Sinclair by Sinclair v. Block

• Decision Date: 31 January 1994
• Docket Number: OB-GYN
• Citation: 534 Pa. 563,633 A.2d 1137
• Parties: Paula SINCLAIR, a minor, by her parents and natural guardians, Joan A. SINCLAIR and Mark Sinclair, individually and in their own right, Appellants, v. Robert Alan BLOCK, M.D., and PhiladelphiaGroup, Ltd., Health Services Plan of Pennsylvania, Appellees.
• Court: Pennsylvania Supreme Court

Page 1137

633 A.2d 1137

534 Pa. 563

Paula SINCLAIR, a minor, by her parents and natural guardians, Joan A. SINCLAIR and Mark Sinclair, individually and in their own right, Appellants, v. Robert Alan BLOCK, M.D., and Philadelphia OB-GYN Group, Ltd., Health Services Plan of Pennsylvania, Appellees.

Supreme Court of Pennsylvania.

Argued Oct. 21, 1992.

Decided Nov. 10, 1993.

Reargument Denied Jan. 31, 1994.

[534 Pa. 565] Lawrence D. Finney, Philadelphia, for appellants.

Joseph H. Foster, Philadelphia, for appellees.

Before NIX, C.J., and FLAHERTY, ZAPPALA, PAPADAKOS and CAPPY, JJ.

OPINION

NIX, Chief Justice.

Appellants, Paula Sinclair, a minor, by her parents and natural guardians, Joan Sinclair and Mark Sinclair, individually and in their own right, appeal from the Order of the Superior Court affirming the Order of the Court of Common Pleas which denied Appellants' post-trial motions and entered judgment in favor of Appellees, Dr. Block and Philadelphia OB-GYN Group, Ltd. Appellants present two issues for our review. The first issue is whether the Superior Court erred in concluding that the use of forceps during delivery was not a surgical or operative procedure to which the "informed consent" doctrine applies. The second issue is whether the Superior Court erred in holding that the trial court properly charged the jury as to the "two schools of thought" doctrine. For the reasons that follow, we affirm in part, reverse in part, and remand for a new trial.

In 1981, Mrs. Sinclair became pregnant. As a result, she sought medical care from Appellees. Towards the end of her pregnancy, Mrs. Sinclair visited Appellee Dr. Block in his office. While there, she signed a consent form which outlined the procedures necessary to treat/diagnose her condition as being "prenatal care, delivery care, postnatal care and/or caesarian section." Appellants' Brief Exhibit C. Mrs. Sinclair was not informed, either in writing or verbally, that Appellee might opt to use forceps during delivery of the baby.

In October of 1982, Mrs. Sinclair's labor commenced. She arrived at the hospital where Appellee Dr. Block monitored her progress. After several hours, although Mrs. Sinclair's cervix reached full dilation, the baby stopped moving through the birth canal, which is referred to by physicians as an "arrest of descent." Dr. Block then observed that the baby was turned to the side and was not proceeding through the birth canal in the usual position. ¹ As a result of the baby's position and the fact that the baby's heart rate had slowed, Dr. Block attempted to deliver the baby by using forceps, which would turn the baby to the correct delivery position. The use of forceps to facilitate natural delivery failed. The baby was subsequently delivered by Caesarian section.

After birth, baby Paula had areas of swelling on her scalp and a faint mark on her face and forehead, which was alleged to be a mark from the forceps. Subsequent examination revealed that Paula had suffered a fractured skull and seizures.

Appellants commenced suit against Appellees as a result of Paula's injuries. A jury trial was conducted. The trial court entered a nonsuit as to Dr. Block and as to Dr. Block's employer, Philadelphia OB-GYN Group, Ltd., on the issue of informed consent. Subsequently, the jury entered a verdict in favor of Appellees on the issue of negligence. Appellants filed post-trial motions which were denied.

Appellants appealed to the Superior Court. The Superior Court affirmed the trial court and found, inter alia, that the use of forceps is not a surgical procedure which requires the application of the informed consent doctrine, and that the trial court properly gave the "two schools of thought" charge to the jury. Sinclair v. Block, 406 Pa.Super. 540, 594 A.2d 750 (1991).

In holding that the use of forceps was not a surgical procedure, the Superior Court stated that the circumstances in this case were "analogous to a situation in which a physician uses a tool to accomplish a particular task." Id. at 554, 594 A.2d at 758. The Superior Court compared a physician's use of forceps with the use of other medical instruments that would not require specific consent to use the tool because it would be covered by the patient's general consent. Id. ²

The Superior Court concluded that "[i]n comparing the use of forceps with the use of [those other] types of instruments, it would be erroneous to treat a forceps delivery as the type of operative or surgical procedure which requires the physician to obtain additional consent." Id. at 554-55, 594 A.2d at 758. Thus, "the use of forceps merely involves the application of a tool to assist the physician in providing treatment ... [and] Dr. Block was not required to obtain Mrs. Sinclair's specific consent to use forceps to deliver the child because she had already given her general consent to the delivery." Id. at 555, 594 A.2d at 758.

The Superior Court also found that the trial court properly gave the "two schools of thought" charge to the jury. The Superior Court stated that the "two schools of thought" instruction was required because the experts "disagreed as to the manner or type of treatment which should have been administered to Mrs. Sinclair to assist her with the delivery of her child." Id. at 552, 594 A.2d at 757. Upon request of Appellants, we granted allocatur. 529 Pa. 623, 600 A.2d 538 (1991).

The first issue presented for our review is whether the Superior Court made an error of law in upholding the trial court's entry of a nonsuit on the informed consent issue and concluding that the use of forceps during delivery was not a surgical or operative procedure to which the "informed consent" doctrine applies. A nonsuit may only be granted where "the plaintiff has failed to establish a right to relief." Pa.R.C.P. No. 230.1. See also Morena v. South Hills Health System, 501 Pa. 634, 462 A.2d 680 (1983). In reviewing the nonsuit entered in favor of Appellees, we must view "the evidence adduced on behalf of the plaintiff[s] as true; reading it in the light most favorable to [them]; giving [them] the benefit of every reasonable inference that a jury might derive from the evidence and resolving all doubts, if any, in [their] favor." Brannan v. Lankenau Hospital, 490 Pa. 588, 595, 417 A.2d 196, 199 (1980) (quoting Auel v. White, 389 Pa. 208, 210, 132 A.2d 350, 352 (1957)).

This Court has upheld the informed consent doctrine, which grants the competent patient the right to medical self-determination regarding an operative or surgical procedure. See Gray v. Grunnagle, 423 Pa. 144 223 A.2d 663 (1966); Smith v. Yohe, 412 Pa. 94, 194 A.2d 167 (1963). We have held

that a physician or surgeon who fails to advise a patient of material facts, risks, complications and alternatives to surgery which a reasonable [person] in the patient's position would have considered significant in deciding whether to have the operation is liable for damages which ensue, and the patient need not prove that a causal relationship exists between the physician's or surgeon's failure to disclose information and the patient's consent to undergo surgery.

Gouse v. Cassel, 532 Pa. 197, 202, 615 A.2d 331, 333 (1992) (emphasis added). Thus, it is apparent that this view protects the patient's right to make an informed choice as to whether to proceed with a surgical or operative procedure.

Instantly, Appellants argue that the use of forceps to facilitate delivery constitutes an operative procedure; therefore, the physician must obtain additional consent to use the forceps, which necessarily includes a discussion of the material risks involved in a "forceps delivery." Appellee argues that the use of forceps does not constitute an operative procedure, but rather, is used to facilitate a natural delivery; thus, the use of forceps falls within the patient's general consent to the delivery. We agree that the use of forceps to facilitate natural childbirth is not an operative procedure that implicates the doctrine of informed consent.

The Superior Court correctly determined that the use of forceps is not an operative procedure. Under the circumstances of this case, the physician's use of forceps involved the application of a tool to assist in the natural delivery process, and as such, was merely an extension of the physician's hands. We agree with the Superior Court's conclusion that the physician's use of forceps in this case is indistinguishable from a physician's use of an otoscope to examine the ear canal or a physician's insertion of a speculum into a woman's vagina in order to perform a vaginal examination. Sinclair v. Block, 406 Pa.Super. 540, 554-55, 594 A.2d 750, 758 (1991). ³ Moreover, we find that the physician's attempt to use forceps is part of one event: the natural delivery process. Thus, the physician's use of forceps to facilitate natural delivery is not a distinct surgical or operative procedure and, as a result, does not require additional consent to use the forceps.

Appellants also assert that, even if this Court finds that the use of forceps during the natural delivery process does not constitute an operative or surgical procedure, the informed consent doctrine should nevertheless apply to this case because the Appellants were not apprised of the risks associated with the forceps delivery. Restated, Appellants argue that regardless of whether a forceps delivery is a surgical or operative procedure, they were not informed of all material facts, risks, complications and alternatives of the delivery process. Appellants submit that, while there are limits to informed consent, nonetheless, any touching of the patient which involves risks of serious injury requires that the physician inform the patient of said risks and then receive the patient's consent in order to perform the procedure. Under the circumstances of this case, we disagree.

The goal of the informed consent doctrine is to provide the patient with...