bradley v. sugarbaker, 1st cir. (2015)

7/26/2019 Bradley v. Sugarbaker, 1st Cir. (2015)

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United States Court of AppealsFor the First Circuit

No. 15- 1128

BARBARA J . BRADLEY and MI CHAEL BRADLEY,

Pl ai nt i f f s , Appel l ant s ,

v.

DAVI D J . SUGARBAKER, M. D. ,

Def endant , Appel l ee.

APPEAL FROM THE UNI TED STATES DI STRI CT COURTFOR THE DI STRI CT OF MASSACHUSETTS

[ Hon. Geor ge A. O' Tool e, U. S. Di st r i ct J udge]

Bef ore

Tor r uel l a, Lynch, and Kayat t a,

Ci r cui t J udges.

I l yas J . Rona, wi t h whom J i n- Ho Ki ng and Mi l l i gan Rona Dur an& Ki ng LLP, wer e on br i ef , f or appel l ant s.

Car ol Ann Kel l y, wi t h whom Phi l i p E. Mur r ay, J r . , J ames L.Wi l ki nson, and Mur r ay, Kel l y & Ber t r and, P. C. , wer e on br i ef , f orappel l ee.

December 16, 2015


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TORRUELLA, Circuit Judge. I n t hi s medi cal mal pr act i ce

act i on, Pl ai nt i f f s- Appel l ant s Bar bar a and Mi chael Br adl ey appeal

t he di st r i ct cour t ' s deci si on t o gr ant summar y j udgment as t o t hei r

medi cal bat t er y cl ai m. Fol l owi ng a j ur y t r i al as t o t hei r i nf or med

consent cl ai m, t hey al so asser t t hat t he di st r i ct cour t er r ed by

excl udi ng exper t t est i mony that a f i ne- needl e aspi r at i on ( "FNA")

bi opsy was a vi abl e non- sur gi cal al t er nat i ve t o a sur gi cal bi opsy.

Af t er car ef ul r evi ew of t he r ecor d, we af f i r mt he di st r i ct cour t ' s

di smi ssal of t he Br adl eys' bat t er y cl ai m but vacat e and r emand

wi t h r espect t o t he excl uded exper t t est i mony.

I. Background

A. The Surgery

Af t er exper i enci ng shor t ness of br eat h and per si st ent

pai n i n her r i ght ar m and wr i st f ol l owi ng a 2002 car acci dent ,

Mr s. Br adl ey underwent magnet i c r esonance i magi ng ( "MRI " ) i n

November 2004. The MRI r eveal ed a mass at t he t op of Mr s.

Br adl ey' s r i ght l ung t hat her physi ci an f ear ed was cancer . Af t er

l ear ni ng t he r esul t s of t he MRI , Mr s. Br adl ey was schedul ed f or a

posi t r on emi ss i on t omogr aphy ( "PET") scan and FNA bi opsy. 1 On

1 An FNA bi opsy i s an out pat i ent pr ocedur e i n whi ch a r adi ol ogi sti nser t s a l ong, hol l ow needl e t hr ough t he ski n and i nt o t he masst o ext r act cel l s. A pat hol ogi st t hen exami nes the speci men undera mi croscope. The di agnost i c yi el d - - or " t he posi t i ve yi el dr at e" - - i s bet ween ni net y t o ni net y- f i ve per cent .


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December 1, 2004, Mr s. Br adl ey r ecei ved her PET scan r esul t s, whi ch

suggest ed t hat t he mass was beni gn, "al t hough mal i gnancy [ coul d

not ] be ent i r el y r ul ed out . "

Mr s. Br adl ey met wi t h Dr . Davi d Sugarbaker , t he

Def endant - Appel l ee, a thor aci c surgeon at Br i gham & Women' s

Hospi t al , i n Bost on on December 7, 2004. Dur i ng t he appoi nt ment ,

Dr . Sugar baker t ook Mr s. Br adl ey' s medi cal hi st or y and l ear ned

t hat she had scar r i ng on her r i ght l ung f r omt he 2002 car acci dent .

Dr . Sugarbaker st ated t hat he was "more than 50 percent sure [ Mr s.

Br adl ey had] cancer , " and t hat Mr s. Br adl ey woul d need t o undergo

a bi opsy. Dr . Sugar baker ' s not es f r om t hat day i ndi cat ed t hat

" [ a] mal i gnancy needs t o be r ul ed out . We wi l l see whether an FNA

can be done t o secur e a di agnosi s. " Lat er t hat same day, Mr s.

Br adl ey met wi t h Dr . Lambr os Zel l os, anot her t hor aci c surgeon at

Br i gham & Women' s, t o r evi ew her MRI r esul t s. Mr s. Br adl ey

expl ai ned t o Dr . Zel l os t hat she had an FNA bi opsy schedul ed and

asked whether she shoul d pr oceed wi t h t hat pr ocedur e. Dr . Zel l os

sai d i t was necessar y "t o check wi t h t he r adi ol ogi st f i r st t o see

i f t he bi opsi es coul d be done that way. "

As r ecount ed i n mor e det ai l her ei n, Mr s. Br adl ey never

r ecei ved an FNA bi opsy. Af t er a second PET scan, Dr . Sugarbaker

agai n met wi t h t he Br adl eys on December 14, 2004. The scan

i ndi cat ed t hat t he mass was unl i kel y t o be cancer ous. Af t er


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r evi ewi ng t he scan, Dr . Sugar baker advi sed t he Br adl eys t hat

" [ t ] hi s l ooks l i ke i t mi ght not be cancer " and r ecommended

schedul i ng a sur gi cal bi opsy t o remove and t est t i ssue sampl es.

Dr . Sugarbaker di d not di scuss t he next st eps once he determi ned

whet her t he mass was beni gn or mal i gnant .

Mr s. Br adl ey pr oceeded t o surgery, whi ch t ook pl ace on

December 17, 2004. The i nf ormed consent f orm t hat she si gned

i ndi cat ed t hat she woul d undergo a br onchoscopy, 2 medi ast i noscopy, 3

and mi ni t hor acot omy4 and descr i bed t he r i sks associ at ed wi t h t hese

pr ocedur es. Dur i ng t he oper at i on, Dr . Sugar baker t ook si x

sampl es, al l of whi ch t est ed negat i ve f or cancer . To obt ai n a

si xt h sampl e, Dr . Sugar baker per f ormed a pul monary wedge

r esect i on, dur i ng whi ch he exci sed a l ar ger sampl e i ncl udi ng

por t i ons of heal t hy l ung t i ssue. Thi s sect i on measur ed 8 x 3. 5 x

3. 5 cent i met er s, whi ch was l arger t han each of t he ot her sampl es.

Fol l owi ng sur gery, Mr s. Br adl ey was di smayed t o wake up

i n t he sur gi cal i nt ensi ve car e uni t . At t hat t i me, she di scover ed

2 Dur i ng t r i al , Dr . Sugar baker descr i bed a br onchoscopy as apr ocedure i n whi ch a camera i s used to "exami ne t he ai r way passagest o l ook f or si gns of cancer . "

3 One of Dr . Sugar baker ' s col l eagues, Dr . Chr i st opher Ducko,descr i bed a medi ast i noscopy as a pr ocedur e t o "sampl e and bi opsyt he l ymph nodes. "

4 A mi ni t horacot omy i s a pr ocedur e whereby doct ors bi opsy a masst o remove t i ssue sampl es.


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" t hat dur i ng the sur ger y t hey act ual l y r emoved a pi ece of my l ung

when t hey r emoved t he mass. " Her admi ss i on notes i ndi cat e t hat

t he pr ocedure had become "more ext ensi ve [ secondary] t o

si gni f i cant scar r i ng f r om pr i or t r auma and sur ger y. " The not es

al so i ndi cat e t hat Mr s. Br adl ey suf f er ed "mul t i pl e ai r l eaks" as

a r esul t of t he wedge r esect i on. She was not di schar ged unt i l

appr oxi matel y a week l ater , on December 25, due t o the ai r l eaks.

Subsequent X- r ays r eveal ed a pneumothorax, otherwi se

known as a col l apsed l ung, wher e t he mass was removed. I n t he

i nt erveni ng mont hs, Mr s. Br adl ey devel oped a cough and worseni ng

arm pai n. A PET scan r eveal ed what r esembl ed an empyema - - a

col l ect i on of pus - - near her l ung. Sampl es f r om Mr s. Br adl ey' s

r i ght upper chest ar ea t est ed posi t i ve f or a f ungus known as

asper gi l l us f umi gat us, and Mr s. Br adl ey was di agnosed wi t h a

br onchopl eur al f i st ul a, a l eak whi ch al l owed t he space wher e her

r i ght upper l obe was r emoved t o be i nf ect ed wi t h asper gi l l us.

Per si st ent i nf ect i ons have l ed t o year s of compl i cat i ons and pai n.

I n March 2006, Mr s. Br adl ey st opped worki ng i n her

posi t i on as a l aw l i br ar i an because she was " t oo si ck t o go t o

work. " Dur i ng t he summer of 2006, she r ecei ved i nt r avenous

t r eat ment s cont ai ni ng ant i f ungal s and ant i bi ot i cs t o t r eat t he

i nf ect i on. When t hese r emedi es pr oved unsuccessf ul , Mr s. Br adl ey

under went addi t i onal surger i es i n 2006 and 2009 t o t r eat her


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ongoi ng i nf ect i ons. Mr s. Br adl ey st i l l t akes pai n medi cat i ons and

an expensi ve ant i f ungal medi cat i on t o pr event f ur t her asper gi l l us

i nf ect i ons .

B. District Court Proceedings and Jury Trial

On December 17, 2007, t he Br adl eys f i l ed a compl ai nt

agai nst Dr . Sugar baker i n t he Uni t ed St at es Di st r i ct Cour t f or t he

Di st r i ct of Massachuset t s. A second amended compl ai nt was f i l ed

on J une 27, 2011, al l egi ng cl ai ms based on medi cal negl i gence, Dr .

Sugar baker ' s f ai l ur e t o obt ai n i nf or med consent , and bat t er y. The

second amended compl ai nt asser t ed, among ot her t hi ngs, t hat Dr .

Sugar baker "negl i gent l y per f or med a maj or surger y t o acqui r e

t i ssue t o submi t t o pat hol ogy when . . . obt ai ni ng t i ssue shoul d

and coul d have been done by l ess i nt r usi ve means, i ncl udi ng a f i ne

needl e aspi r at ed bi opsy. " The Br adl eys al l eged t hat Mr s. Br adl ey

di d not have enough i nf ormat i on t o "ma[k] e an i nf ormed choi ce [ as

t o] whet her t o under go l ess i nt r usi ve met hods f or obt ai ni ng bi opsy

t i ssue t han an open sur gi cal bi opsy. " The Br adl eys al so cl ai med

t hat Mr s. Br adl ey nei t her consent ed t o nor was i nf or med " t hat [ Dr .

Sugar baker ] i nt ended t o t ake t i ssue of any si gni f i cant si ze" and,

as a r esul t , t he wedge r esect i on const i t ut ed bat t er y.

Fol l owi ng di scover y, Dr . Sugar baker f i l ed a mot i on f or

summar y j udgment as t o al l of t he Br adl eys' cl ai ms. The di st r i ct

cour t deni ed t he mot i on as t o the i nf or med consent cl ai ms,


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expl ai ni ng t hat " t her e ar e mat er i al f act s i n di sput e about what

Dr . Sugar baker t ol d Bar bar a Br adl ey about her al t er nat i ves and t he

associ ated r i sks . " Summary j udgment was gr ant ed as t o t he medi cal

bat t er y cl ai m because, accor di ng t o t he di st r i ct cour t , "t he

common- l aw t or t of bat t ery i s based on t he absence of consent t o

a par t i cul ar t r eat ment r at her t han t he l ack of i nf or med consent . "

So l ong as Mr s. Br adl ey consent ed t o sur ger y, "what ever t he di sput e

about i t s par amet er s, " t he di st r i ct cour t r easoned, her bat t er y

cl ai m must f ai l .

The case proceeded t o t r i al i n Februar y 2014. As

descr i bed i n mor e det ai l bel ow, Dr . Sugar baker f i l ed a mot i on i n

l i mi ne seeki ng t o excl ude t est i mony f r om t he Br adl eys' exper t

wi t ness, Dr . J oe Put nam, whi ch t he di st r i ct cour t j udge al l owed i n

par t . At t he end of t he t r i al , t he j ur y r et ur ned a ver di ct f or

Dr . Sugar baker . The j ur y f ound t hat Mr s. Br adl ey was not pr ovi ded

suf f i ci ent i nf or mat i on t o make an i nf or med j udgment as t o whet her

t o consent t o t he pr ocedur e, but t hat she f ai l ed t o pr ove " t hat

nei t her she nor a r easonabl e per son i n her si t uat i on woul d have

consent ed t o t he sur ger y had the mat er i al i nf or mat i on been

pr ovi ded. "

II. Discussion

On appeal , t he Br adl eys asser t t wo ar gument s. Fi r st ,

t hey cl ai m t hat t he di st r i ct cour t er r ed i n gr ant i ng t he mot i on


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f or summary j udgment as t o t he bat t er y cl ai m. Second, t hey f aul t

t he di st r i ct cour t f or excl udi ng por t i ons of Dr . Put nam' s

t est i mony. We addr ess each argument i n t ur n.

A. Battery Claim

1. Standard of Review

Or ders gr ant i ng or denyi ng summary j udgment are subj ect

t o de novo r evi ew. Loubr i el v. Fondo del Segur o del Est ado, 694

F. 3d 139, 142 ( 1st Ci r . 2012) . We vi ew " t he f act s i n t he l i ght

most f avorabl e t o t he non- movi ng part y, " Romn v. Pot t er , 604 F. 3d

34, 38 ( 1st Ci r . 2010) , and "af f i r m onl y i f t he r ecor d r eveal s

' t hat t her e i s no genui ne di sput e as t o any mat er i al f act and t he

movant i s ent i t l ed t o j udgment as a mat t er of l aw. ' " Aver y v.

Hughes, 661 F. 3d 690, 693 ( 1st Ci r . 2011) ( quot i ng Fed. R. Ci v. P.

56( a) ) .

2. Battery Under Massachusetts Law

A di ver si t y sui t such as t hi s i s gover ned by

Massachuset t s subst ant i ve l aw. See Net t v. Bel l ucci , 269 F. 3d 1,

5 ( 1st Ci r . 2001) . I n Massachuset t s, bat t er y i s def i ned as "an

i nt ent i onal of f ensi ve t ouchi ng of a per son done wi t hout consent . "

Moor e v. El i Li l l y & Co. , 626 F. Supp. 365, 368 ( D. Mass. 1986)

( ci t i ng Bel ger v. Ar not , 183 N. E. 2d 866, 869 ( Mass. 1962) ) . I n

t he medi cal cont ext , bat t er y qual i f i es as "medi cal t r eat ment of a

compet ent pat i ent wi t hout hi s consent . " I n r e Spr i ng, 405 N. E. 2d


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115, 121 ( Mass. 1980) . The Br adl eys cont end t hat Dr . Sugarbaker

commi t t ed bat t er y by f ai l i ng t o obt ai n consent t o r emove a l ar ge

sect i on of Mr s. Br adl ey' s l ung bef or e per f or mi ng t he wedge

r esect i on pr ocedur e.

For medi cal bat t er y cl ai ms, Massachuset t s cour t s

di st i ngui sh "l ack of consent " f r om "a l ack of i nf or med consent . "

Moor e, 626 F. Supp. 2d at 368. Accor di ngl y, whi l e an al l egat i on

t hat t here was no consent may be br ought as a bat t ery cl ai m, where

t he quest i on of consent t ouches on t he appr opr i at e st andar d of

car e - - f or exampl e, whet her a pat i ent was i nf or med of t he r i sks

accompanyi ng a pr ocedur e - - t he act i on i s bet t er under st ood as

soundi ng i n negl i gence. See, e. g. , i d. ( "Whi l e ear l y cases

t r eat ed l ack of i nf or med consent as vi t i at i ng t he consent t o

t r eat ment so t her e was l i abi l i t y f or bat t er y, t he moder n vi ew i s

t hat t he acti on i s i n r eal i t y one f or negl i gence i n f ai l i ng t o

conf or m t o t he pr oper st andar d. " ( quot i ng Mi nk v. Uni v. of Chi . ,

460 F. Supp. 713, 716 ( N. D. I l l . 1978) ) ) ; Feel ey v. Baer , 679

N. E. 2d 180, 182 n. 4 ( Mass. 1997) ( "Most aut hor i t i es pr ef er t o t r eat

i nf or med consent l i abi l i t y sol el y as an aspect of mal pr act i ce or

negl i gence. " ( i nt er nal ci t at i on omi t t ed) ) . The r easoni ng i n

Hei nr i ch v. Sweet sheds l i ght on t he di f f er ence bet ween bat t er y

cl ai ms and medi cal mal pr act i ce cl ai ms premi sed on a l ack of

i nf or med consent . Di smi ssi ng a medi cal bat t er y cl ai m, t he


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di st r i ct cour t expl ai ned, "[ t ] he Pl ai nt i f f s do not cont end t hat

[ t hey] gave no consent at al l "; r at her , t he di st r i ct cour t not ed,

t hey cl ai med t hat r el evant r i sks had not been di scl osed. Hei nr i ch

v. Sweet , 49 F. Supp. 2d 27, 38 ( D. Mass. 1999) ( emphasi s added) .

As a r esul t , t he cl ai m "shoul d be t r eat ed as a cl ai m f or medi cal

mal pr acti ce. " I d.

The Br adl eys i dent i f y documents l eadi ng up t o t he

surgery as evi dence t hat she never consent ed t o a wedge resect i on

pr ocedur e. For exampl e, whi l e Mr s. Br adl ey' s consent f or m

expl i ci t l y ref er s t o a br onchoscopy, medi ast i noscopy, and

mi ni t hor acot omy, i t cont ai ns no ment i on of a wedge resect i on.

Si mi l ar l y, whi l e br onchoscopy, medi ast i noscopy, mi ni t hor acot omy,

and bi opsy are mar ked on Mr s. Br adl ey' s sur gi cal booki ng f or m, t he

box f or wedge r esect i on i s not mar ked. Mr s. Br adl ey essent i al l y

argues t hat she consent ed t o cer t ai n enumerated pr ocedur es, and

t hat t he l ack of r ef er ences t o a wedge resect i on bef or e sur ger y

i ndi cat es t hat t her e was no consent f or t hat pr ocedur e. But Mr s.

Br adl ey' s f ocus on nomencl at ur e i s unavai l i ng.

To be sure, Mr s. Br adl ey i dent i f i es cr i t i cal di f f er ences

bet ween t he f i r st f i ve sampl es and t he f i nal sampl e. She asser t s

t hat t he t i mi ng of t he t est r esul t s f or t he f i r st f i ve sampl es

suggest s t hat Dr . Sugarbaker conf i r med t hat t he mass was not

mal i gnant bef or e he per f or med t he wedge r esect i on, and that - -


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wher eas t he ot her sampl es wer e t est ed i n t hei r ent i r et y - - onl y a

smal l por t i on of t he wedge r esect i on was t est ed. As a r esul t ,

Mr s. Br adl ey' s ar gument appear s t o be that she onl y consent ed t o

di agnost i c pr ocedur es, wher eas t he removal of scar t i ssue ( t he

wedge resect i on) was a t r eat ment t o whi ch she di d not consent .

Whi l e t he r ecor d i s "vi ewed i n t he l i ght most f avor abl e t o t he

nonmovant " on summary j udgment , Casas Of f i ce Machs. , I nc. v. Mi t a

Copyst ar Am. , I nc. , 42 F. 3d 668, 679 ( 1st Ci r . 1994) , t he evi dence

here si mpl y does not suppor t t he cont ent i on t hat t he wedge

r esect i on had no di agnost i c pur pose. To t he cont r ary, t he mass

was t est ed f or mal i gnanci es and t hose resul t s wer e i ncor por at ed

i nt o Dr . Sugar baker ' s concl usi on t hat Mr s. Br adl ey di d not have

cancer .

Mr s. Br adl ey consent ed t o surger y f or t he pur pose of

di agnosi ng an i r r egul ar mass on her l ung. And t her e i s no genui ne

di sput e t hat Dr . Sugar baker ' s sur ger y f ur t her ed t hat pur pose. The

di sput e concer ns, i nst ead, whet her Dr . Sugar baker adequat el y

descr i bed t he extent of t he cut t i ng and t he t i ssue r emoval t hat

woul d be i nvol ved dependi ng on t he r esul t s of i ni t i al bi opsi es

dur i ng t he surger y. Massachuset t s l aw di st i ngui shes bet ween

"t ouchi ng wi t hout consent whi ch al l concede i s a bat t er y, " and "a

consented t ouchi ng f or whi ch consent was i nduced by i nadequate

i nf or mat i on, " whi ch i s addr essed under t he mal pr act i ce r ubr i c.


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Er i kson v. Garber , No. 1511, 2003 WL 21956025, at *3 ( Mass. App.

Di v. Aug. 13, 2003) . The ci r cumst ances her e do not qui t e f al l

i nt o ei t her categor y because the i nadequacy of t he i nf or mat i on

i ncl uded a f ai l ur e t o descr i be t he ext ent of t he cut t i ng.

Nevert hel ess, where a surgery and i t s pur pose were agr eed t o, and

wher e the act ual ext ent of t he sur ger y was i n keepi ng wi t h t he

pur pose, we woul d expect Massachuset t s cour t s t o t r eat t he

i nadequacy under a t heor y of mal pr act i ce. See Feel ey, 679 N. E. 2d

at 183 ( quot i ng appr ovi ngl y f r om a t r eat i se di scussi ng t he pol i cy

r easons f or f unnel i ng cl ai ms of t hi s t ype i nt o t he mal pr act i ce

rubr i c) .

We do not f or ecl ose the possi bi l i t y t hat a quest i on as

t o t he scope of consent may sust ai n a medi cal bat t er y cl ai m i n

some i nst ances. See Reddi ngt on v. Cl ayman, 134 N. E. 2d 920, 922

( Mass. 1956) ( r ecogni zi ng a bat t er y cl ai m wher e a doct or r emoved

t he uvul a af t er onl y r ecei vi ng consent t o remove t he adenoi ds and

t onsi l s) ; 14C Mass. Pr ac. , Summar y of Basi c Law 17. 151 ( " [ I ] f

t he pat i ent has consent ed t o one t ype of t r eat ment and t he

physi ci an per f or ms anot her , a case of bat t er y i s al so

est abl i shed. " ) . But t her e was a l ogi cal nexus bet ween t he wedge

r esect i on and t he other f i ve sampl es: t he wedge r esect i on came

f r om t he gener al ar ea f or whi ch Mr s. Br adl ey had consent ed t o

sur ger y, and sampl es f r om t he wedge resect i on wer e t est ed f or


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cancer . As Mr s. Br adl ey cont ends, quest i ons r emai n as t o whet her

she was adequat el y appr i sed of t he pot ent i al scope of t he surger y

bef or ehand. But , because t hi s cl ai m ul t i mat el y cent er s on t he

st andar d of car e used by Dr . Sugar baker , i t shoul d be t r eat ed as

an act i on i n negl i gence, not bat t er y. Feel ey, 679 N. E. 2d at 183

( st at i ng t hat "t he pr obl em of i nf or med consent i s essent i al l y one

of pr of essi onal r esponsi bi l i t y, not i nt ent i onal wr ongdoi ng, and

can be handl ed more coherent l y wi t hi n t he f r amework of negl i gence

l aw t han as an aspect of bat t er y" ( i nt er nal quot at i on mar ks

omi t t ed) ) .

The Br adl eys al so f ocus on t he r el at i ve si ze of t he

sampl es, cont endi ng t hat Mr s. Br adl ey under st ood t hat Dr .

Sugar baker woul d onl y be ext r act i ng much smal l er sampl es of t i ssue.

The Br adl eys expl ai n, " i f [ Mr s. Br adl ey] had asked Dr . Sugar baker

t o . . . avoi d maj or sur ger y, her bat t er y cl ai m woul d succeed

because the wedge resect i on, whi ch was maj or sur gery, woul d have

f al l en out si de t he scope of her nar r ow consent . " But even wer e

we to accept Mr s. Br adl ey' s cont ent i on t hat a wedge resect i on

qual i f i ed as a "maj or sur ger y, " t her e i s no evi dence i n t he r ecor d

t hat Mr s. Br adl ey ever asked Dr . Sugarbaker t o remove onl y smal l

sampl es. Dur i ng her deposi t i on, Mr s. Br adl ey st at ed t hat Dr .

Sugar baker di d not i ndi cat e how many sampl es he woul d t ake or how

l arge t hose sampl es woul d be. Rather , Mr s. Br adl ey assumed t hat


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t he sur ger y woul d onl y consi st of "l i t t l e sni ppet s of t he mass. "

Vi ewed i n t he l i ght most f avor abl e to Mr s. Br adl ey, such t est i mony

does not suppor t t he i nf er ence t hat Dr . Sugar baker ever

af f i r mat i vel y repr esent ed t hat he woul d t ake onl y smal l sampl es;

at wor st , i t suggest s t hat Dr . Sugar baker f ai l ed t o pr ovi de

adequat e i nf or mat i on as t o t he si ze of t he sampl es t hat woul d be

r emoved.

B. Negligence and Informed Consent Claims

1. Informed Consent Under Massachusetts Law

Massachuset t s l aw r ecogni zes t he r i ght of a compet ent

adul t t o f or go t r eat ment , and t he " [ k]nowi ng exer ci se of t hi s r i ght

r equi r es knowl edge of t he avai l abl e opt i ons and t he r i sks at t endant

on each. " Har ni sh v. Chi l dr en' s Hosp. Med. Ct r . , 439 N. E. 2d 240,

242 ( Mass. 1982) . For a pl ai nt i f f t o pr evai l on a t heor y of

i nf or med consent , " ( 1) t he physi ci an must have a dut y t o di scl ose

t he i nf or mat i on at i ssue t o t he pat i ent , and ( 2) t he br each of

t hat dut y must be causal l y rel at ed t o t he pat i ent ' s i nj ur y. "

Hal l ey v. Bi r bi gl i a, 458 N. E. 2d 710, 715 ( Mass. 1983) . Under t he

dut y i nqui r y,

( a) a suf f i ci ent l y cl ose doctor - pat i ent r el at i onshi p

must exi st ; ( b) t he i nf or mat i on subj ect t o di scl osur emust be t hat whi ch t he doct or knows or r easonabl y shoul dknow; ( c) t he i nf or mat i on must be of such a nat ur e thatt he doct or shoul d r easonabl y recogni ze t hat i t i smat er i al t o t he pat i ent ' s deci si on; and ( d) t he doct ormust f ai l t o di scl ose t he subj ect i nf or mat i on t o t hepat i ent .


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I d. I n t ur n, f or t he causat i on i nqui r y, t he pl ai nt i f f must

demonst r ate "t hat had the pr oper i nf or mat i on been pr ovi ded nei t her

he nor a r easonabl e person i n si mi l ar ci r cumst ances woul d have

undergone t he pr ocedur e. " Harni sh, 439 N. E. 2d at 244.

A physi ci an need onl y di scl ose i nf or mat i on " t hat i s

mat er i al t o an i nt el l i gent deci si on by t he pat i ent whet her t o

under go a pr oposed pr ocedur e. " I d. at 243. Mat er i al i t y i s

def i ned as " t he si gni f i cance a r easonabl e per son, i n what t he

physi ci an knows or shoul d know i s hi s pat i ent ' s posi t i on, woul d

at t ach t o t he di scl osed r i sk or r i sks i n deci di ng whet her t o submi t

or not t o submi t t o sur ger y or t r eat ment . " I d. ( i nt er nal ci t at i on

omi t t ed) ; accor d Pr ecour t v. Freder i ck, 481 N. E. 2d 1144, 1146

( Mass. 1985) . I n addi t i on t o encompassi ng t he r i sks associ at ed

wi t h a par t i cul ar pr ocedur e, mat er i al i nf or mat i on al so i ncl udes

"t he avai l abl e al t er nat i ves, i ncl udi ng t hei r r i sks and benef i t s. "

Har ni sh, 439 N. E. 2d at 243.

2. Medical Negligence Under Massachusetts Law

The Br adl eys al so asser t cl ai ms of medi cal negl i gence.

To show medi cal negl i gence, t he "pl ai nt i f f must show ( 1) t he

exi st ence of a doct or or nur se- pat i ent r el at i onshi p, ( 2) t hat t he

per f or mance of t he doct or or nur se di d not conf or mt o good medi cal

pr act i ce, and ( 3) t hat damage r esul t ed t her ef r om. " St . Ger mai n

v. Pf ei f er , 637 N. E. 2d 848, 851 ( Mass. 1994) . To est abl i sh t he


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appr opr i at e st andar d of car e, a pl ai nt i f f t ypi cal l y must pr esent

exper t t est i mony t o t hat ef f ect . Pags- Ram r ez v. Ram r ez-

Gonzl ez, 605 F. 3d 109, 113 ( 1st Ci r . 2010) ( " I n or der t o det er mi ne

t he appl i cabl e st andar d of car e i n a medi cal mal pr act i ce act i on

and t o make a j udgment on causat i on, a t r i er of f act wi l l gener al l y

need t he assi st ance of exper t t est i mony. " ) .

3. Admissibility of Expert Testimony

Rul e 702 of t he Federal Rul es of Evi dence governs t he

admi ssi on of exper t t est i mony. Fed. R. Evi d. 702. Rul e 702

r equi r es t hat t he " t est i mony be ( 1) ' based upon suf f i ci ent f act s

or dat a, ' ( 2) ' t he pr oduct of r el i abl e pr i nci pl es and met hods, '

and ( 3) t hat t he wi t ness appl y ' t he pr i nci pl es and met hods r el i abl y

t o t he f act s of t he case. ' " Pags- Ram r ez, 605 F. 3d at 113

( quot i ng Fed. R. Evi d. 702) . When determi ni ng whether such

evi dence i s admi ssi bl e, " t he j udge must det er mi ne: ' whet her t he

exper t i s pr oposi ng t o t est i f y t o ( 1) sci ent i f i c knowl edge t hat

( 2) wi l l assi st t he t r i er of f act t o under st and or det er mi ne a

f act i n i ssue. ' " Mi t chel l v. Uni t ed St at es, 141 F. 3d 8, 14 ( 1st

Ci r . 1998) ( quot i ng Dauber t v. Mer r el l Dow Phar m. , I nc. , 509 U. S.

579, 59293 ( 1993) ) . A di st r i ct cour t enj oys br oad di scr et i on

when maki ng such evi dent i ar y det er mi nat i ons, i d. at 15, and i t s

deci si on t o admi t or excl ude t est i mony i s r evi ewed f or an abuse of

di scr et i on, Pags- Ram r ez, 605 F. 3d at 115. But " [ t ] he st andar d


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i s not monol i t hi c: wi t hi n i t , embedded f i ndi ngs of f act ar e

r evi ewed f or cl ear er r or , [ and] quest i ons of l aw ar e r evi ewed de

novo. " Mi l war d v. Acui t y Speci al t y Pr ods. Gr p. , I nc. , 639 F. 3d

11, 1314 ( 1st Ci r . 2011) ( quot i ng Ungar v. Pal est i ne Li ber at i on

Or g. , 599 F. 3d 79, 83 ( 1st Ci r . 2010) ) . We af f i r mwher e t he l ower

cour t ' s "er r or [ does] not af f ect t he par t i es' subst ant i al r i ght s

and l i kel y [ does] not af f ect t he out come of t he case. " Mar t nez

v. Cui , 608 F. 3d 54, 59 ( 1st Ci r . 2010) .

4. Analysis

The Br adl eys cont end t hat t he di st r i ct cour t er r ed i n

excl udi ng Dr . Put nam' s t est i mony r el at ed t o t he avai l abi l i t y of an

FNA bi opsy, expl ai ni ng t hat such t est i mony was r el evant t o t he

st andar d of car e f or bot h t hei r i nf or med consent and medi cal

negl i gence cl ai ms. 5 The exper t di scl osur e r epor t i dent i f i ed t hr ee

opi ni ons t hat subsequent l y were excl uded:

1. The surgeon depar t ed f r omt he st andar d of car eby f ai l i ng t o per f orm a l ess i nvas i vepr ocedur e ( such as needl e bi opsy orbr onchoscopy) , r ather t han t horacot omy as t hef i r st di agnost i c pr ocedur e.

2. I f t he sur geon di ssuaded t he pat i ent f r omconsi der at i on of needl e bi opsy, an al t er nat i vet o di agnosi s of t he super i or sul cus t umor andwhi ch woul d modi f y t he pat i ent ' s t r eat ment

opt i ons, t he sur geon depar t ed f r om t hest andar d of car e.

5 The par t i es do not di sput e Dr . Put nam' s pr of essi onalqual i f i cat i ons on appeal . Rat her , t hei r di sput e i s l i mi t ed t o t her el evance of hi s t est i mony.


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3. I f t he sur geon di d not do so, t he sur geondepar t ed f r om t he st andar d of car e by f ai l i ngt o di scuss wi t h t he pat i ent and f ami l y t heal t er nat i ve di agnost i c opt i ons t o wedger esect i on ( such as needl e bi opsy orbr onchoscopy) as part of i nf ormed consent . 6

The Br adl eys cont end t hat Dr . Putnam' s t est i mony

r egar di ng Dr . Sugar baker ' s f ai l ur e t o di scuss t he avai l abi l i t y of

t he FNA bi opsy was r el evant t o the avai l abl e al t er nat i ves and t he

st andar d of car e f or t he i nf or med consent cl ai ms. Dur i ng t he

t r i al , t he Br adl eys expanded upon Dr . Put nam' s expect ed t est i mony,

whi ch woul d t ouch on t he "general appr oach of get t i ng i nf ormed

consent whi ch i nvol ves a gener al di scussi on of what you' r e goi ng

t o do, t he r i sks, t he benef i t s, t he r easonabl e al t er nat i ves and

t he r i sks and benef i t s of t hose. " The Br adl eys acknowl edged t hat

t hi s was not a si t uat i on where an FNA bi opsy had never been of f ered

- - i ndeed, one had been schedul ed, wi t h anot her hospi t al , pr i or t o

t he PET scan. Never t hel ess, t he Br adl eys cont end t hat Dr .

Sugar baker di d not sat i sf y t he st andar d of car e ar t i cul at ed i n

Har ni sh by f ai l i ng t o engage i n a di scussi on of " t he al t er nat e

r out es of obt ai ni ng a bi opsy" af t er her PET scan: " [ Mr s. Br adl ey]

can' t possi bl y have underst ood t hat somethi ng she was t ol d was not

6 The di st r i ct cour t di d admi t por t i ons of Dr . Put nam' s t est i monyper t ai ni ng t o Dr . Sugar baker ' s f ai l ur e t o di scuss Mr s. Br adl ey' si ncreased r i sk of compl i cat i ons i n l i ght of her pr evi ous chestt r auma.


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goi ng to be pursued anymore woul d have gi ven her t he al t ernate

means of obt ai ni ng t he i nf ormat i on she want ed on December 14t h

[ t he dat e of t he PET scan] . "

As t o Dr . Sugar baker ' s f ai l ur e t o per f or ma l ess i nvasi ve

pr ocedur e, Dr . Put nam woul d have t est i f i ed t hat per f or mi ng an FNA

bi opsy was r el evant t o t he st andar d of car e f or pur poses of t he

medi cal negl i gence cl ai m. 7 I n t hi s r espect , t he Br adl eys i nt ended

t o have Dr . Put nam t est i f y t hat an FNA bi opsy " i s l ess i nvasi ve

and . . . saf er t han doi ng sur ger y. " Dr . Put nam woul d expl ai n

t hat an FNA bi opsy "i s a st andar d i ni t i al di agnost i c pr ocedur e"

t hat woul d pr ovi de "cr uci al " i nf or mat i on "bef or e an oper at i on

woul d be per f ormed. "

As t o causat i on, t he Br adl eys al so i nt ended f or Dr .

Put namt o t est i f y t hat "what happened to Bar bar a Br adl ey woul d not

have happened had t he st andard of care been f ol l owed. " Dr . Put nam

woul d have expl ai ned t hat , where an FNA bi opsy r etur ns negat i ve

r esul t s, t he doct or shoul d di scuss wi t h t he pat i ent t he l i kel i hood

t hat t he mass i s never t hel ess cancer ous. I n t he case of Mr s.

7 Dur i ng t r i al , t he Br adl eys' counsel r ef er r ed t o t hi s t est i monyas Dr . Put nam' s " second speci f i c opi ni on. " As l i st ed on t he

di scl osur e r epor t , t he "second" opi ni on concer ns whet her Dr .Sugar baker , havi ng al l egedl y di ssuaded Mr s. Br adl ey f r omunder goi ng an FNA bi opsy, devi at ed f r omt he st andar d of car e. Thedi scussi on t hat f ol l ows, however , t ouches on t he f ai l ur e t o per f or mt he pr ocedur e, whi ch i s i n f act t he f i r st opi ni on l i st ed on t hedi scl osur e repor t .


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Br adl ey, who had suf f ered pr evi ous chest t r auma, t he doctor woul d

t hen expl ai n t he "great er t han aver age r i sk" posed by sur ger y and

quer y whet her ot her t her apy opt i ons are avai l abl e.

a. Federal Rule of Evidence 103(a)(2)

Dr . Sugar baker f i r st cont ends t hat t he Br adl eys di d not

pr eser ve t hei r evi dent i ar y i ssue as t hey f ai l ed t o compl y wi t h

Rul e 103( a) ( 2) of t he Feder al Rul es of Evi dence, whi ch r equi r es

one "cl ai m[ i ng] er r or i n a r ul i ng t o admi t or excl ude evi dence" t o

"i nf or m[ ] t he cour t of i t s subst ance by an of f er of pr oof , unl ess

t he subst ance was appar ent f r omcont ext . " Dr . Sugar baker cont ends

t hat " t he Br adl eys di d not make an of f er of pr oof wi t h r espect t o

t he speci f i cs of t he r el evant opi ni on t est i mony that t hey sought

t o el i ci t f r om Dr . Put nam. "

Thi s asser t i on i s unsuppor t ed by t he r ecor d. The

Br adl eys' pr of f er i ncl uded a det ai l ed Di scl osur e Repor t f r om Dr .

Put nam as wel l as a deposi t i on. I ndeed, when det er mi ni ng whi ch

sect i ons of Dr . Put nam' s di scl osur e r epor t wer e admi ssi bl e, t he

di st r i ct cour t met hodi cal l y anal yzed each par agr aph of t he

di scl osur es. Such speci f i ci t y i s a st r ong i ndi cat i on t hat t he

Br adl eys' pr of f er sat i sf i ed Rul e 103' s r equi r ement s.

Turni ng t o t he mer i t s, we address each of Dr . Putnam' s

t hr ee opi ni ons i n t ur n.


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b. Opinion 3: Dr. Sugarbaker Failed to Discuss the

Alternative Diagnostic Options

The di st r i ct cour t excl uded Dr . Putnam' s t est i mony

r egar di ng Dr . Sugar baker ' s f ai l ur e t o di scuss al t er nat i ves. I t

r easoned t hat , whi l e t he FNA bi opsy t heor et i cal l y was an

al t er nat i ve, i t was not an al t er nat i ve i n t hi s i nst ance: "[ t he

FNA bi opsy] was . . . consi der ed an al t er nat i ve unt i l i t st opped

bei ng one. " The di st r i ct cour t not ed t hat t hi s deci si on was based

on " t he f act s of t he case, " whi ch i ndi cat e t hat an FNA bi opsy "was

not a pr acti cal al t er nat i ve. "

Dr . Sugarbaker cont ends t hat Dr . Put nam' s t est i mony

i mpr oper l y spoke t o t he mat er i al i t y of t he avai l abi l i t y of t he FNA

bi opsy. Under Massachuset t s l aw, " [ t ] he mat er i al i t y det er mi nat i on

i s one t hat l ay per sons ar e qual i f i ed t o make wi t hout t he ai d of

an exper t . " Har ni sh, 439 N. E. 2d at 243. As a t hr eshol d mat t er ,

a j udge wi l l consi der t he "sever i t y of t he i nj ur y" as wel l as t he

"l i kel i hood t hat i t wi l l occur . " Pr ecour t , 481 N. E. 2d at 1148.

The det er mi nat i on of whet her t hat i nf or mat i on i s "mat er i al " i s

t hen l ef t t o t he f act f i nder . I d. at 114849. As a mat t er of l aw,

a negl i gi bl e r i sk i s not mat er i al and need not be submi t t ed t o t he

j ury. I d. at 1149.8

I n Pr ecour t , t he Supr eme J udi ci al Cour t

8 I n Har r i son v. Uni t ed St at es, 284 F. 3d 293 ( 1st Ci r . 2002) , weexpanded upon Precour t , not i ng t hat " t he casel aw st ands f or t hepr oposi t i on t hat t her e i s no dut y t o di scl ose negl i gi bl e r i sks,not t hat al l non- negl i gi bl e r i sks ar e act i onabl e i f not r eveal ed. "


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( "SJ C") of Massachuset t s caut i oned, " [ t ] he devel opment of our l aw

concerni ng r i sks t hat as a mat t er of l aw may be consi dered r emote,

and t hose that may be l ef t t o t he det er mi nat i on of a f act f i nder ,

must awai t f ut ur e cases. " I d.

As di scussed herei n, Opi ni on 3 woul d have i ncl uded

t est i mony t ouchi ng on the "gener al appr oach t o get t i ng i nf or med

consent . " Dr . Put nam woul d have expl ai ned t hat Dr . Sugar baker

f ai l ed t o i nf or m Mr s. Br adl ey of an FNA bi opsy, whi ch woul d "be

t he easi est , most st r ai ght f or war d, [ and] car r y t he gr eat est

benef i t of a di agnost i c wi t h t he l east r i sk, of any pr ocedur e. "

Cont r ar y to Dr . Sugar baker ' s asser t i ons, Dr . Put nam' s t est i mony

does not i nf r i nge on t he j ur y' s mat er i al i t y anal ysi s. Rat her , i t

woul d expl ai n t he gener al cat egor y of r i sks and al t er nat i ves t hat

a physi ci an must di scl ose t o hi s pat i ent and t he f act or s r el evant

t o whether an FNA bi opsy shoul d have been di scl osed as an

al t er nat i ve i n t hi s i nst ance. I n t hi s way, Dr . Put nam' s t est i mony

was r el evant t o what t he st andar d of care requi r es when a physi ci an

engages i n a di scussi on of al t er nat i ves wi t h hi s pat i ent . I n

Har ni sh, t he SJ C expl ai ned, " [ w] hat t he physi ci an shoul d know

i nvol ves prof essi onal exper t i se and can or di nar i l y be pr oved onl y

t hr ough t he t est i mony of exper t s. " 439 N. E. 2d at 243. 9 Li kewi se,

I d. at 300.

9 The Br adl eys cont end t hat t he di st r i ct cour t i mpr oper l y excl uded


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t he manner t hat a physi ci an di scusses a pr ocedur e wi t h a pat i ent

and t he t ypes of i nf or mat i on he must i ncl ude i n t hat conver sat i on

are areas where an expert may be necessary to ai d t he j ur y. The

f act t hat Har ni sh does not r equi r e exper t t est i mony on what i s

mat er i al does not mean t hat expert t est i mony on the avai l abl e

choi ces t hat doct or s i n t he exer ci se of st andar d car e of f er t o

t hei r pat i ent s i s not r el evant .

Fur t her , t he di st r i ct cour t ' s det er mi nat i on t hat an FNA

bi opsy was not avai l abl e as an al t er nat i ve i s not suppor t ed by the

evi dence adduced at t r i al . 10 Mr s. Br adl ey r ecount ed a cal l f r om

t hi s evi dence on t he theor y t hat i t embr aced an ul t i mat e i ssue.See Fed. R. Evi d. 704( a) ( "An opi ni on i s not obj ect i onabl e j ustbecause i t embr aces an ul t i mat e i ssue. " ) . To t he cont r ar y, t hedi st r i ct cour t st at ed t hat " t he ul t i mat e quest i on of eval uat i ngsever i t y and l i kel i hood i s one f or t he j ur y, " whi ch i s an accur at er est at ement of t he l aw t hat t he i ssue of mat er i al i t y i s f or t hej ury. Har ni sh, 439 N. E. 2d at 243.

10 The Br adl eys cont end t hat t he di st r i ct cour t i mpr oper l y usur pedt he j ur y' s f unct i on by deci di ng t hi s i ssue of f act . Under Dauber t ,however , when det er mi ni ng t he admi ssi bi l i t y of exper t t est i mony," t he t r i al j udge must det er mi ne at t he out set , pur suant t o [ Feder alRul e of Evi dence] 104( a) , whet her t he exper t i s proposi ng t ot est i f y t o ( 1) sci ent i f i c knowl edge t hat ( 2) wi l l assi st t he t r i erof f act t o under st and or det er mi ne a f act i n i ssue. " Dauber t , 509U. S. at 592; cf . Fed. R. Evi d. 104( b) ( "When t he r el evance ofevi dence depends on whether a f act exi st s, pr oof must be i nt r oducedsuf f i ci ent t o suppor t a f i ndi ng t hat t he f act does exi st . ") . Dr .

Put nam' s t est i mony as t o whet her di ssuasi on or non- di scussi on ofavai l abl e al t er nat i ves ( Opi ni ons 2 and 3, r espect i vel y) sat i sf i est he st andar d of car e i s onl y rel evant i nsof ar as t he Br adl eysdemonst r at ed t hat non- di scussi on and di ssuasi on of avai l abl eal t er nat i ves ar e f act s at i ssue her e, and t he di st r i ct cour t di dnot er r i n maki ng t hi s pr el i mi nar y f act ual det er mi nat i on. SeeBogosi an v. Mer cedes- Benz of N. Am. , I nc. , 104 F. 3d 472, 476 ( 1st


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Dr . Sugar baker ' s physi ci an assi st ant , Wi l l i am Hung, i n whi ch he

expl ai ned t hat an FNA bi opsy was not possi bl e as t hey woul d be

unabl e t o access t he mass usi ng t hat pr ocedur e. I n l i ght of t hat

conver sat i on, Mr s. Br adl ey cancel l ed her pr evi ousl y schedul ed FNA

bi opsy. Hung does not r ecal l t hi s conver sat i on and hi s not es f r om

t hat day do not ment i on t he FNA pr ocedur e. At t r i al , Hung

expl ai ned t hat he spoke wi t h a r adi ol ogi st , Dr . Franci ne J acobsen,

and t hat Dr . J acobsen had r ecommended agai nst an FNA bi opsy. But

Hung' s not es cont ai n no ment i on of Dr . J acobsen' s suggest i ons

r egar di ng t he pr ocedur e. I n addi t i on, Dr . Sugar baker r ecal l ed

havi ng a conver sat i on wi t h ei t her Hung or Dr . J acobsen i n whi ch

t hey agr eed not t o pr oceed wi t h an FNA bi opsy "gi ven t he l ocat i on

of t he mass. " As Br adl ey' s t r i al counsel not ed, t her e wer e no

r ecor ds of t hese conver sat i ons, and Dr . Sugar baker ' s t est i mony

r egar di ng hi s conver sat i on wi t h Dr . J acobsen i s i nconsi st ent wi t h

Ci r . 1997) ( " [ T] he cour t per f or ms a gat ekeepi ng f unct i on t oascer t ai n whet her t he t est i mony i s hel pf ul t o t he t r i er of f act ,i . e. , whet her i t . . . i s rel evant t o t he f act s of t he case. ") .

The Br adl eys' r el i ance on Mi l war d i s unavai l i ng. Ther e, t hi sCour t det er mi ned t hat , " [ w] hen t he f act ual under pi nni ng of an

exper t ' s opi ni on i s weak, i t i s a mat t er af f ect i ng t he wei ght andcr edi bi l i t y of t he t est i mony - - a quest i on t o be r esol ved by t hej ury. " Mi l war d, 639 F. 3d at 22 ( i nter nal ci t at i on omi t t ed) . ButMi l war d concer ned t he di st r i ct cour t ' s ext ensi ve eval uat i on of t her el i abi l i t y of t he sci ent i f i c theor i es under scor i ng t he exper t ' st est i mony, and not t he t hr eshol d i ssue of f act ual r el evance.


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ear l i er st at ement s t hat he di d not r ecal l di scussi ng t he

avai l abi l i t y of t he FNA bi opsy wi t h anot her medi cal pr of essi onal .

Mor eover , t he di st r i ct cour t ' s det er mi nat i on t hat an FNA

bi opsy was not an avai l abl e al t er nat i ve i s f ur t her under cut by i t s

deci si on t o admi t t he test i mony of exper t Dr . Mar k Edel man, Mr s.

Br adl ey' s i nt er vent i onal r adi ol ogi st , who t est i f i ed t o t he

benef i t s of t he FNA bi opsy. At t r i al , he expl ai ned t hat an FNA

bi opsy "coul d have been saf el y per f ormed wi t h r espect t o Barbara

Br adl ey" and opi ned t hat t he l ocat i on of t he mass di d not r ender

i t i naccessi bl e by FNA bi opsy. He al so r emar ked on t he benef i t

of t hi s non- sur gi cal al t er nat i ve due t o t he "compl i cat i ons of

sur ger y and di f f i cul t y r ecover i ng f r om sur ger y. " Cont r ar y t o t he

di st r i ct cour t ' s det er mi nat i on, such t est i mony suggest s t hat t he

FNA bi opsy was a vi abl e al t er nat i ve her e. 11

Nor can i t be sai d t hat t he r i sks associ at ed wi t h a

sur gi cal bi opsy wer e so mi ni mal t hat , as a mat t er of l aw, Dr .

Sugar baker was not obl i gat ed t o di scl ose l ess i nvasi ve

al t ernat i ves . At t r i al , Dr . Put nam t est i f i ed t hat t he r i sk of

compl i cat i ons ar i si ng f r om sur ger y wer e hei ght ened due t o Mr s.

Br adl ey havi ng "sust ai ned si gni f i cant t hor aci c t r auma j ust 18

11 I n addi t i on, dur i ng hi s deposi t i on, Dr . Ral ph Rei chl e, ani nt er vent i onal r adi ol ogi st and exper t f or Dr . Sugar baker ,t est i f i ed that he coul d have per f or med an FNA bi opsy on Mr s.Br adl ey wi t hout compl i cat i on.


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mont hs or so pr evi ousl y. " Dr . Put namexpl ai ned t hat scar r i ng f r om

a pr evi ous t r auma may i ncr ease t he r i sk of bl eedi ng or ot her wi se

compl i cat e t he sur ger y - - pot ent i al l y requi r i ng a l onger pr ocedur e

or adver sel y af f ect i ng t he sur geon' s " abi l i t y t o do t he oper at i on

as ef f i ci ent l y as [ he] coul d wi t hout i t . " Fur t her mor e, Mr s.

Br adl ey' s scar r i ng f r omher chest t r auma l i kel y cont r i but ed t o t he

api cal space12 t hat f or med f ol l owi ng sur ger y. Whi l e a physi ci an

i s not r equi r ed t o di scl ose al l non- negl i gi bl e r i sks, Har r i son v.

Uni t ed St at es, 284 F. 3d 293, 300 ( 1st Ci r . 2002) , Dr . Put nam' s

t est i mony demonst r at ed t hat t he l i kel i hood t hat compl i cat i ons

mi ght ar i se was f ar f r om r emot e, see Har ni sh, 439 N. E. 2d at 243

( suggest i ng t hat a sur geon need not di scl ose "r emot el y possi bl e

r i sks") and, f ur t her , t hat t hese r i sks wer e not "i nher ent i n any

oper at i on, " i d. On t he cont r ar y, t hey wer e speci f i c t o Mr s.

Br adl ey' s medi cal si t uat i on.

At t r i al , t he j ur y hear d t est i mony f r omDr . Gar y St r auss,

an oncol ogy exper t , t hat an FNA bi opsy, even i f negat i ve, woul d

not r ul e out t he possi bi l i t y of cancer , especi al l y wher e a pat i ent

had a par t i cul ar l y hi gh r i sk of cancer , and t hat Mr s. Br adl ey' s

comput ed t omogr aphy ( "CT") and PET scans i ndi cat ed t hat she was at

12 An api cal space r ef er s t o an ar ea wher e t her e i s no l ungi mmedi at el y af t er sur ger y. I t can al so be descr i bed as a non-expansi on of t he l ung.


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a hi gh r i sk. Dr . St r auss al so t est i f i ed t hat "i t woul d not be

r easonabl e f or Dr . Sugar baker t o r el y upon a negat i ve FNA i n t hi s

set t i ng wher e ever yt hi ng el se r eal l y poi nt s t o i t bei ng cancer t o

say she di dn' t have a cancer . " Thi s t est i mony i ndi cat ed t hat ,

under t he appr opr i at e st andard of car e, Dr . Sugar baker was not

r equi r ed t o pr esent an FNA bi opsy as an al t er nat i ve pr i or t o t he

sur gi cal bi opsy. By excl udi ng Dr . Put nam' s t est i mony, t he

di st r i ct cour t ef f ect i vel y pr event ed Mr s. Br adl ey f r om pr esent i ng

evi dence t hat Dr . Sugar baker ' s "dut y t o di scl ose i n a r easonabl e

manner al l si gni f i cant medi cal i nf or mat i on, " Har ni sh, 439 N. E. 2d

at 243, necessi t at ed a di scussi on of non- sur gi cal al t er nat i ves and

t her ef or e f r om r ebut t i ng Dr . St r auss' s t est i mony t o t he cont r ar y,

see Pags- Ram r ez, 605 F. 3d at 116 ( f i ndi ng t hat t he di st r i ct cour t

abused i t s di scret i on by r ef usi ng t o al l ow an exper t t o t est i f y i n

a medi cal mal pr act i ce case wher e, "wi t hout [ t he exper t ] ' s

t est i mony on causat i on and t he st andar d of car e, t he pl ai nt i f f s

wer e unabl e to pr esent evi dence on t wo el ement s of t hei r case") .

Dr . Sugarbaker argues t hat t he Br adl eys cannot

demonst r at e causat i on because Dr . Put nam conceded i n hi s

deposi t i on t hat , i f t he r esul t s of an FNA bi opsy had been negat i ve,

t he mass woul d never t hel ess have needed t o be r emoved. But Dr .

Put nam made no such cut - and- dr i ed st at ement . Whi l e he

acknowl edged t hat r emoval of t he mass was a possi bi l i t y, he al so


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st at ed t hat a di scussi on of next st eps was necessar y i n l i ght of

Mr s. Br adl ey' s pr evi ous chest t r auma. I n par t i cul ar , Dr . Put nam' s

t est i mony woul d have support ed t he vi ew t hat a non- surgi cal

al t er nat i ve such as " wat chf ul wai t i ng" was a reasonabl e opt i on

f ol l owi ng a negat i ve FNA bi opsy. " I t woul d make l i t t l e sense t o

expand t he l aw of i nf or med consent such t hat a pl ai nt i f f , i n

addi t i on t o demonst r at i ng t hat she woul d have chosen an al t ernate

cour se of t r eat ment , must al so del i neat e t he pr eci se pl an of act i on

t hat she woul d have f ol l owed t o obt ai n t hat t r eat ment . . . . "

Har r i son v. Uni t ed St at es, 233 F. Supp. 2d 128, 135 ( D. Mass.

2002) . Accor di ngl y, we concl ude t hat t he di st r i ct cour t abused

i t s di scr et i on by excl udi ng Opi ni on 3.

c. Opinion 2: Dr. Sugarbaker Dissuaded Mrs. Bradley

from Considering an FNA Biopsy

The di st r i ct cour t excl uded Opi ni on 2, not i ng t hat , at

most , t here was "evi dence of nonper f ormance and perhaps . . . non-

di scussi on, " but not evi dence of "di ssuasi on. " But t her e was

cl ear evi dence of di ssuasi on: as descr i bed her ei n, Mr s. Br adl ey

t est i f i ed t hat Dr . Sugar baker ' s assi st ant , Hung, t ol d her t hat

surger y l i kel y woul d be necessar y as t he mass woul d be i naccessi bl e

by an FNA bi opsy. Moreover , Mr s. Br adl ey' s conver sat i on wi t h Hung

i n f act di ssuaded her f r om under goi ng an FNA bi opsy. Fol l owi ng

t he conver sat i on, she cancel l ed her pr evi ousl y schedul ed FNA

bi opsy at Har t f or d Hospi t al because she di d not "want t o go t o


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Har t f or d t o have an FNA done onl y t o f i nd out t hey coul dn' t access

[ t he mass] wi t h an FNA. "

The f act t hat Dr . Sugar baker di d not per sonal l y di ssuade

Mr s. Br adl ey does not change t he r esul t . Hung served as Dr .

Sugar baker ' s assi st ant , and Dr . Sugar baker ' s t est i mony at t r i al

suggest ed t hat he was aware of Hung' s vi ews t hat an FNA bi opsy

woul d not be f easi bl e f or Mr s. Br adl ey. See Mass. Gen. Laws ch.

112, 9E ( " I f a physi ci an assi st ant i s empl oyed by a physi ci an or

gr oup of physi ci ans, t he assi st ant shal l be super vi sed by and shal l

be t he l egal r esponsi bi l i t y of t he empl oyi ng physi ci an or

physi ci ans. " ) . Never t hel ess, Dr . Sugar baker never r ecant ed Hung' s

i ni t i al r ecommendat i ons r egar di ng t he FNA bi opsy. I n such an

i nst ance, a j ur y r easonabl y coul d at t r i but e the rel evant

di ssuasi ve st at ement s t o Dr . Sugar baker . Cf . Sant os v. Ki m, 706

N. E. 2d 658, 66162 ( Mass. 1999) ( eval uat i ng i nst ances where a

physi ci an may be l i abl e f or "hi s f ai l ur e t o i nst i t ut e pr act i ces

and pr ocedur es") . Accor di ngl y, t he di st r i ct cour t ' s f actual

f i ndi ng t hat t her e was no evi dence of di ssuasi on was cl ear l y

er r oneous, and t he di st r i ct cour t abused i t s di scr et i on by

excl udi ng Opi ni on 2.


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d. Opinion 1: Dr. Sugarbaker Failed to Perform an FNA

Biopsy

The di st r i ct cour t excl uded Dr . Putnam' s t est i mony

r egar di ng Dr . Sugar baker ' s f ai l ur e t o per f or man FNA bi opsy because

i t f ound t hat t hi s t est i mony was not r el at ed t o "an i nf or mi ng

obl i gat i on but a per f or mi ng obl i gat i on. " The di st r i ct cour t

r easoned t hat , because Dr . Sugarbaker woul d not have been t he

doctor t o per f or m t he pr ocedur e, "t he f ai l ur e [ coul d] have . . .

no l egal si gni f i cance. " I nsof ar as t hi s r ul i ng per t ai ned t o t he

i nf or med consent cl ai m, t he di st r i ct cour t i s cor r ect : t he

i nf or med consent i nqui r y f ocuses on t he physi ci an' s di scl osur e

obl i gat i ons, r ather t han how a medi cal pr ocedur e was per f ormed.

Har ni sh, 438 N. E. 2d at 154 ( descr i bi ng t he i nf or med consent

doct r i ne as r el at i ng t o "a physi ci an' s f ai l ur e t o di vul ge i n a

r easonabl e manner t o a compet ent adul t pat i ent suf f i ci ent

i nf or mat i on to enabl e t he pat i ent t o make an i nf ormed j udgment " ) .

The Br adl eys cont end t hat t hi s Cour t has "emphasi zed t hat a dut y

t o di scl ose, i f i t exi st s . . . does not necessar i l y i ndi cat e any

dut y t o of f er or t o per f or m" t he pr ocedur e at i ssue. Har r i son,

284 F. 3d at 301 n. 8. But t hey mi sconst r ue our pr ecedent s. I t i s

t r ue that t he f act t hat a physi ci an woul d not per f or m a par t i cul ar

pr ocedur e wi l l not i mmuni ze hi m f r om an i nf or med consent cl ai m.

Har r i son, 233 F. Supp. 2d at 134 ( " [ A] doct or cannot ' save' hi msel f

f r om l i abi l i t y f or br each of i nf or med consent by mer el y ar gui ng


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t hat . . . causat i on i s l acki ng because he hi msel f woul d have been

unwi l l i ng t o per f or mt hat pr ocedur e upon t he pat i ent ' s r equest . ") .

But t hi s l egal anal ysi s does not i mpl y t hat t he conver se i s t r ue,

i . e. , t hat t he nonper f or mance of a speci f i c pr ocedur e wi l l sust ai n

an i nf or med consent cl ai m. Agai n, i nf or med consent i s about

di scl osur e, not per f or mance.

The Br adl eys al so cont end t hat t hi s t est i mony i s

r el evant t o t hei r medi cal negl i gence cl ai m, whi ch was br ought

" i ndependent of any of [ Mr s. Br adl ey' s] i nf or med- consent cl ai ms. "

Dr . Sugarbaker does not addr ess t hi s ar gument . The Br adl eys

asser t t hat t he st andar d of car e r equi r ed t hat Dr . Sugar baker

per f or ma l ess i nvasi ve pr ocedur e t o obt ai n t i ssue f or t he sur gi cal

bi opsy. As t he Br adl eys cont end, t he f act t hat Dr . Sugar baker

hi msel f woul d not have per f or med t he pr ocedur e wi l l not f or ecl ose

a cl ai m i n t he medi cal negl i gence cont ext . Sant os, 706 N. E. 2d at

663 ( expl ai ni ng t hat t he f act t hat a doct or woul d not per sonal l y

t r eat a pat i ent does not "aut omat i cal l y absol ve hi mof l i abi l i t y") .

Mor eover , a physi ci an' s f ai l ur e t o per f or m a l ess i nvasi ve

pr ocedur e may speak to whether he devi ated f r om t he st andard of

car e. See Emerson v. Bent wood, 769 A. 2d 403, 409 ( N. H. 2001)

( r ever si ng a t r i al cour t ' s di r ected ver di ct wher e "[ t ] he exper t ' s

t est i mony was suf f i ci ent f or a r at i onal t r i er of f act t o concl ude

t hat t he def endant shoul d have empl oyed l ess i nvasi ve measures


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. . . and t hat sai d devi at i on f r om t he st andar d of car e r esul t ed

i n t he pl ai nt i f f ' s i nj ur y") . Accor di ngl y, t he nonper f or mance

t est i mony i n Opi ni on 1 may be rel evant t o t he Br adl eys' medi cal

negl i gence cl ai m.

That sai d, t he negl i gence cl ai m does not appear ever t o

have r eached t he j ur y: t he ver di ct f or m onl y r ef er ences Mr s.

Br adl ey' s i nf or med consent cl ai m, and t he j ur y i nst r uct i ons wer e

l i mi t ed t o t he el ement s of i nf or med consent . I ndeed, t he j ur y was

t ol d t hat " [ t ] hi s [ case] i s about whet her t her e was an adequat e

consent t o t he sur ger y t hat f ol l owed, " and not about t he manner i n

whi ch t he surgery was per f ormed. Nei t her par t y addr esses whether

t hese f act s suppor t a f i ndi ng of wai ver as t o t he medi cal

negl i gence cl ai m. I n l i ght of t he poor l y devel oped r ecor d on t hi s

i ssue, we l eave f or t he di st r i ct cour t t he quest i on of Opi ni on 1' s

r el evance t o t he Br adl eys' medi cal negl i gence cl ai m.

III. Conclusion

For t he f or egoi ng r easons, t he j udgment i s vacat ed, and

t he case i s r emanded f or f ur t her pr oceedi ngs consi st ent wi t h t hi s

opi ni on.

Vacated and Remanded. No costs are awarded.

bradley v. sugarbaker, 1st cir. (2015)

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