Hicks v. United States

United States Court of Appeals Fourth Circuit
368 F.2d 626 (1966)

ELI5:

Rule of Law:

When a patient's symptoms are consistent with both a benign and a potentially lethal condition, a physician breaches the standard of due care by failing to perform standard diagnostic procedures to rule out the more serious condition. This negligence is the proximate cause of death if it destroys any substantial possibility of the patient's survival, and the plaintiff is not required to prove that the patient would have survived with absolute certainty.

Facts:

Carol Greitens, a 25-year-old with controlled diabetes, was the wife of a Navy enlisted man.
Around 4 a.m. on August 25, 1963, her husband brought her to a Naval dispensary with intense abdominal pain and vomiting that had begun an hour prior.
The on-duty doctor examined her for approximately ten minutes, which included feeling her abdomen and listening to her bowel sounds.
The doctor diagnosed her with gastroenteritis, prescribed pain medication, and instructed her to return in eight hours.
After returning home, Mrs. Greitens vomited again, took the medication, and rested.
At about noon, she drank water, vomited, and collapsed unconscious.
She was rushed back to the dispensary but could not be revived and was pronounced dead.
An autopsy revealed the cause of death was a massive hemorrhagic infarction of the intestine resulting from a strangulated high intestinal obstruction.

Procedural Posture:

The administrator of Carol Greitens' estate filed a lawsuit against the United States under the Federal Tort Claims Act in a U.S. District Court (trial court).
The suit alleged medical negligence by a doctor at a U.S. Naval dispensary.
After a bench trial, the District Court found the evidence was insufficient to prove negligence or proximate cause and dismissed the complaint.
The plaintiff, as the appellant, appealed the dismissal to the United States Court of Appeals for the Fourth Circuit.

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Issue:

Does a physician's failure to conduct standard diagnostic tests to differentiate between gastroenteritis and a lethal high intestinal obstruction constitute negligence and the proximate cause of death when the patient is sent home and subsequently dies from the obstruction?

Opinions:

Majority - Sobeloff, Circuit Judge

Yes. A physician’s failure to conduct a thorough examination and perform standard diagnostic procedures when symptoms could indicate a lethal condition constitutes a breach of the standard of care, and this negligence is the proximate cause of death if it destroys any substantial possibility of survival. The standard of care in Virginia requires a physician to use the skill and diligence of an ordinary, prudent practitioner in the community. Where symptoms are consistent with both a minor ailment (gastroenteritis) and a lethal condition (high obstruction), due care demands more than a cursory examination before releasing the patient. Experts for both parties agreed that inquiring about diarrhea and performing a rectal exam were standard procedures to differentiate between the two conditions. The doctor's failure to perform these accepted tests constituted a lack of due care. By sending the patient home with instructions not to return for eight hours, the doctor made a final diagnosis based on an inadequate investigation, nullifying any chance for observation and revision. The negligence was the proximate cause of death because expert testimony confirmed that with prompt surgery, the patient would have survived. When a defendant’s negligence terminates a person’s chance of survival, the law does not require the plaintiff to show to a certainty that the patient would have lived.

Analysis:

This case significantly clarifies the standard of care in medical malpractice cases involving diagnostic errors. It establishes that a physician cannot 'gamble' by choosing the most probable diagnosis when a more lethal condition with similar symptoms is possible, without first conducting standard tests to rule out the graver condition. The decision also reinforces the 'loss of chance' doctrine for causation, lowering the plaintiff's burden of proof. Instead of proving that the patient would have certainly survived but for the negligence, the plaintiff need only show that the doctor's negligence destroyed a 'substantial possibility of survival,' making it easier to hold physicians accountable for premature or incomplete diagnoses.

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