentiation does not pass constitutional muster under any of the equal protection standards of
review. Defendants counter that the statute does not violate equal protection, as confirmed by
the Missouri Supreme Court in Adams.
In the Adams case, the Missouri Supreme Court also addressed an equal protection claim.
832 S.W.2d at 903. In Adams, the plaintiffs claimed that “the right to a trial by jury, the right to
open courts and the right to a certain remedy are ‘fundamental rights’ and that victims of medical
malpractice are a ‘suspect class.’” Id. at 903. The Adams Court concluded that § 538.210 did
not violate a fundamental right and that victims of medical malpractice are not a suspect class.
Id. Accordingly, the Court exercised rational basis review and found that the statutory cap was
rationally related to reducing medical costs by lowering medical malpractice insurance
premiums. Id. at 904.
Notably, the Watts Court overturned Adams, but only “to the extent that it holds that
Section 538.210 caps on noneconomic damages do not violate the right to trial by jury.” Watts,
376 S.W.3d at 646. Therefore, the Adams decision regarding equal protection still stands.
Nonetheless, Plaintiffs’ challenge to the constitutionality of § 538.210 is based upon the
distinction between medical negligence and wrongful death plaintiffs that Sanders and Watts
created. Here, Plaintiffs do not argue that medical malpractice plaintiffs, on the whole, are a
suspect class, but rather that wrongful death plaintiffs are similarly situated to other medical
malpractice plaintiffs. Missouri’s constitution states “that all persons are created equal and are
entitled to equal rights and opportunity under the law.” MO. CONST. art. I, § 2. The legislature
may pass laws that treat different groups differently; however, similarly situated persons cannot
12 be treated differently without adequate justification. Doe v. Phillips, 194 S.W.3d 833, 845 (Mo.
banc 2006).
The situation created by § 538.210, Watts, and Sanders is that wrongful death and
medical negligence plaintiffs are treated differently under the noneconomic damage cap.
Because the Missouri Supreme Court has not addressed this issue, it is a question of first
impression, which is a “clear indication that a constitutional challenge is real and substantial and
made in good faith.” Sharp, 138 S.W.3d at 738. It is not for us to determine whether wrongful
death and common law medical negligence plaintiffs are similarly situated, or what level of
scrutiny should apply in equal protection analysis. Because Plaintiffs’ claim regarding equal
protection appears to be real and substantial, and not merely colorable, the Missouri Supreme
Court has exclusive appellate jurisdiction. Id. at 735. Accordingly, this Court lacks jurisdiction
and is without the power to address any other issue in the case. Id.
Conclusion
Because we lack jurisdiction, we order the case transferred to the Missouri Supreme
Court where jurisdiction lies.
________________________________ Philip M. Hess, Judge
Sherri B. Sullivan, P.J. and Robert M. Clayton, III, J, concur.