Ashe v. Radiation Oncology Associates

Supreme Court of Tennessee, at Nashville
9 S.W.3d 119 (1999)

ELI5:

Rule of Law:

In a medical malpractice informed consent case, the standard for causation is objective: the plaintiff must prove that a reasonable person in the patient's position would not have consented to the treatment if they had been adequately informed of all significant perils.

Facts:

In 1988, Patricia P. Ashe was diagnosed with breast cancer and successfully treated with a double mastectomy and chemotherapy.
In 1993, Ashe developed symptoms that led to the discovery of a mass in her left lung, which could have been either metastatic breast cancer or a new primary lung cancer.
Ashe was referred to Dr. Steven L. Stroup, a radiation oncologist, who prescribed radiation therapy.
Dr. Stroup did not inform Ashe of the risk that the radiation treatment could result in permanent injury to her spinal cord, a risk he estimated at less than one percent.
Ashe underwent the prescribed radiation treatment.
As a result of the treatment, Ashe developed radiation myelitis, a permanent radiation injury to her spinal cord that rendered her a paraplegic.

Procedural Posture:

Patricia P. Ashe filed suit against Dr. Steven L. Stroup in a state trial court, alleging medical malpractice and lack of informed consent.
During the trial, Ashe's testimony about whether she would have consented to the therapy if warned of the risk of paralysis was found to conflict with her earlier deposition testimony.
The trial court struck Ashe's trial testimony on the consent issue and granted a directed verdict in favor of Dr. Stroup on the informed consent claim.
The medical malpractice claim went to the jury, which was unable to reach a verdict, resulting in a mistrial on that count.
Ashe (appellant) appealed the directed verdict on the informed consent claim to the Tennessee Court of Appeals, with Dr. Stroup as the appellee.
The Court of Appeals reversed the trial court's directed verdict, holding that the conflicting testimony was a credibility issue for the jury and that the proper standard required proof that a reasonable person would have refused the procedure.
The Supreme Court of Tennessee granted an appeal to determine the appropriate standard for causation in informed consent cases.

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Issue:

Is the standard for determining causation in a medical malpractice informed consent case an objective one, based on what a reasonable person in the patient's position would have done, rather than a subjective one, based on what the specific patient testifies they would have done?

Opinions:

Majority - Holder, J.

Yes, the standard for causation in an informed consent case is an objective one. To establish causation, a plaintiff must prove that a reasonable person in the patient’s position would have chosen a different course of treatment if the significant risks had been disclosed. The court rejected the subjective standard, which relies on the patient's own testimony about what they would have done, because it is unreliable due to hindsight bias and the patient's bitterness after a poor outcome. The objective standard, rooted in the seminal case of Canterbury v. Spence, aligns with general negligence principles that measure conduct against that of a reasonable person. It provides a more realistic and fair framework for resolving the issue of causation, preventing physicians from being held liable based solely on a patient's speculative, post-injury testimony. While objective, the standard is not impersonal; it allows the fact-finder to consider the specific patient's individual characteristics, such as age, medical condition, fears, and beliefs, when determining what a 'reasonable person in the patient's position' would have decided.

Analysis:

This decision establishes the objective 'reasonable person' standard as the definitive test for causation in informed consent cases in Tennessee, aligning the state with the majority of U.S. jurisdictions. By rejecting the subjective test, the court provides greater predictability in litigation and protects healthcare providers from liability based purely on a patient's hindsight. The ruling clarifies that a patient's own testimony is relevant but not dispositive, shifting the focus to what a prudent person with the patient's unique characteristics and circumstances would have decided. This creates a balanced standard that respects patient autonomy while maintaining a rational framework for legal analysis.

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