Morgan v. MacPhail

704 A.2d 617, 550 Pa. 202, 1997 Pa. LEXIS 2739

• Court: Supreme Court of Pennsylvania
• Decided: December 24, 1997
• Docket: 59 E.D. Appeal Docket 1996, and 63 W.D. Appeal Docket 1996
• Status: Published

Opinions

OPINION OF THE COURT

CASTILLE, Justice.

The sole issue before this Court in these consolidated appeals is whether the doctrine of informed consent should be expanded to include the non-surgical administration of medication where the claimed injury results from the method and location of administration of the medication rather than the medication itself. Because we find that the doctrine of informed consent applies only to surgical procedures, we affirm the Superior Court holdings in both cases.

A. Morgan

On October 20, 1988, appellant Barbara Morgan fell and fractured two ribs. The pain of the injury did not subside with time; therefore, Mrs. Morgan sought treatment from Dr. MacPhail. On December 14,1988, Dr. MacPhail performed an intercostal nerve block¹ in an effort to alleviate Mrs. Morgan’s pain. Later that day, Mrs. Morgan experienced weakness and shortness of breath and telephoned appellee. She then reported to the hospital emergency room where she learned that she suffered a right pneumothorax² as a result of the intercostal nerve block procedure.

Mrs. Morgan and her husband filed suit against Dr. MacPhail claiming that he failed to obtain informed consent prior to performing the procedure. Dr. MacPhail filed preliminary objections in the nature of a demurrer arguing that informed consent is necessary only for surgical or operative procedures, and the trial court granted a demurrer. Mrs. Morgan appealed to the Superior Court, and the Superior Court affirmed.

B. Walker

On February 12, 1991, appellant Kathleen Breslin Walker began treatment with appellee Albert Rose, D.P.M., for complaints of pain in her right heel. Dr. Rose injected a long-acting steroid into Mrs. Walker’s right superficial adventitious bursa.³ On April 15, 1991, Dr. Rose administered a second steroid injection into Mrs. Walker’s right superficial adventitious bursa. Mrs. Walker’s pain had not subsided by June 6, 1991 when she consulted appellee Curt Miller, M.D., an orthopedic surgeon. He diagnosed “Achilles tendonitis” and treated the condition. In August of 1991, Mrs. Walker’s Achilles tendon ruptured. Dr. Miller surgically repaired the tendon, and Mrs. Walker developed a skin slough over the incision behind her right heel.⁴

Mrs. Walker and her husband filed suit against Drs. Rose and Miller claiming that Dr. Rose failed to obtain informed consent prior to injecting the steroids into Mrs. Walker’s right superficial adventitious bursa and that Dr. Miller failed to inform Mrs. Walker that she could develop a skin slough as a result of the surgery. Following a three-day trial, the jury returned a defense verdict. Specifically, the jury found that Dr. Rose was negligent, but his negligence was not a substantial factor in causing the injury. The jury also determined that no reasonable person in Mrs. Walker’s position would have considered the risk of a skin slough in her decision to undergo the surgery and, therefore, found in favor of Dr. Miller. Post-trial relief was denied. Mrs. Walker appealed to the Superior Court, and the Superior Court affirmed.

It has long been the law in Pennsylvania that a physician must obtain informed consent from a patient before performing a surgical or operative procedure. See Sinclair v. Block, 534 Pa. 563, 633 A.2d 1137 (1993); Gray v. Grunnagle, 423 Pa. 144, 223 A.2d 663 (1966). Informed consent, however, has not been required in cases involving non-surgical procedures.⁵

Neither the Pennsylvania legislature nor courts have defined surgical or operative procedure; however, “operate” is defined in Taber’s Cyclopedic Medical Dictionary 1256 (16th ed.1989) as “[t]o perform an excision or incision, or to make a suture on the body or any of its organs to restore health.” “Surgery” is defined in Black’s Law Dictionary 1442 (6th ed.1990) as “that branch of medical science which treats of mechanical or operative measures for healing diseases, deformities or injuries.” “Operation” is defined as “an act or succession of acts performed upon the body of a patient, for his relief or restoration to normal conditions, by the use of surgical instruments as distinguished from therapeutic treatment by the administration of drugs or other remedial measures.” Id. at 1092.

The procedures involved in the instant appeals do not fall within the definition of surgical or operative procedures because neither involved an excision or incision or the use of surgical instruments; rather, they involved the therapeutic administration of drugs. In fact, the procedures are more closely analogous to the introduction of medication through an intravenous needle or line because the instant procedures and the intravenous use of medication both involve the use of needles to inject medication rather than the use of surgical instruments. Courts applying Pennsylvania law have not required informed consent in cases involving intravenous administration of medication. Wu v. Spence, 413 Pa.Super. 352, 605 A.2d 395 (1992)(no informed consent needed for intravenous administration of antibiotics). Accord, Karibjanian v. Thomas Jefferson University Hospital, 717 F.Supp. 1081 (E.D.Pa.1989)(doctrine not applicable to intravenous administration of prescription drugs).

The rationale underlying requiring informed consent for a surgical or operative procedure and not requiring informed consent for a non-surgical procedure is that the performance of a surgical procedure upon a patient without his consent constitutes a technical assault or a battery because the patient is typically unconscious and unable to object. Gray v. Grunnagle, 423 Pa. at 155, 223 A.2d at 668-69. Appellants here argue that the traditional battery or assault-based theory should be abandoned in favor of a negligence standard. The basis for their argument is their assertion that a patient has the right to determine the scope and direction of medical treatment no matter which form the treatment takes, whether surgical or non-surgical. The patient, appellants urge, has the right to make an informed choice as to electing to undergo a medical procedure after having been presented with the alternatives and the risks attendant to each alternative. This argument, however, flies in the face of the traditional battery theory. It is the invasive nature of the surgical or operative procedure involving a surgical cut and the use of surgical instruments that gives rise to the need to inform the patient of risks prior to surgery. Id. Neither of the procedures performed in the instant appeals were invasive in nature as both involved the injection of medication which does not rise to the same level of bodily invasion as surgery.⁶

Given that prior case law mitigates against the application of the doctrine of informed consent to the instant cases, and adding to that the recent legislation embodying the legislative branch’s codification of the law of informed consent which would not require informed consent in these cases, we can conceive of no sound reason to expand the doctrine of informed consent judicially to cover these cases, only to have the recent legislation effectively overturn such a decision as of January 25, 1997. Accordingly, the decisions of the Superior Court in both cases are affirmed.

NIGRO, J., files a dissenting opinion.

1 . An intercostal nerve block is a procedure whereby a local anesthetic is injected into the area around the ribs.

2 . A pneumothorax is a collapse of the lung.

3 . The right superficial adventitious bursa is located behind the Achilles tendon between the tendon and the skin.

4 . A skin slough is an area of the skin that becomes necrotic and does not heal.

5 . See, e.g., Sinclair v. Block, 534 Pa. 563, 633 A.2d 1137 (1993)(informed consent doctrine does not apply to obstetrician's use of forceps during natural childbirth); Hoffman v. Brandywine Hospital, 443 Pa.Super. 245, 661 A.2d 397 (1995)(informed consent not required for a blood transfusion); Matukonis v. Trainer, 441 Pa.Super. 570, 657 A.2d 1314, appeal granted, 542 Pa. 648, 666 A.2d 1057 (1995)(doctrine inapplicable to chiropractic manipulation of patient’s neck); Dible v. Vagley, 417 Pa.Super. 302, 612 A.2d 493 (1992), appeal denied, 535 Pa. 619, 629 A.2d 1380 (1993) (informed consent not required for radiation treatments); Wu v. Spence, 413 Pa.Super. 352, 605 A.2d 395 (1992)(no informed consent needed for intravenous administration of antibiotics); Boyer v. Smith, 345 Pa.Super. 66, 497 A.2d 646 (1985)(doctrine not applicable to oral administration of prescription drugs). See also, Karibjanian v. Thomas Jefferson University Hospital, 717 F.Supp. 1081 (E.D.Pa.1989)(doctrine not applicable to intravenous administration of prescription drugs).

6 . Recently, our legislature codified the law of informed consent in the Healthcare Services Malpractice Act which states:

(a) Except in emergencies, a physician owes a duty to a patient to obtain the informed consent of the patient or the patient's authorized representative prior to conducting the following procedures:

(1) Performing surgery, including the related administration of anesthesia.

(2) Administering radiation or chemotherapy.

(3) Administering a blood transfusion.

(4) Inserting a surgical device or appliance.

(5) Administering an experimental medication, using an experimental device or using an approved medication or device in an experimental manner.

40 P.S. § 1301.811-A, effective January 25, 1997.

This legislation expands in several material ways the applicability of the doctrine of informed consent to cover procedures and treatments not previously included in case law. For example, prior to this legislation, courts had held that the informed consent doctrine did not to apply to radiation or chemotherapy (Dible v. Vagley, 417 Pa.Super. 302, 612 A.2d 493 (1992), appeal denied, 535 Pa. 619, 629 A.2d 1380 (1993)), or to blood transfusions unless incident to surgery (Hoffman v. Brandywine Hospital, 443 Pa.Super. 245, 661 A.2d 397 (1995)). Such procedures, however, now require informed consent under the new statute.

While this new legislation is not applicable to the instant appeals because the injuries complained of occurred prior to the effective date, even under this legislation informed consent would not be required in these cases. Informed consent under the statute is only required’ for the administration of medication where the medication being administered is experimental or is administered in an experimental maimer. Neither appellant has asserted either of these situations which would arguably require this Court to look to the statute for guidance.