Bernard v. Char
1995 Haw. LEXIS 70, 79 Haw. 362, 903 P.2d 667 (1995)
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Rule of Law:
In a medical malpractice action based on the doctrine of informed consent, causation is determined by an objective standard: whether a reasonable person in the patient's position would have refused the treatment had they been adequately informed of the material risks.
Facts:
- On January 10, 1987, Noah Phillip Bernard, III visited dentist Dr. John K. Char, complaining of a severe toothache.
- An x-ray revealed Bernard's second molar (tooth no. 15) was extensively decayed, and Dr. Char suspected it was ankylosed, or fused, to the jawbone.
- Dr. Char testified that he recommended a root canal, discussed its risks, and only suggested extraction as a last resort when Bernard stated he could not afford the root canal, at which point he explained the risks of extraction.
- Bernard testified that Dr. Char recommended extraction as the best alternative and did not inform him of any possible adverse consequences or complications. Two of Dr. Char's dental assistants corroborated Bernard's testimony.
- Unable to afford the more expensive root canal procedure, Bernard consented to the tooth extraction.
- During the extraction of tooth no. 15, Dr. Char felt a crack and ultimately removed not only tooth no. 15 but also the adjoining wisdom tooth (no. 16) and portions of Bernard's buccal plate and antrum bone, all of which were fused together.
- The procedure left Bernard with a dime-sized hole from his mouth into his sinus cavity, which caused blood from his mouth to flow out through his nose.
- Following the procedure, Bernard experienced multiple bleeding episodes and required follow-up care.
Procedural Posture:
- Noah Phillip Bernard, III sued Dr. John K. Char in the First Circuit Court of Hawai'i (trial court) for dental malpractice and lack of informed consent.
- A jury returned a special verdict in favor of Bernard, finding Dr. Char negligent and awarding damages.
- The trial court entered judgment for Bernard. Dr. Char filed a post-trial motion for remittitur or a new trial.
- The trial court granted the motion for remittitur, reducing the damage award, but denied the motion for a new trial, entering an amended judgment for Bernard.
- Dr. Char, as appellant, appealed the judgment to the Intermediate Court of Appeals of Hawai'i (ICA).
- The ICA affirmed the trial court's judgment, applying a 'modified objective standard' for causation.
- Dr. Char, as petitioner, applied for a writ of certiorari to the Supreme Court of Hawai'i, which the court granted.
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Issue:
In a medical malpractice claim for lack of informed consent, is the causation element determined by an objective standard, which asks whether a reasonable person in the patient's position would have refused the treatment if properly informed of the risks?
Opinions:
Majority - Moon, Chief Justice
Yes. The proper standard for determining causation in an informed consent claim is an objective one, asking what a reasonable person in the patient’s position would have done if properly informed of the risks. The court rejected both the purely subjective standard (what the actual patient claims they would have done) and the 'modified objective standard' previously used by the intermediate appellate court. The court reasoned that a subjective standard is unreliable, as it is based on the patient's self-serving hindsight after an injury has occurred. The court found the 'modified objective standard' (what the actual patient, acting rationally, would have done) to be overly complex and difficult to apply. The objective standard, as articulated in cases like Canterbury v. Spence, provides a more equitable, uniform, and predictable framework consistent with general negligence principles. Crucially, this objective standard is not applied in a vacuum; it requires the factfinder to consider all of the characteristics and circumstances of the particular patient—including their pain, financial situation, idiosyncrasies, and beliefs—when determining what a 'prudent person in the patient's position' would have decided.
Analysis:
This decision formally establishes the objective standard for causation in informed consent cases in Hawaii, aligning state doctrine with the majority of U.S. jurisdictions. By rejecting the intermediate court's novel 'modified objective standard,' the Hawaii Supreme Court prioritized a more established and workable legal test. The ruling balances the principle of patient self-determination with the need to protect healthcare providers from liability based on a patient's hindsight bias. Future informed consent cases in Hawaii will now focus not on the patient's subjective testimony about their decision-making, but on objective proof of what a reasonable person with the patient's specific life circumstances would have done.
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