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Malpractice Issues in Radiology |
1 Department of Radiology, Rush North Shore Medical Center, 9600 Gross Point Rd., Skokie, IL 60076, and Rush Medical College, Chicago, IL 60612.
Received February 16, 2001;
accepted after revision February 21, 2001.
Case summaries are based on actual events and lawsuits, although certain
facts have been omitted or modified by the author. All opinions expressed
herein are those of the author and do not necessarily reflect those of the
American Journal of Roentgenology or the American Roentgen Ray
Society.
Introduction
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On the day of the visit, the radiologist and his chief technologist traveled to the outpatient radiology facility to observe the operation of the CT unit. They chatted briefly with the radiologist working there, who mentioned that he would be leaving soon. About 1 hr later, while a CT examination of the abdomen was being performed on an elderly woman, the CT technologist conducting the examination noticed that the patient, who had just been administered IV contrast media, began experiencing difficulty breathing. Worried that the patient was undergoing a severe reaction and knowing that the facility's own radiologist was no longer on the premises, the technologist asked the visiting radiologist if he could examine the patient and assist in treatment. The visiting radiologist replied that he was there only to evaluate equipment, didn't "work" at the facility, and "didn't want to get involved." The radiologist added that if the technologist thought the problem was "serious," he should "call 911." The technologist did make the emergency telephone call, and within 10 min a team of paramedics arrived. At about the same time, the visiting radiologist and the sales representatives left the outpatient facility. Although the radiologist expressed regret to the sales representatives about his decision not to assist in treatment of the patient, he never made any later inquiry about what happened after he left.
Ten months later, the radiologist was served notice that he was being sued for malpractice, along with the outpatient radiology facility, for failing to "render appropriate emergency medical treatment that would have prevented the death of the patient."
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At a hearing scheduled by a local judge to argue the merits of the motion to dismiss, the defense attorney took the position that because the defendant radiologist had not established a physician—patient relationship with the patient who had suffered the reaction while undergoing the CT examination, the radiologist had no affirmative duty to examine the patient or to render any treatment. The attorney for the plaintiff responded that as an appropriately trained and experienced radiologist who was duly licensed to practice medicine and radiology in the state, the defendant radiologist had a "clear moral and legal duty" to render emergency treatment to the patient, and added that the state's Good Samaritan Act in fact "required" the doctor to render such care.
The defense attorney countered that the Good Samaritan Act should be construed as encouraging treatment by the radiologist but not compelling it. Furthermore, argued the defense attorney, "Whether my client had a moral duty to act is not an issue in this case; it is only the legal duty about which this Court should be concerned, and my client had no such legal duty."
Three days after the hearing, the judge ruled in favor of the defense and dismissed the radiologist from the lawsuit. The malpractice suit against the outpatient facility proceeded and eventually resulted in an out-of-court settlement, the terms of which were not made public. Although exonerated legally from the lawsuit, the radiologist was left with feelings of guilt and self-recrimination about whether he had acted immorally by declining to be a Good Samaritan.
This article can shed only limited light on the moral issues raised in this case; the legal issues, however, are more easily illuminated.
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From a strictly religious point of view, there is little question that every person, irrespective of his or her socioeconomic class or profession, has the duty to rescue or at least to assist those whose lives are in physical danger, if it can be done safely. In marked contrast, however, under American law there is no such affirmative legal duty to do so, although certain exceptions apply to physicians. This article will focus on how the courts view the question of whether physicians should act as Good Samaritans when obliged by circumstances to do so, and whether they will suffer any consequences by acting, or refusing to act, as such.
We shall begin, however, by examining how the courts have dealt with the Good Samaritan concept as it relates to the nonphysician.
The Ordinary Citizen as the Good Samaritan
The position of American courts on the question of whether one citizen owes
any legal duty to another citizen who is in serious physical danger was
eloquently stated by the Supreme Court of New Hampshire more than a century
ago [3]:
Negligence is neglect of a legal duty. Defendants are not liable unless they owed to the plaintiff a legal duty which they neglected to perform. With purely moral obligations, the law does not deal. For example, the priest and Levite who passed by on the other side were not, it is supposed, liable at law for the continued suffering of the man who fell among thieves, which they might and morally ought to have prevented or relieved. Suppose A, standing close by a railroad, sees a 2-year-old babe on the track and a car approaching. He can easily rescue the child with entire safety to himself, and the instincts of humanity require him to do so. If he does not, he may, perhaps, justly be styled a ruthless savage and a moral monster; but he is not liable in damages for the child's injury, or indictable for its death....No action will lie against a spiteful man, who, seeing another running into danger, merely omits to warn him.... In short, if [the man does] nothing, lets the other entirely alone, in no manner interferes with him, [the other man] can have no cause of action for any injury that he may receive.
The viewpoint expressed by the New Hampshire Supreme Court still, more than 100 years later, remains the law throughout the nation today. Why do American courts not impose on citizens an affirmative duty to assist others who may be in physical danger? The most plausible explanation is that given by a Chicago law professor, Sheldon Nahmod [2]:
Under the common law the person in danger and the potential rescuer are for the most part considered to be autonomous strangers because there is no causal or other pre-existing relationship between them. For the common law to impose a duty to rescue would mean that the coercive power of government would be brought to bear on the potential rescuer to enter into a possibly dangerous or inconvenient relationship without his consent and against his will. Government would, at least for this purpose, be taking control of the potential rescuer's body, enforcing it to act in a certain manner. In short, imposing a duty to rescue would directly interfere with the personal autonomy and liberty of the potential rescuer.
The Good Samaritan ethic asserts that there is a strong ethical presumption in favor of assisting an individual who is in danger or in need of help [4]. Because this ethic is one that is endorsed by our culture, all states have enacted Good Samaritan laws. California enacted the first in 1959, and by the mid 1970s, every state had such a law. These Good Samaritan laws arose from two perceptions: first, that lawsuits by ungrateful emergency victims against their voluntary benefactors are unjust and should be precluded; and second, that the persons who possess skills, particularly physicians, should be encouraged to use them during emergencies for the public good [5]. The legislature of the State of Illinois set forth the purpose of its Good Samaritan Act this way: "...to establish numerous protections for the generous and compassionate acts of its citizens who volunteer their time and talents to help others" [6].
Good Samaritan laws share certain provisions: no legal obligation to provide aid; immunity from malpractice litigation if aid is provided, unless there is gross negligence or lack of good faith; and no payment can be accepted for aid given. In 46 of the 50 states, these Good Samaritan laws encourage citizens who possess certain skills, including but not limited to physicians, to render assistance in emergency situations; however, they do not compel them to do so. However, four states—Louisiana, Rhode Island, Vermont, and Wisconsin—have enacted Good Samaritan legislation, more properly termed failure-to-act legislation, applicable to all citizens, not just physicians, that assigns an affirmative duty to aid a victim in need. Violation of these laws is punishable criminally, although I have been unable to find any American case in which an alleged violation has resulted in prosecution. Minnesota also passed similar legislation, but it was later repealed [2, 4].
Parenthetically, several European countries have also enacted failure-to-act legislation that is applicable to all citizens. Thus, it may be remembered that the photographers who allegedly pursued Princess Diana in the high-speed car chase that resulted in her death in Paris in 1997 were legally charged not only with involuntary homicide for contributing to the cause of the automobile crash, but also with failure to offer assistance to the victim [4].
The Physician as a Good Samaritan
Discussion thus far has centered on ordinary citizens acting or refusing to
act as a Good Samaritan. Although the statutory and common laws do not
necessarily single out physicians for special attention, physicians are
nonetheless treated differently in certain respects. Many in society feel that
the freedom to refuse to give assistance in emergency situations granted to
ordinary citizens should not be granted to physicians; these individuals
believe that because physicians possess unique medical skills they should have
imposed upon them the duty to assist when sudden or emergent medical needs
arise [4]. Such individuals, to
support their opinion, point to the American Medical Association's Principles
of Medical Ethics, which states
[7]:
A physician shall, in the provision of appropriate medical care, except in emergencies [italics added], be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.
In addition, even though it has been written specifically for emergency physicians, the following words from the Code of Ethics for Emergency Physicians are seen by some to apply to all physicians [8]:
Because of their unique expertise, emergency physicians have an ethical duty to respond to emergencies in the community and offer assistance as a special resource... They have a societal duty to render emergency aid outside their natural health care setting when such intervention may save life or limb.
Moral issues notwithstanding, let us now turn to legal issues that deal with the Good Samaritan physician. A necessary element for any cause of action for negligence is the existence of a duty of care that a defendant owes to a plaintiff [9]. In the usual case of medical malpractice, this duty arises from the physician—patient relationship. Normally, the relationship between physician and patient is a consensual one, wherein the patient knowingly seeks the assistance of the physician and the physician knowingly accepts the individual as a patient. No patient has the authority to unilaterally compel the physician to render service to him or her without the latter's assent. In addition, the public policy of most states is to protect the right of conscience of physicians with respect to their decisions to participate in the delivery of particular types of medical care. Accordingly, for example, Illinois state law provides that no physician shall be civilly or criminally liable "by reason of his or her refusal to perform, assist, counsel, suggest, recommend, refer, or participate in any way in any particular form of medical care which is contrary to the conscience of such physician" [10].
In any case of malpractice litigation filed against a physician, if the physician can show that no physician—patient relationship existed, this "no duty" defense usually suffices to defeat the plaintiff's action [11]. However, for public policy reasons, courts give persons alleging injury from medical malpractice considerable latitude as to the evidence required to establish the existence of a physician—patient relationship [12]. Although physicians are generally free to choose their patients and are not obligated to treat anyone with whom they have no special relationship, this is not always the case. If the circumstances of the specific situation caused the patient to have a reasonable expectation of treatment, or a belief that the physician actually began to render treatment, the courts may well imply the existence of a relationship. The broad interpretation that most courts are willing to apply may result in the legal establishment of a physician—patient relationship that the physician did not intend to create [12].
Whether courts will impose on a defendant physician a physician—patient relationship that the physician did not want to create, thereby allowing a malpractice lawsuit against the physician to proceed, is case-specific. Given similar circumstances, various courts can rule differently. Let us consider three examples.
In North Carolina, a 22-year-old man involved in an automobile accident was taken to a local hospital. There, a physician approached the victim, smelled alcohol on the victim's breath, "worked" the victim's arms and legs up and down, and said, "That is all we can do; take him home or I will turn him over to the cops." The patient was taken home and, 2 days later, died of a brain hematoma. A medical malpractice lawsuit was filed against the physician, claiming negligence for failure to appropriately diagnose and treat the patient. The defense of the defendant physician was that he had not accepted the plaintiff as a patient and that the patient had never requested that he render any treatment. The Supreme Court of North Carolina ruled in favor of the defendant physician, holding that no physician—patient relationship had been established [13]:
The law applicable to the care and treatment a physician must give his patient applies only when the relationship of physician and patient has been established, it being the privilege of a physician to accept or reject an injured man as a patient.... A physician or surgeon is not bound to render professional services to everyone who applies, and he may therefore limit the extent and scope of his employment.... Of course a physician or surgeon could not make a contract with an unconscious man, and hence the ultimate test of liability would depend upon whether the physician actually accepted the injured person as a patient and under-took to treat him. Upon conflicting testimony, such undertaking or acceptance would ordinarily raise an issue for the determination of a jury. In the case [here], all the evidence tends to show that when the injured man was brought into the hospital, the defendant looked him over and, upon discovering that the patient had been drinking, declined to accept him as a patient or to undertake the necessary treatment. Conceding that the defendant was not justified in assuming that [the patient] was drunk, still the law did not compel him to accept the injured man as a patient.... The evidence shows a refusal by the physician to accept the injured man as a patient is insufficient to establish the relationship of physician and patient, and the [defendant] was properly non-suited.
A case with somewhat similar facts resulted in an opposite judicial determination in Kentucky. There, a man believing that he was "having a heart attack" was brought by his brother to a hospital. A physician "dressed like a doctor and bearing a stetho-scope" passed by the patient, who was now seated in a wheelchair in the emergency room area. The patient's brother said to the doctor, "Help my brother; he's having a heart attack." The physician, who was not on emergency room duty at the time, replied, "Get in line and sign in." The physician then walked away. Displeased with the lack of treatment, the brother took the patient to another hospital, where he died the next day of a myocardial infarction. A medical malpractice lawsuit was filed against the physician, who responded that he should not be held accountable because no physician—patient relationship had been established. The appellate court ruled in favor of the defendant physician, stating [14]:
The defendant physician's statement concerning his conception of his duty to emergency patients is an acknowledgement of his moral and medical obligations, the apparent disregard of which we find appalling. Such a judicial admission, however, can in no way establish a legal duty not otherwise extant.... Violation of ethical standards or administrative regulations may give rise to professional disciplinary proceedings, but do not establish a civil cause of action.... In sum, although we find [the defendant physician's] callous disregard for the patient to be morally reprehensible, we can find no legal duty to treat a non-patient, either in statute, regulation, or the common law.
Unhappy with the appellate court ruling, the patient's family brought an appeal to the Kentucky Supreme Court, which reversed the lower court decision [15]:
The premise underlying [the defendant physician's] position that he had no duty in this case, is that a physician's duty to act with reasonable care only arises after he agrees to treat a patient, thus establishing a physician—patient relationship. While this is true as an abstract proposition, the question is whether that abstract proposition applies in the specific circumstances of this case. Here we have a physician in a hospital, obviously functioning as a physician on the staff does, who takes it upon himself to direct the decedent's brother what to do.... The concept of liability for negligence expresses a universal duty owed by all to all.... The question here becomes whether the actions of the physician were negligent in the circumstances and if so, whether the jury could infer that what he did was a substantial factor in contributing to [the patient's] death.Ironically, the evidence shows that [the defendant physician] was the only physician available at the hospital on the morning in question who could have treated a heart attack victim. He admits that he rendered no emergency medical care, even though he was available and capable of rendering potential life-saving treatment. Certainly, a physician who is consulted in an emergency has a duty to respect that interest, at least to the extent of making a good-faith attempt to provide adequate treatment or advice. We think a jury could infer from the evidence that the defendant willfully or recklessly failed to perform that duty. Thus, although we recognize that in the usual situation a doctor is under no obligation to treat a person, we also recognize the law implies a duty wherever circumstances put parties in a relationship to each other where when one acts negligently, it causes injury to the other. The evidence is such that a jury may infer that the defendant was negligent in the circumstances.
In a third case, in Arizona, a medical staff physician specializing in internal medicine was hired to provide care to all patients arriving at the hospital's emergency department. One night a woman in diabetic coma was brought to the department. The physician refused to come to the hospital to examine the patient, instead instructing the nurse to call the patient's private physician. By the time the private physician arrived at the hospital to treat the patient, a significant delay had occurred, and the patient later died. Claiming that the patient's death was directly caused by the delay in instituting appropriate treatment, the patient's family sued the physician who had been covering the emergency department. The defendant physician contended that he could not be sued for malpractice because no physician—patient relationship had been established. The Arizona Appellate Court disagreed with the physician, ruling that he was indeed subject to malpractice litigation [16]:
[The defendant physician] contends that medical malpractice can only arise where the relationship of physician—patient is established; that this relationship is a consensual one; and that in the absence of special circumstances not present here, no physician can be required to treat a particular patient or incur liability for failure to do so.... In examining this issue we start with the general rule, with which we agree, that a medical practitioner is free to contract for his services as he sees fit and in the absence of prior contractual obligations, he can refuse to treat a patient, even under emergency situations. We speak here only of legal obligations. As to ethical obligations, the Code of Ethics of the American Medical Association provides, "A physician may choose whom he shall serve. In an emergency, however, he should render services to the best of his ability."Bylaws adopted by the hospital to which the defendant physician was a party and bound provide... [that its physician members] ensure that all patients admitted to this hospital or treated in the emergency room receive the best possible care [and] the Principles of Medical Ethics as adopted by the American Medical Association shall govern the professional conduct of members of the medical staff, [and] in case of emergency the provisional diagnosis shall be stated as soon after admission as possible....
In our opinion, [the defendant physician], by assenting to these bylaws, and rules and regulations...personally became bound "to ensure that all patients...treated in the emergency room receive the best possible care," and agreed to ensure "in the case of emergency the provisional diagnosis shall be started as soon after admission as possible." Moreover, these services were to be performed for all persons whom the "hospital shall admit...suffering from all types of disease"....
We hold on the basis of the record and the issues presented to us that [the defendant physician] was obligated by contract to treat the patient to the best of his ability. Our holding, as such, is not in any sense based upon the Code of Ethics previously quoted. Our holding would be the same even without the incorporation of the Code of Ethics into the bylaws. The provision in the Code of Ethics in regard to emergency treatment is confirmatory, however, of an overall intent that emergency patients be treated as quickly as possible.
In reaching its decision that the defendant physician had the duty to render treatment to the patient, the Arizona Court looked to the bylaws of the hospital's medical staff to bolster its ruling. AJR readers are reminded that to obtain and retain privileges on a hospital medical staff, physicians agree to abide by all provisions contained in the bylaws of that medical staff. Therefore, a physician's failure to adhere to a bylaw provision that could be construed as mandating emergency treatment could subject that physician to malpractice litigation, irrespective of existing common law to the contrary.
Protection Afforded by Good Samaritan Laws
Thus far we have discussed the potential liability incurred by physicians
who refuse to render emergency treatment. Let us now turn to the protection
afforded by Good Samaritan laws for physicians who do. How effective are these
laws, and do they offer sufficient immunity to litigation? For Good Samaritan
statutes to apply, three requirements must generally be met: first, the doctor
must not have previous knowledge of the illness or injury; second, the doctor
must provide emergency care; and third, the doctor must not charge a fee
[17]. Good Samaritan statutes
are usually also applicable to emergencies occurring in a hospital, as long as
the other conditions stated in the statute are met. Even if all these
requirements are satisfied, can the physician who renders emergency care be
guaranteed that he or she will not be sued or found liable for malpractice?
The answer is not particularly clear. One medical—legal scholar answers
the question this way [5]:
Good Samaritan laws are remarkably fluid in application, and physicians must fulfill numerous conditions to obtain the benefit of immunity. A physician asked to help during a life-threatening event will find that calculating the legal variables immediately to decide whether a Good Samaritan statute applies is an impossible task. Winning a case is more a matter of legal serendipity than a considered analysis of risks and benefits.
Another medical—legal commentator echoes these sentiments [18]:
In the current form, the Good Samaritan defense is ineffective because it does not prevent a lawsuit or a trial. Thus, whether a physician was acting as a Good Samaritan must be decided by a judge or jury. This means that the "Good Samaritan physician" must go through an entire trial and prove that he or she acted as a Good Samaritan.... If the jury determines that the physician was, in fact, acting as a Good Samaritan, that does not end the jury's deliberation. The "Good Samaritan doctor" in many states is only immunized from liability for everything but willful, wanton, or gross negligence. This means that the jury must then decide whether the physician's conduct was not willful, wanton, or grossly negligent....Another issue is what I call the medical staff exception. For example, some hospitals have enacted a provision in their medical staff bylaws that requires members of the medical staff to respond to in-hospital emergencies. One interpretation of these bylaws would be that a physician practicing in the hospital would therefore have a pre-existing duty to respond to any inpatient hospital emergency.... Thus, standard negligence principles and not the Good Samaritan defense would apply.
In view of the foregoing, it is probably no surprise, then, to discover that despite the existence of Good Samaritan laws and the protection they offer, many physicians choose not to get involved in emergency situations. In a 1963 survey that asked physicians whether they would stop to help at a roadside accident, half said that they would not, and that the Good Samaritan law would not make any difference [19]. Thirty-five years later, a survey among internists disclosed similar findings. Most respondents would help if asked to give emergency care in restaurant and airplane scenarios (69% and 54%, respectively). Forty-four percent indicated that they would be helpers at a highway accident, as would 33% in a subway. Only 2% would help a man lying on the sidewalk. Of the reasons cited for not helping, concern for personal risk was the most common. Fifty-two percent indicated that it was simply not their responsibility to help, 36% were concerned about contracting infectious disease, 29% had a lack of comfort with their acute medical care skills, and 17% feared legal repercussions.
The Radiologist as the Good Samaritan
Let us now return to the lawsuit described at the beginning of this
article, using it as a basis to analyze the impact of Good Samaritan laws on
the conduct of radiologists. In this specific case, the defendant radiologist
found himself in a situation in which he was asked to respond to a reaction
from contrast material, using the expertise that most radiologists are
expected to possess. To the defendant radiologist's legal good fortune, a
judge dismissed the lawsuit. We have no way of knowing what the state's
appellate or supreme court would have ruled had the attorney for the plaintiff
decided to appeal the judge's dismissal. The plaintiff's attorney apparently
felt that it simply wasn't worth the time or money to appeal, inasmuch as most
of the fault lay with the outpatient radiology facility and the attorney was
able to negotiate a satisfactory settlement. Based on what we have discussed
in this article, it is by no means a foregone conclusion that an appeals court
would have upheld the defendant radiologist's dismissal. The legal duty of any
radiologist who might be placed in similar circumstances remains murky.
Let us consider some other hypothetical Good Samaritan situations in which radiologists may find themselves, and speculate how a court would rule:
The radiologist is on vacation and flying in an airplane. Suddenly the airline pilot announces that a passenger is having a heart attack and asks whether a physician on board can give assistance. The radiologist does not offer assistance. Clearly, the radiologist has no legal duty to offer emergency care, but if he did, he would very likely be granted Good Samaritan immunity.
The radiologist is sitting in the consultation room of his or her radiology department, interpreting radiographs. Suddenly, a technologist runs into the room, clamoring with some urgency, "A patient down the hall who has just been administered contrast media is having a reaction; please come." The radiologist refuses, saying, "I didn't administer the injection; call somebody else." Is it likely that the radiologist will be held liable if the patient dies and a lawsuit is filed against the radiologist for failing to assist? The answer is probably "yes." In this hypothetical scenario, a patient has been registered in the radiology department in which the defendant radiologist is working, and even though the defendant radiologist may not have established a formal physician—patient relationship with the patient because no radiographs have yet been obtained or interpreted by the radiologist, I would think it likely that a judge would rule that such a relationship existed nonetheless.
In Summary: Should the Radiologist Be a Good Samaritan?
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One California expert in emergency medicine ethics has expressed his opinions regarding the moral responsibility of physicians as follows [4]:
As a rule, legal standards are unreliable guides to ethical conduct and should not be allowed to substitute for or dominate moral decisions. In addition, no lawsuit in the United States against physicians for execution of Good Samaritan acts has yet been reported, and even if such a legal case were to be brought and the physician to lose, potential penalties are minimal. Fear of legal repercussions is a rationalization rather than a legitimate reason not to provide Good Samaritan aid....All professional standards support, and some mandate, intervention. Unless compelling extenuating factors pertain, for example, substantial risk or urgent other duty, the moral obligation of the physician in such situations is to provide Good Samaritan aid. The location of the victim (inside, outside, or far from the hospital) does not affect the obligation. Even if the victim is an alleged perpetrator of a criminal or antisocial act, aid should be provided unless he or she presents a risk of further immediate harm to someone else. It is the function of the legal system and not the physician to determine innocence or guilt.
I have reviewed the reasons many physicians give for refusing to render emergency care. Would any of these reasons pass muster with a jury? Let us not forget that whether a radiologist or other physician can even be brought before a jury for alleged malpractice resulting from refusal to render emergency treatment is a decision that is made by a judge, presumably only on the basis of the law. Should that judge decide that the accused defendant radiologist be brought to trial, a jury of laypersons is not likely to view with great enthusiasm or sympathy statements offered by the defendant radiologist that he or she refused to render care to a patient who was in immediate danger of serious injury or death because the defendant "wasn't qualified," "didn't think it was his or her responsibility," "didn't want to get involved," or "was afraid of getting sued."
Perhaps when it comes to the Good Samaritan issue, the law—and morality—more often than not coincide.
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