'Sudden emergency' doesn't spare driver from jury trial

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A medical emergency did not necessarily let a driver off the hook for an injury-accident, the Massachusetts Appeals Court ruled yesterday, in a rare appellate appearance of "the sudden emergency doctrine."

The sudden emergency, or "inevitable accident," doctrine is less doctrine and more self-evident application of negligence law. The simple rule is that if a driver has a medical emergency and thus unavoidably causes an accident, that's not negligence. The doctrine requires that the medical emergency be confirmed by expert testimony.

You can get to that conclusion readily enough through the usual negligence analysis. A reasonable person having a heart attack could not have averted the same accident, so there was no negligence. "Sudden emergency" is just a shortcut that sanctions the conclusion and perhaps enhances a judge's confidence in awarding the defense summary judgment without a jury trial.

By the same token, however, the usual rules of negligence still apply. Saliently, the doctrine relieves the defendant of liability only insofar as the emergency is alleged to have been the proximate cause of the accident. If the plaintiff points somewhere else on the timeline, to a different alleged misconduct as proximate cause, then the defendant is not necessarily off the hook.

That's where the lower court erred in the instant cases, according to the Appeals Court. The plaintiff alleged that the defendant should have known of the risk of his medical condition and should not have been driving. That's a negligence allegation, and driving despite risk is not an emergency.

The medical evidence, even if weakly contested, supported the defendant's theory that he lost consciousness because of undiagnosed sleep apnea. As a result, his truck ran into the back of the unmoving bus ahead, which the plaintiff was driving. The loss of consciousness was a proximate cause of the accident. But not necessarily the only proximate cause.

The plaintiff's experts proffered evidence that sleep apnea is not something that attacks acutely out of the blue. Though the defendant denied chronic drowsiness, he had a medical history of difficulty sleeping at night and heavy snoring. He also suffered from comorbid conditions, such as obesity.

A reasonable person in the plaintiff's circumstances would have been on notice of the risk of driving, the plaintiff argued. And the evidence was sufficiently in dispute that the plaintiff was entitled to a jury trial on the question, the court agreed.

The court also reversed and remanded the summary judgment for the defendant's employer, as the employer would be vicariously liable for its employee's on-the-job conduct. But the court affirmed summary judgment for the employer on the direct negligence theories the plaintiff had leveled against it.

The evidence developed pretrial did not bear out plaintiff's allegations that the employer had any knowledge of a medical condition that could have impaired driving. So the jury may not hear theories of negligent hiring or supervision.

The case is Cottrell v. Laidley, No. 21-P-740 (Mass. App. Ct. Oct. 18, 2023). Justice Joseph M. Ditkoff wrote the opinion of the unanimous panel, which also comprised Chief Justice Green and Justice Hodgens.

'Error in judgment' jury instruction properly cuts room for doctor to escape liability for delay of surgery

Ischemic bowel in CT scan
(image by James Heilman, MD, CC BY-SA 3.0)

A doctor did not commit malpractice by awaiting test results before committing a patient to surgery for an ischemic bowel, even if permanent disability resulted from delay, the Massachusetts Appeals Court ruled before Memorial Day weekend.  The jury was properly instructed to allow leeway for error in judgment.

The plaintiff-patient presented at the emergency room at 1 a.m. in severe abdominal pain and with a history of gastric bypass surgery and hernia repair.  The defendant-doctor correctly suspected ischemic bowel, a blood blockage, and, at 3 a.m., sent the patient for a CT scan.  Based on the scan results, the doctor, at 4:23 a.m., ordered the patient to surgery, which commenced by 6:30 a.m.

The court summarized, "The main dispute at trial was whether [the doctor] acted within the standard of care by ordering the CT scan and waiting for the results, or whether he instead should have contacted a surgeon earlier."  On appeal from judgment entered for the doctor, the plaintiff charged that the jury was erroneously instructed to allow for error in the doctor's professional judgment.

Tracking model jury instructions (p. 5), the trial judge had instructed, inter alia:

"If, in retrospect, the physician's judgment was incorrect, it is not, in and of itself, enough to prove medical malpractice or negligence.

"Doctors are allowed a range in the reasonable exercise of professional judgment and they are not liable for mere errors of judgment so long as that judgment does not represent a departure from the standard of care resulting in a failure to do something that the standard of care requires or in doing something that should not be done under the standard of care.

"In other words, a doctor is liable for errors of judgment only if those errors represent a departure from the standard of care."

In affirming for the doctor, the court upheld the instruction.  The court reviewed a range of approaches in other states to "error of judgment" instruction in medical malpractice cases.  Hawaii and Oregon, for example, reject the instruction as posing too great a risk of confusion for the jury.  California accords with the Massachusetts position.  Other states, such as New York, use the instruction "only where there is evidence at trial that the physician chose from one of several medically acceptable alternatives."  In defense of the Massachusetts position, the court reasoned:

If properly formulated, such an instruction focuses the jury's attention on the standard of care, rather than the particular results in a case.  The instruction also recognizes the reality that, like all professionals, medical professionals need to make judgment calls between various acceptable courses of actions and they should not be found liable unless those judgment calls fall outside the standard of care.

The range of approaches demonstrates civil courts' long struggle with hindsight bias, especially in medical malpractice.  Hindsight bias is a natural human tendency to overestimate one's ability to make a decision correctly when viewing the decision as if in the past, ignorant of consequences, but from a perspective in the present, informed, in fact, by subsequently acquired information.  Shankar Vedantam talked about the problem on The Hidden Brain podcast in 2020.

Hindsight bias is not unique to medical malpractice, nor even to tort law.  Psychologists have documented hindsight bias in "accounting and auditing decisions, athletic competition, and political strategy," besides medicine.  As I wrote in a book on legal pedagogy in 2019, the cartoon South Park even invented a character, Captain Hindsight, to make fun of the human foible.  Hindsight bias inevitably contaminates every tort case, and countering it often is an appropriate strategy in legal argument and jury instruction.  For a juror, like any decision maker, it is difficult to reconstruct a past decision to the complete exclusion of undesired consequences.

The problem is exaggerated in the medical context because of the simplicity of the doctor-patient relationship.  A patient sees a doctor for one purpose, exclusively: to get better.  A doctor has one and only one job: to heal.  When healing is not the result that a patient experiences, and the jury has knowledge of that consequence, it is deceptively easy for jurors to confuse the doctor's failure to heal with a departure from the standard of care.  The Massachusetts instruction is designed to clarify the distinction for jurors.

The case is Paiva v. Kaplan, No. 19-P-1789 (Mass. App. Ct. May 28, 2021).  Justice Joseph M. Ditkoff authored the opinion of the unanimous panel that also comprised Justices Vuono and Milkey.  In a former post as general counsel of the District Court, Justice Ditkoff's responsibilities included drafting standardized jury instructions.