IN THE SUPREME COURT OF IOWA No. 06–0655
Filed November 21, 2008
SHIRLEY A. SMITH, as Executor of the Estate of DONALD E. SMITH and SHIRLEY A. SMITH, Individually,
Appellant,
vs.
ALAN R. KOSLOW and IOWA HEART CENTER, P.C.,
Appellees.
On review from the Iowa Court of Appeals.
Appeal from the Iowa District Court for Polk County, John D.
Lloyd, Judge.
Appeal by plaintiff from judgment for defendants in a medical
malpractice case. DECISION OF COURT OF APPEALS VACATED.
DISTRICT COURT JUDGMENT AFFIRMED.
Timothy Semelroth of Riccolo & Semelroth, P.C., Cedar Rapids, for
appellant.
Robert D. Houghton, Nancy J. Penner, and Jennifer E. Rinden of
Shuttleworth & Ingersoll, P.L.C., Cedar Rapids, for appellees. 2
CADY, Justice.
In this appeal, we must decide if a district court committed error
by instructing a jury in a medical malpractice action that the mere fact of
an injury does not mean the doctor was negligent. We conclude the
district court did not commit error. We vacate the decision of the court
of appeals and affirm the judgment of the district court.
I. Background Facts and Proceedings. Donald Smith tragically died during surgery to repair an
abdominal aortic aneurism and an iliac artery aneurism.1 He was
seventy-two years of age and was a successful businessman. He lived in
Blakesburg and was survived by his wife and six children.
The surgery was performed by Dr. Alan R. Koslow, M.D., who was
employed by the Iowa Heart Center, P.C., in Des Moines.2 Dr. Koslow
planned to utilize the stent graft procedure to repair the aneurisms. He
began the operation on the iliac artery aneurism. The procedure
required him to first perform angioplasty on the artery. He chose to
perform the angioplasty by using the Dotter technique. This technique
involved the insertion of sequential retinal dilators to widen the artery
prior to inserting the stent at the location of the aneurism. The stent would then allow blood to flow through the area without putting pressure
on the artery wall.
After Dr. Koslow inserted the dilators, he was unable to pass the
stent graft through the artery. Within a short period of time, Dr. Koslow
1The aneurism was discovered after Smith began to experience pain in his lower
abdomen. He sought medical attention after the pain intensified and began to keep him awake at night. Doctors performed a CT scan on Smith, which revealed the aortic aneurism. An aortic aneurism is a weakening of the wall of the artery. Left unrepaired, it can spontaneously rupture and cause certain death. 2In this opinion, the defendants will be collectively referred to as Koslow. 3
discovered Smith was suffering from internal bleeding. He tried in vain
through a variety of means to locate and stop the bleeding. His efforts
were unsuccessful, and Smith died on the operating room table after
suffering a series of heart attacks.
Shirley Smith, his wife and the executor of his estate, brought an
action against Dr. Koslow and the Iowa Heart Center for negligence. She
primarily claimed Dr. Koslow breached the accepted standard of medical care by using dilators to widen the artery, instead of using balloon
angioplasty. She claimed the dilators caused the artery to rupture.
Dr. Koslow claimed one of the known risks of the stent graft procedure is
that aneurisms can spontaneously rupture during surgery.
In the course of instructing the jury at trial on the claim of
negligence, the district court, in addition to the instruction setting out
the elements of recovery, included the following supplemental
instruction:
The mere fact that a party was injured does not mean that a party was negligent.
Smith objected to the instruction, claiming it unduly emphasized
Dr. Koslow’s defense. She also claimed the instruction was an
incomplete statement of the law in the absence of the following language
she requested to be added to the instruction:
While the result alone is not, by itself, evidence of negligence, yet the same may nevertheless be considered, together with other facts and circumstances disclosed by the evidence in a given case in determining whether or not such result is attributable to negligence or want of skill.
The district court overruled the objection, and the jury returned a
verdict in favor of Dr. Koslow and the Iowa Heart Center. The jury found
Smith failed to prove Dr. Koslow was negligent. 4
On appeal, Smith seeks a new trial based on error in giving the
instruction to the jury that the existence of an injury does not mean the
doctor was negligent. The court of appeals concluded that the district
court did not err in instructing the jury. We granted further review.
II. Standard of Review.
“We review a claim that the court gave an instruction that was not
supported by the evidence for correction of errors of law.” Summy v. City of Des Moines, 708 N.W.2d 333, 340 (Iowa 2006) (citing State v. Piper,
663 N.W.2d 894, 914 (Iowa 2003)). We review the converse claim that
the trial court should have given a requested instruction for abuse of
discretion. Id. (citing Anderson v. State, 692 N.W.2d 360, 363 (Iowa
2005)).
III. “Bad Result/Injury is Not Negligence” Instruction.
It is a fundamental tenet of tort law that the fact a plaintiff has
suffered an injury, without more, does not mean the defendant was
negligent. Novak Heating & Air Conditioning v. Carrier Corp., 622 N.W.2d
495, 497 (Iowa 2001); Brewster v. United States, 542 N.W.2d 524, 528
(Iowa 1996). Instead, to recover for an injury, our law requires an
injured person to establish the existence of a duty of care, breach of the duty of care, and that the breach was the cause of the injuries suffered.
Novak Heating, 622 N.W.2d at 497.
While we have applied these universal propositions in the past to
decide the propriety of a directed verdict in a negligence case, we have
not previously addressed the propriety of submitting the specific
disputed proposition to a jury in the form of an instruction. However,
the uniform jury instructions authored by the special committee on
uniform court instructions of the Iowa State Bar Association includes an
instruction for general negligence cases that incorporates this general 5
proposition. It provides that the “mere fact of an accident or injury does
not mean a party was negligent.” See Iowa Uniform Jury Instruction
700.8. This model instruction is nearly identical to the instruction given
by the district court in this case.
Smith claims the instruction served as a comment on the evidence
by emphasizing Koslow’s claim that the blood loss and death during the
surgery was not the result of any negligence. At the same time, she asserts the instruction minimized the importance of such evidence in her
efforts to establish her claim that Koslow was negligent.
While we have not specifically addressed the propriety of
instructing a jury in a negligence case on the proposition of law at
dispute in this case, we have on several occasions applied the rule to
claims involving medical malpractice actions in deciding whether the
underlying claim was submissible to a jury. Specifically, in Johnson v.
Van Werden, 255 Iowa 1285, 1290, 125 N.W.2d 782, 784 (Iowa 1964), we
said, quoting from O’Grady v. Cadwallader, 183 Iowa 178, 192, 166 N.W.
755, 759 (1918):
“[I]t is the general holding of the courts that the bare fact that full recovery does not result, or that a surgical operation is not entirely successful, is not, in and of itself, evidence of negligence . . . .”
Other jurisdictions, however, have considered various forms of the
proposition as a jury instruction in various types of medical malpractice
actions, with differing results.3 Some jurisdictions have approved
3At the outset, we recognize a distinction is made between medical malpractice cases involving the doctrine of res ipsa loquitur and standard medical malpractice cases. Some jurisdictions hold that such an instruction should not be given with a res ipsa loquitur instruction, while other jurisdictions conclude the two instructions may be given together. See Carver v. El-Sabawi, 107 P.3d 1283, 1285–86 (Nev. 2005) (citing cases taking each position). This is not a question we face, of course, because this case does not involve the res ipsa loquitur doctrine. 6
various versions of the “bad result/injury is not negligence” instruction,
while others have disapproved of the instruction or discouraged the use
of the instruction. Yet, most all courts agree the “bad result/injury is
not negligence” instruction reflects “well nigh universally recognized
principles of medical malpractice law.” Jones v. Porretta, 405 N.W.2d
863, 869 (Mich. 1987); accord Watson v. Hockett, 727 P.2d 669, 673
(Wash. 1986); see W. Page Keeton et al., Prosser and Keeton on Torts § 32, at 186 n.33 (5th ed. 1984); see also Armsbruster v. Gray, 225 Iowa
1226, 1230, 282 N.W. 342, 344 (1938) (“ ‘It is universally agreed that no
inference of negligence arises from the mere fact that a collision
occurred.’ ” (quoting Harvey v. Borg, 218 Iowa 1228, 1232, 257 N.W.
190, 193 (1934))).
Moreover, courts that disapprove of the instruction do so mainly
due to the particular variation of the general proposition, not because of
a disagreement with the general proposition itself. For example, the
court in Kennelly v. Burgess, 654 A.2d 1335, 1340–41 (Md. 1995), found
a “bad result” instruction was improper in a medical malpractice case
because it told the jury that an unsuccessful result following medical
treatment was “not evidence of negligence.” (Emphasis added.) The court found the instruction went beyond the general proposition that an
unsuccessful result was not itself negligence and improperly “implied
that the jury should give no consideration at all to the unsuccessful
medical treatment of [the plaintiff].” Kennelly, 654 A.2d at 1341.
On the other hand, even those jurisdictions that approve the “bad
result/injury is not negligence” instruction find it tends to state an
obvious proposition and is best reserved for those medical malpractice
cases in which the jury might improperly use a bad medical result to find
negligence. See Porretta, 405 N.W.2d at 870 (“We agree with the plaintiff 7
that there are times when the giving of such an instruction may mislead
the jury by focusing the jury’s attention on an irrelevant issue
unsupported by the defendant’s theory of the case or the evidence
submitted.”). On the other hand, in Watson, the court said:
Such an instruction is particularly appropriate where the jury has heard evidence or argument from which it might reach an improper conclusion that doctors guarantee good results or can be found negligent merely because of a bad result.
727 P.2d at 673.
We agree with the majority of courts that the submission of the
“bad result/injury is not negligence” instruction to a jury in a standard
medical malpractice action would not normally constitute prejudicial
error. It reflects a correct statement of the law. We recognize, however,
the instruction could constitute reversible error in a particular case if it
would unduly emphasize a particular theory or otherwise distract the
jury in performing its responsibilities to decide the issues in the case.
In this case, we conclude the district court did not err by giving the
supplemental instruction. Although the instruction was essentially
embodied in the instruction on the elements for recovery of negligence, it
was appropriate in this case to separately advise the jury that the injury,
alone, did not mean Koslow was negligent. The closing argument
presented by counsel for Smith supported the instruction in this case.
In his argument, counsel for Smith repeatedly told the jury the bad
result of the surgery was either caused by a spontaneous rupture of the
artery or the care administered by the doctor.4 Consequently, the choice
4Plaintiff’s counsel argued: The cause of this injury occurred in one of two ways. It was either a spontaneous rupture of this vessel, or it was caused by the doctor. Those are your two choices in this case. 8
invited the jury to infer liability from the bad result in the event it
concluded the artery did not spontaneously rupture. The instruction
properly informed the jury that its verdict could not be decided in such a
manner. Courts generally give jury findings considerable weight, and a
supplemental instruction that properly assists the jury in the correct
application of the law to the facts is not error.
Finally, Smith claims the instruction was erroneous because it was an incomplete statement of the law. If a jury is given the “bad
result/injury is not negligence” instruction, she asserts the jury must
also be told that it may still consider the bad result in assessing whether
negligence occurred. Smith primarily relies on Daiker v. Martin, 250 Iowa
75, 91 N.W.2d 747 (1958), in which we said:
“[W]hile the result alone is not, in itself, evidence of negligence, yet same may nevertheless be considered, together with other facts and circumstances disclosed by the evidence in a given case in determining whether or not such result is attributable to negligence or want of skill.”
Daiker, 250 Iowa at 81, 91 N.W.2d at 750 (quoting Kirchner v. Dorsey &
Dorsey, 226 Iowa 283, 294–95, 284 N.W. 171, 178 (1939)).
It is important to recognize that Daiker involved the placement of a
cast by a doctor on the leg of the plaintiff that was too tight, resulting in
the amputation of the limb. 250 Iowa at 76, 91 N.W.2d at 747. The
question presented was whether the medical malpractice claim could
proceed to trial without expert testimony, and we held the question of
negligence by the doctor under such circumstances was one of common
On rebuttal, plaintiff’s counsel again argued: The choice ultimately is, was this a spontaneous rupture or was it caused by the doctor? Those are the two choices, when you ultimately get down to it. Did lightening happen to strike at the moment that Dr. Koslow was doing his procedure? In order to find for Dr. Koslow in this case, you’re going to have to find that. 9
knowledge that did not require expert testimony. Id. at 83–84, 91
N.W.2d at 752. Thus, our statement in the case, that the injury may
nevertheless be considered by the jury as evidence of negligence, applied
to a finding of negligence that did not require expert testimony.
We agree with Smith that the “bad result/injury is not negligence”
instruction “does not mean that a bad result cannot be presented by
plaintiffs as part of their evidence of negligence, but, rather, that, standing alone, it is not adequate to create an issue for the jury.”
Porretta, 405 N.W.2d at 874. Instead, “[s]omething more is required, be
it the common knowledge that the injury does not ordinarily occur
without negligence or expert testimony to that effect.” Id. However,
when expert testimony is required in a medical malpractice case, the
expert, not the jury, is permitted to use the unsuccessful result in
formulating the expert opinion that negligence occurred. See Meda v.
Brown, 569 A.2d 202, 207 (Md. 1990) (holding an expert, as
distinguished from a lay witness, may properly rely on an unsuccessful
result in concluding a doctor is negligent). In Kennelly, the court
properly summarized the applicable rule:
If any form of a “mere happening” instruction is to be given in a medical malpractice case requiring expert testimony, the jury should be informed that, although an unsuccessful result does not create a presumption of negligence, it still may be considered as some evidence of negligence and that an expert witness may consider it in formulating his or her opinion that there was negligence.
654 A.2d at 1341.
In this case, Smith did not seek an additional instruction that
would have informed the jury that a bad result could be considered by an
expert witness in formulating his or her opinion. Instead, she sought an
instruction that would permit the jury to do so in a case that required 10
expert testimony. Under Iowa law, a court must give a requested
instruction when it states a correct rule of law applicable to the facts of
the case and is not embodied in other instructions. Herbst v. State, 616
N.W.2d 582, 585 (Iowa 2000). Under the circumstances of this case, the
district court did not abuse its discretion in refusing to give the
requested instruction because the instruction was not applicable to the
facts of this case. IV. Conclusion.
We conclude the trial court did not err or abuse its discretion in
instructing the jury. We vacate the court of appeals decision and affirm
the judgment of the district court.
DECISION OF COURT OF APPEALS VACATED. DISTRICT
COURT JUDGMENT AFFIRMED.
All justices concur except Hecht and Wiggins, JJ., who dissent,
and Appel and Baker, JJ., who take no part. 11
#73/06–0655, Smith v. Koslow
HECHT, Justice (dissenting).
I respectfully dissent. “Stuff happens” is a cute phrase on a
bumper sticker, but it should not be included in jury instructions. I
would hold the district court committed reversible error in giving the
“mere fact of injury” instruction. My analysis begins with the
observation that the instruction was entirely unnecessary. The jury was told through other instructions everything they needed to know about
the definition of negligence. There simply was no need to remind the jury
that the fact Mr. Smith died did not mean Dr. Koslow was negligent in
performing the procedure.
That the instruction was unnecessary is not, however, its principal
defect. The court’s instructions on the law should not give undue
prominence to any part of the case. Stover v. Lakeland Square Owners
Ass’n, 434 N.W.2d 866, 868 (Iowa 1989). In particular, the instructions
should not “overemphasize one party’s theory of the case.” Sunrise Dev.
Co. v. Iowa Dep’t of Transp., 511 N.W.2d 641, 644 (Iowa Ct. App. 1993).
The “mere fact of injury” instruction violated these cardinal principles by
gratuitously affirming a central premise of Dr. Koslow’s theory of defense: Bad things occasionally happen during emergent medical treatments
despite a physician’s compliance with the relevant standard of care.
The worst feature of the challenged instruction was its capacity to
communicate to the jury the notion the court doubted the treatment
provided by Dr. Koslow fell below the relevant standard of care. I believe
a reasonable juror could interpret the “mere fact of injury” instruction in
this untoward way because the definition of negligence as conduct falling
below the standard of care had already been given in other instructions.
Why, a reasonable juror could wonder, would the court feel the need to 12
augment that definition? Why, a reasonable juror could inquire, after
properly defining the concept of negligence, would the court give a
separate instruction emphasizing the essence of one of Dr. Koslow’s
principal arguments—that bad outcomes can occur in the absence of
negligence—unless the court has doubts about the merits of the
plaintiffs’ claim? Although the “mere fact of injury” instruction
communicated an accurate statement of law, it was in my view completely unnecessary and prejudicial.
I believe the challenged instruction was also inappropriate because
it could be understood by a reasonable juror as a backhanded comment
on the evidence. See Peters v. Vander Kooi, 494 N.W.2d 708, 712 (Iowa
1993) (instructions by the court that comment “on potential factual
scenarios in which a standard of care may or may not have been adhered
to” are impermissible comments on the evidence). It commented on the
evidence by reminding the jurors they could find the plaintiffs produced
no evidence other than the fact of injury to support their claim. Such a
suggestion in the court’s jury instructions was in my view inappropriate
just as it would have been improper to remind jurors in the instructions
that frivolous negligence cases are not submitted to the jury. The majority suggests the instruction was appropriate given the
substance of Smith’s counsel’s closing argument. Counsel’s argument
suggested the jury must decide whether Mr. Smith’s aneurysm burst
during the procedure either coincidentally or as a consequence of the
doctor’s treatment. The majority interprets this argument as an
assertion the bad outcome of the procedure should be viewed by the jury
as conclusive evidence of negligence. In my view, counsel’s argument
can be understood as a more nuanced attempt to persuade the jury that
the outcome was not coincidental, and was a consequence of the 13
technique used by Dr. Koslow which precipitated a tear in the surface of
the aneurysm. The question of whether the doctor’s choice and
execution of the technique fell below the standard of care was a separate
and distinct question for the jury to decide in conformity with
appropriate instructions defining the plaintiff’s burden to prove
negligence and proximate cause. The argument made by Smith’s counsel
did not suggest otherwise, and it neither provoked nor justified the district court’s deployment of the “mere fact of injury” instruction.
I would reverse and remand this case for a new trial.
Wiggins, J., joins this dissent.