ÿWPC …# V %a 0(g4£²UNºUN 0lV 0D L bR w@Z 0Jš 0Tä 0^8 0h– 0rþ 0|p 0†ì 0r 1u 0dw BÛU>øB)6DC_ AM¢U*ï  D3&v~YvÓ× 0@ª AOêÆ9 0Dÿ D/C Br˜HP LaserJet 4SiHPPCL5MS,ü,,,,,ü0nLlÎ X($¡¡¥Hœ$ x°°3|xÄ (ÖÃ9 Z ‹6Times New Roman Regular(ÖÃ9 Z ‹6Times New Roman Regular((3üÝ$¤¤Ý ƒ!ÝÝ  Ýà  àòòÚ  Ú0Ú  Úóó(#Ã$òòÚ  Ú0Ú  ÚóóC:\OFFICE\WPWIN\TEMPLATE\STANDARD.WPT- ù- ² ³ U´ Uµ ¶ I· D¸ D¹ Uº U» Ó€2 ÿÿ0Indent1Ô2ÔÔ3  Ô2" ÿÿ0Indent2à0 àÔ2ÔÔ3  Ô2, ÿÿ0Indent3à0 àà0 àÔ2ÔÔ3  Ô26 ÿÿ0Indent4à0 àà0 àà0 àÔ2ÔÔ3  Ô2@ ÿÿ0Indent5à0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2J ÿÿ0Indent6à0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2T ÿÿ0Indent7à0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2^ ÿÿ0Indent8à0 àà0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô ÿÿ?AGMSYaioIndent0I.A.1.a.(1)(a)i)a)P ÿÿ8Mac DefaultMac DefaultÓ ` °šXÓ d< Œ 9p`(&Times New Roman% Line 7 d%%%%7Border 1dd€-&Cþÿ << Gÿÿ< Œ 9p`(Arial Ý ƒ!ÝÑ  ÑÑ#€d#ÑÔ€$ÔÝ  ÝÔ€(ÔÔ€(ÔÓ  Óò òÔ YYY ÔFILEDÔ€(XÔÌÌJuly€31,€1998ÌÌCecil€W.€CrowsonÌAppellate€Court€ClerkÔ  Ôó ó'ÿÿdxdPtPtHHÚ(ÿáÿâùFG(üHHÚ(d'hStyl{WP}01•ÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃà Ãà Ãà Ãà Ãà ÃÃÃÃÃÃÃÃÃÃÃÐ ÐÐHHÐÐ  ÐÐ2ÐÐÿÿ¸æ$ÿÐÐHHÐÐÐÐÐÐÐÐ  ÐÐ ÐÐ ÐÑÑÑGenevaÑÑ ÑÑ € ÑÑ<Px–ÈÑÒÒÒ443!#4ÒÒ$ *$ÒÒ$*$ÒÒ ÿKK ÒÒ  Geneva ÒÒ  Geneva ÒÓ.,ÓÓÓÓ6ÓÓ ÓßßßßßßßßßßßßßßßßßßÑGenevaÑÑ ÑÒ  h HD: Geneva ÒÒ  h HD: Geneva Ò("ÿÿ$££Ò  ÒÒ  Ò€-‚ƒCþÿ<< CÿÿƒLevel 1Level 2Level 3Level 4Level 5($$””ò òÚ  Ú1Ú  Úó ó„„'÷ÿ dxdüÿP PdÝ ƒ!ÝÔ . ÔÔ€$ÔÝ  ÝÒ € ÒÒ „ ÒÓ ` Ü‚Xœ ’X ÓÑ\R AØ'\Ñ›Ñ7€.xXdìXXdð7ÑÑ  ќـ€ÙßR€')&A1-j|` ç `€€@ÿRßÞ ÞÌÌÌÌÌÌÌÌÌPATRICIA›€P.€ASHE,à à)Ìà àà à)ÌÓ#` Ü‚Xœôx‘X#Óà àPlaintiff/Appellant,à à)à àAppeal€No.Ìà àà à)à à01„A„01„9710„CV„00563Ìv.à àà à)Ìà àà à)à àDavidson€CircuitÌRADIATION€ONCOLOGY€ASSOCIATESà à)à àNo.€95C„58Ìand€STEVEN€L.€STROUP,€M.D.,à à)Ìà àà à)Ìà àDefendants/Appellees.à à)ÌÌÌÌÌÌÓ  ÓÔ€$¼ÔCOURT€OF€APPEALS€OF€TENNESSEEÌÌÌAPPEAL€FROM€THE€CIRCUIT€COURT€FOR€DAVIDSON€COUNTYÌÌAT€NASHVILLE,€TENNESSEEÌÌÌTHE€HONORABLE€HAMILTON€V.€GAYDEN,€JR.,€JUDGEÌÓ ` Ü‚XœÈ“X ÓÌÌÓ  ÓÌÌÌÌÔ€$XÔDAVID€RANDOLPH€SMITHÌROBERT€BLAKE€MENZELÌDavid€Randolph€Smith€&€AssociatesÌNashville,€Tennessee€€37203Ìà àATTORNEYS€FOR€PLAINTIFF/APPELLANTÌÌÌÌTHOMAS€A.€WISEMAN,€IIIÌNationsBank€Plaza,€Suite€1900Ì414€Union€StreetÌNashville,€Tennessee€€37219„1782Ìà àATTORNEY€FOR€DEFENDANTS/APPELLEESÌÌÌÌÌÌÌÌÑ7€ .x XXdìXdì7ÑÑ€ÑÓ  ÓREVERSED€AND€REMANDEDÌÌÌÌÌÌÌÓ  ÓÔ€$¼ÔWILLIAM€B.€CAIN,€JUDGEÌÓ  ÓÓÓòòÔ€$°ÔOPINIONóóÌÓ  ÓÓ#` Ü` ä œÈ“X#ÓÓ€ÓÔ€$¼Ôà àThis€case€was€tried€before€a€jury€in€the€Circuit€Court€in€DavidsonÏCounty€on€two€issues€to„wit:€€(1)€informed€consent€and€(2)€professionalÏnegligence.ÌÌà àOn€the€issue€of€informed€consent€the€trial€court€directed€a€verdictÏfor€the€defendant€at€the€conclusion€of€the€plaintiff's€proof.€€On€the€issue€ofÏprofessional€negligence€a€mistrial€was€declared€when€the€jury€was€unable€toÏagree€on€a€verdict.ÌThe€case€is€now€before€this€court€on€the€sole€issue€of€informed€consent.€€ÌÌà àPlaintiff€Patricia€Ashe€was€diagnosed€with€breast€cancer€in€1988.€ÏShe€underwent€a€double€mastectomy€and€chemotherapy.€€In€July€of€1993Ïchest€x„ray€and€CT€scan€confirmed€the€presence€of€cancer€in€her€left€lung.€ÏAs€a€result,€doctors€performed€surgery€at€Baptist€Hospital€on€July€30,€1993Ïto€remove€the€upper€portion€of€her€left€lung.€€She€resumed€chemotherapyÏunder€the€care€of€Dr.€Michael€Kuzur.€€Dr.€Kuzur€was€also€consulting€withÍthe€defendant,€Dr.€Steven€L.€Stroup€regarding€the€possible€need€for€radiationÏtherapy.€€At€this€time€the€physicians€were€unable€to€determine€with€certaintyÏwhether€her€lung€cancer€was€metastatic€from€her€1988€breast€cancer€or€wasÏprimary€lung€cancer€unrelated€to€the€previous€breast€cancer.€€If€Mrs.€AsheÏsuffered€from€primary€lung€cancer,€radiation€therapy€would€significantlyÏincrease€her€chances€for€survival€for€five€years€and€beyond.Ì€€Ìà àRadiation€therapy€involves€the€use€of€a€photon€beam€to€kill€cancerÏcells.€€Radiation,€however,€causes€chemical€changes€to€both€normal€cells€andÏcancer€cells.€€The€intent€for€use€of€this€therapy€is€to€cause€only€sublethalÏdamage€to€the€normal€cells€but€lethal€damage€to€the€cancer€cells€which€areÏless€resistant€to€radiation.€ÌÌà àOn€her€first€visit€to€Dr.€Stroup€Mrs.€Ashe€received€a€completeÏexplanation€of€the€procedure€and€went€through€a€"dress€rehearsal"€ofÏradiation€therapy.ÌÌà àThereafter€Mrs.€Ashe€submitted€herself€to€radiation€therapy.€€InÏthis€case€Mrs.€Ashe€sustained€radiation€injury€to€her€spinal€cord€resulting€inÏparalysis€of€her€lower€extremities.ÌÌà àAll€expert€witnesses€agreed€that€any€patient€undergoing€suchÏradiation€therapy€is€at€some€risk€for€spinal€cord€injury.€€Plaintiff's€expert,ÏDr.€Carlos€Perez,€testified€that€this€risk€at€the€dosage€received€by€Mrs.€AsheÏwas€from€one€to€two€percent.€€Other€medical€testimony€asserted€thisÏpercentage€to€be€much€smaller,€but,€for€the€purpose€of€reviewing€the€trialÏcourt€action€in€directing€a€verdict€for€Dr.€Stroup€we€are€required€to€acceptÍthe€testimony€of€Dr.€Perez.€€ÌÌà àIt€is€admitted€that€Dr.€Stroup€did€not€inform€Patricia€Ashe€of€thisÏrisk€of€spinal€cord€injury€prior€to€administering€radiation€therapy.ÌÌà àPlaintiff€testified€both€by€pre„trial€deposition€and€at€the€trial.€€SheÏwas€questioned€in€deposition€as€to€what€she€would€have€decided€aboutÏradiation€therapy€had€she€been€informed€of€the€possibility€of€spinal€cordÏinjury.€€At€trial€she€testified€again€on€the€same€subject.€€Her€testimony€at€trialÏdiffered€significantly€from€her€previous€testimony€by€deposition€and€at€theÏconclusion€of€the€plaintiff's€proof€the€trial€court€directed€a€verdict€againstÏher€on€the€informed€consent€issue€applying€the€"rule€of€cancellation"€statedÏin€òòò òTaylor€v.€Nashville€Banner€Publishing€Co.ó óóó,€573€S.W.2d€476,€482Ïœ(Tenn.€Ct.€App.€1978).›€€Says€the€trial€judge:ÌÓÓà8 àThe€court€however,€does€grant€your€motion€on€the€issueÏof€informed€consent€on€the€same€basis€that€you€made€forÏDr.€Perez.€€It's€the€opinion€of€the€court€that€the€plaintiffÏhas€irreconcilably€and€totally€contradicted€herself€in€herÏdeposition€and€in€testimony€here€today.€€So€I€will€grantÏthe€motion€on€the€issue€of€informed€consent.ÌÌÓ€ÓÌà àWe€are€thus€called€upon€in€this€appeal€to€answer€three€pertinentÏquestions:ÌÓ&` Ü` ä Äœ ’X&Óà à1.à àDid€the€plaintiff's€proof€offered€at€trial€present€a€jury€questionÏas€to€whether€or€not€Dr.€Stroup€obtained€"informed€consent"€of€PatriciaÏAshe€under€the€standards€of€T.C.A.€29„6„118€before€administering€radiationÏtherapy.Ìà à2.€à àIf€a€jury€question€is€presented€as€to€"informed€consent"€is€theÏplaintiff's€only€burden€as€to€causation€to€establish€that€the€radiation€therapyÍin€fact€caused€the€paralysis.Ìà à3.à àIf,€in€addition€to€radiation„paralysis€causation,€plaintiff€mustÏfurther€prove€causation€in€a€consent€context,€does€the€"rule€of€cancellation"Ïjustify€a€directed€verdict€against€her.ÌÌÓÓI.à àòòDid€the€plaintiff's€proof€offered€at€trial€present€a€jury€question€Ìà àas€to€whether€or€not€Dr.€Stroup€obtained€"informed€consent"€Ìà àof€Patricia€Ashe€under€the€standards€of€T.C.A.€29„6„118€ÌÓ€Óà àbefore€administering€radiation€therapyóó.ÌÌà àPlaintiff's€qualified€expert€Dr.€Carlos€Perez€testified€that€theÏstandard€of€€care€in€procuring€informed€consent€required€the€disclosure€byÏDr.€Stroup€of€the€small€but€potentially€catastrophic€risk€of€spinal€cord€injuryÏfrom€radiation€therapy.€€Although€his€testimony€is€hotly€disputed€by€expertÏwitnesses€offered€for€the€defendant,€we€are€reviewing€a€directed€verdict€forÏthe€defendant€wherein€the€evidence€must€be€construed€most€favorably€to€theÏplaintiff.€€ò òòòCecil€v.€Hardinó óóó,€575€S.W.2d€268€œ(Tenn.€1978).›ÌÌà àIn€discussing€informed€consent€this€court€stated€in€ò òòòGerman€v.ÏNichopolousó óóó,€577€S.W.2d€197,€202€œ(Tenn.€Ct.€App.€1978):›ÌÓÓà8 àLiability€predicated€on€the€doctrine€of€informed€consent€isÏnot€dependent€upon€the€existence€of€negligence€in€theÏperformance€of€a€physical€act.€€Liability€is€predicatedÏupon€negligence€of€the€physician€in€the€failure€toÏreasonably€advise€the€patient€regarding€the€treatmentÏrecommended.ÌÌÓ€ÓÌà àThis€particular€language€is€reiterated€by€the€court€of€appeals€inÏò òòòBryant€v.€Baugussó óóó,€1996€WL€465539€œ(Tenn.€App.€1996)›€and€inÏò òòòBlanchard€v.€Kellumó óóó,€1997€WL€147525€œ(Tenn.€App.€1997).›€€We€note€thatÍpermission€to€appeal€in€ò òòòBlanchard€v.€Kellumó óóó€was€granted€by€the€SupremeÏCourt€on€September€29,€1997.€ÌÌà àThe€reference€in€ò òòòNichopolousó óóó€to€the€physician€failing€toÏreasonably€advise€the€patient€regarding€the€treatment€recommended€in€termsÏof€"negligence"€is€inconsistent€with€ò òòòCardwell€v.€Bechtoló óóó,€724€S.W.2d€739Ïœ(Tenn.€1987).›€€Said€the€supreme€court€in€ò òòòCardwelló óóó:ÌÓÓà8 àà àAlthough€this€provision€is€part€of€the€malpracticeÏstatute€and€while€determining€whether€the€DefendantÏfailed€to€obtain€informed€consent€is€dependent€upon€theÏstandard€of€care€of€the€profession€or€specialty,€ifÏinformed€consent€is€not€effectively€obtained,€theÏdefendant's€departure€from€the€standard€of€care€is€notÏnegligence€but€battery€because€"the€doctrine€of€battery€[is]Ïapplicable€to€cases€involving€[treatment]€performedÏòòwithout€informed€or€knowledgeable€consent.óó"€€òòRay€v.ÏScheibert,óó€484€S.W.2d€63,€71€(Tenn.App.),€òòcert.€deniedóóÏ(Tenn.1972)(emphasis€in€original).€€As€observed€inÏòòLanford€v.€Yorkóó,€224€Tenn.€503,€457€S.W.2d€525€(1970),Ïmalpractice€"'is€based€on€lack€of€care€or€skill€in€theÏperformance€of€services€contracted€for,€and€[battery]€onÏwrongful€trespass€on€the€person€regardless€of€the€skillÏemployed.€€The€assertion€of€one€is€the€denial€of€theÏother.'"€€224€Tenn.€at€510„511,€457€S.W.2d€at€528Ï(citation€omitted).Ìà8 àà à[9]€€We€found€it€necessary€to€note€this€because€theÏPlaintiffs€alleged€and€the€trial€court€instructed€the€jury€onÏ"negligent€failure€to€obtain€informed€consent."€€T.C.A.€ððÏ29„26„118€does€not€codify€or€otherwise€create€such€aÏcause€of€action.€€While€the€determination€of€theÏeffectiveness€of€consent€cannot€be€made€without€expertÏtestimony€on€the€standard€of€care€concerning€whatÏinformation€is€usually€supplied€to€enable€a€patient€to€giveÏinformed€consent,€considering€both€the€seriousness€of€theÏtreatment€and€any€expression€of€concern€by€the€patient,Ïfailure€to€give€such€information€is€not€the€type€ofÏomission€that€results€in€negligence,€but€rather€it€negatesÍconsent€for€the€treatment.€€Without€consent,€the€treatmentÏconstitutes€a€battery.Ìà8 àà à[10]€€Under€the€case€law,€the€correct€analysis€in€ourÏopinion€is€that€if€the€evidence€shows€that€the€person€hadÏthe€capacity€to€consent,€then€the€question€becomes€whetherÏthe€consent€given€was€effective€because€it€was€based€uponÏadequate€information€on€which€to€make€the€decision€toÏsubmit€to€treatment;€if€not,€then€a€battery€results,€but€ifÏso,€then€the€question€becomes€whether€the€defendantÏsubsequently€did€anything€negligent€in€the€administrationÏof€the€treatment€for€which€consent€was€obtained,€proof€ofÏwhich€is€controlled€by€T.C.A.€ðð€29„26„115.€€The€trialÏcourt's€instruction€on€negligent€failure€to€obtain€informedÏconsent€was,€therefore,€error,€but€in€view€of€the€verdictÏand€our€decision€in€this€case,€it€was€harmless€error.€€RuleÏ36,€T.R.A.P.Ìà8 àà à[11]€€These€theories,€battery€and€malpractice,€are€notÏordinarily€inconsistent,€and€no€election€of€remedies€isÏgenerally€required;€if€a€battery€exists,€then€malpracticeÏmay€not€necessarily€be€reached,€but€if€no€battery€can€beÏshown,€then€the€issue€clearly€emerges€as€one€ofÏmalpractice.€€This€distinction€between€battery€andÏmalpractice€(as€a€form€of€negligence)€is€consistentlyÏrecognized€in€the€case€law.ÌÌò òòòCardwell€v.€Bechtoló óóó,€724€S.W.2d€739,€750€œ(Tenn.€1987).›ÌÌÓ€ÓÌà àThus€we€come€to€the€line€that€must€be€drawn€between€that€which€isÏrequired€by€the€standard€of€care€to€be€disclosed€to€the€patient€and€that€whichÏis€not€so€required.€€€This€inexact€and€case„sensitive€line€was€discussed€by€theÏsupreme€court€in€the€recent€case€of€ò òòòShadrick€v.€Cokeró óóó,€963€S.W.2d€726Ïœ(Tenn.€1998).›€€Said€the€court:ÌÓÓà8 àà à[10]€€This€is€not€to€suggest,€however,€that€a€healthÏcare€provider€is€required€to€enumerate€in€detail€everyÏaspect€of€the€proposed€treatment€or€procedure€or€discussÏevery€possible€thing€that€might€go€wrong€in€an€effort€toÏobtain€the€patient's€informed€consent.€€"In€the€first€place,Íto€do€so€is€humanly€impossible.€€In€the€second€place,€if€allÏthe€gory€details€of€a€proposed€surgery€were€graphicallyÏexplained€to€every€patient€and€all€possible€medicalÏmaladies€that€might€result€were€enumerated,€we€doubt€thatÏa€lay€person€would€have€the€stomach€to€listen€to€it€all;€andÏif€the€patient€did,€would€probably€be€in€such€a€fearfulÏstate€that€no€rational€decision€could€be€made."€€òòLongmireÏv.€Hoeyóó,€512€S.W.2d€307,€310€(Tenn.App.1974).€ÏAccordingly,€health€care€providers€are€generally€notÏrequired€to€disclose€risks€that€are€not€material,€such€asÏthose€that€are€extremely€unlikely€to€occur€or€one€that€aÏreasonable€patient€would€not€care€to€know€due€to€itsÏinsignificance;€risks€that€are€obvious€or€already€known€byÏthe€patient;€risks€that€are€unforeseeable€or€unknowable;€orÏwhere€the€patient's€medical€condition€renders€discussionÏof€the€risks€and€benefits€of€the€treatment€or€procedureÏimpossible€or€medically€inadvisable,€such€as€in€anÏemergency€where€the€patient€is€unconscious€or€otherwiseÏincapable€of€consenting,€or€where€full€disclosure€would€beÏdetrimental€to€the€patient's€total€care,€i.e.,€the€patient€isÏunduly€alarmed€or€apprehensive€to€start€with€andÏadditional€information€would€overload€the€patient€andÏjeopardize€his€or€her€physical€or€emotional€well„being.ÌÌ963€S.W.2d€726,€733€(Tenn.1988).ÌÌÓ€ÓÌà àThe€court€of€appeals€in€ò òòòLongmire€v.€Hoeyó óóó,€512€S.W.2d€307Ïœ(Tenn.€Ct.€App.€1974)›€observed:ÌÓÓà8 àà àWe€are€cited€to€cases€from€other€jurisdictions€whereÏthe€failure€to€advise€of€a€1%€risk€has€been€the€basis€of€aÏfinding€of€liability.€€òòBowers€v.€Talmageóó€(1963€Fla.App.)Ï159€So.2d€888,€òòCanterbury€v.€Spence€and€WashingtonÏHospital€Centeróó€(1972)€150€U.S.App.D.C.€263,€464€F.2dÏ772.Ìà8 àà à[2]€€We€have€no€particular€quarrel€with€the€resultsÏreached€in€other€jurisdictions,€but€we€are€not€of€theÏopinion€that€proof€of€any€particular€percentage€figure€isÏdeterminative€of€whether€or€not€a€plaintiff€has€made€out€aÍòòprima€facieóó€case.€€We€are€of€the€opinion€that€the€seriousÏnature€of€the€risk€involved€is€paramount€to€any€percentageÏfigure€of€occurrence.Ìà8 àà àOf€course,€the€percentage€of€risk€of€occurrence€mustÏbe€considered€along€with€the€nature€of€that€which€isÏrisked.€€In€the€reported€cases€which€have€held€that€failureÏto€advise€of€a€1%€risk€or€such€other€low€percentage€mayÏbe€a€basis€for€liability,€we€also€find€that€which€was€riskedÏwas€of€a€devastating€nature;€such€as€complete€or€partialÏparalyses,€blindness€or€deafness.€€We€readily€admit€thatÏwhen€such€is€the€nature€of€the€risk€reasonable€mindsÏmight€differ€on€whether€or€not€the€patient€should€haveÏbeen€advised€of€that€risk.€€There€are€those€who€would€riskÏdeath€itself€before€a€lifetime€of€paralyses€or€blindness.€ÏOthers€might€prefer€to€suffer€a€certain€amount€of€painÏrather€than€risk€such€disastrous€results.€€The€occurrenceÏrisked€may€itself€be€of€great€magnitude€while€theÏpercentage€of€its€occurrence€may€be€small.Ìò òÌó ó512€S.W.2d€307,€310€œ(Tenn.€Ct.€App.€1974).›ÌÌÓ€ÓÌà àBoth€the€òòò òLongmireó óóó€court€and€the€supreme€court€in€òòò òShadrickó óóóÏrefer€to€the€landmark€case€of€ò òòòCanterbury€v.€Spence€&€WashingtonÏHospital€Center,ó óóó€15€U.S.App.D.C.€263,€464€F.2d€772€(1972).€€The€factsÏunderlying€ò òòòCanterburyó óóó€are€parallel€to€the€facts€in€this€case.€€In€discussingÏthe€crucial€question,€the€ò òòòCanterbury€ó óóócourt€says:ÌÓÓà8 àDr.€Spence€further€testified€that€even€without€traumaÏparalysis€can€be€anticipated€"somewhere€in€the€nature€ofÏone€percent"€of€the€laminectomies€performed,€a€risk€heÏtermed€"a€very€slight€possibility."€€He€felt€thatÏcommunication€of€that€risk€to€the€patient€is€not€goodÏmedical€practice€because€it€might€deter€patients€fromÏundergoing€needed€surgery€and€might€produce€adverseÏpsychological€reactions€which€would€preclude€the€successÏof€the€operation.ÌÌÓ  Ó.€.€.€ÌÓ  ÓÌà8 àWe€reverse.€€The€testimony€of€appellant€and€his€motherÏthat€Dr.€Spence€did€not€reveal€the€risk€of€paralysis€fromÏthe€laminectomy€made€out€a€prima€facie€case€of€violationÏof€the€physician's€duty€to€disclose€which€Dr.€Spence'sÏexplanation€did€not€negate€as€a€matter€of€law.ÌÌ464€F.2d€772,€778€(1972).ÌÌÓ€ÓÌà àò òòòLongmireó óóó€did€not€deal€with€catastrophic€injury€but€rather€with€aÏureterovaginal€fistula€developing€in€an€area€not€associated€with€the€surgery.€ÏWhen€considered€in€the€context€of€the€case€at€bar€the€ò òòòLongmireó óóó€dicta€isÏrevealing:ÌÓÓà8 àIn€the€reported€cases€which€have€held€that€failure€toÏadvise€of€a€1%€risk€or€such€other€low€percentage€may€beÏa€basis€of€liability,€we€also€find€that€which€was€risked€wasÏof€a€devastating€nature;€such€as€complete€or€partialÏparalysis,€.€.€.ÌÌ512€S.W.2d€307,€310€œ(Tenn.€Ct.€App.€1974).›ÌÌÓ€ÓÌà àAgainst€this€background€we€consider€T.C.A.€29„26„118€specificallyÏentitled€"proving€inadequacy€of€consent."€€In€cases€involving€informedÏconsent€Tennessee€has€long€followed€the€"battery"€rule.€€ò òòòCardwell€v.ÏBechtoló óóó,€724€S.W.2d€739€œ(Tenn.€1987);›€ò òòòRay€v.€Scheibertó óóó,€484€S.W.2d€63Ïœ(Tenn.€Ct.€App.€1972);›€ò òòòLanford€v.€Yorkó óóó,€244€Tenn.€503,€457€S.W.2d€525Ï(1970).ÌÌà àBefore€undertaking€a€medical€procedure€it€is€necessary€for€theÏdoctor€to€adequately€inform€the€patient€as€to€serious€risks€and€problems€thatÏmight€develop€from€the€procedure.€€This€includes€serious€risks€that€areÍinherent€in€the€procedure€itself€no€matter€how€carefully€this€procedure€isÏperformed.€€Under€the€ò òòòLongmireó óóó€observations€a€small€risk€of€chicken€poxÏwould€be€one€thing€and€a€small€risk€of€small€pox€quite€something€else.€€WeÏneed€go€no€further€in€the€case€at€bar€than€hold€that€the€catastrophic€nature€ofÏparalysis€presents€a€jury€question€under€the€facts€of€this€case€when€a€dulyÏqualified€expert€witness€testifies€that€the€applicable€standard€of€care€forÏinformed€consent€requires€the€disclosure€of€the€risks.ÌÌÓÓII.à àòòIf€a€jury€question€is€presented€as€to€"informed€consent"€is€Ìà àthe€plaintiff's€only€burden€as€to€causation€to€establish€that€ÌÓ€Óà àthe€radiation€therapy€in€fact€caused€the€paralysisóó.ÌÌà àPlaintiff€asserts€that€in€those€jurisdictions€like€Tennessee€followingÏthe€"battery"€rule€in€cases€involving€informed€consent€the€only€causationÏissue€is€whether€or€not€the€procedure€caused€the€result.€€Thus€in€this€case€didÏthe€radiation€treatment€cause€the€spinal€cord€injury€resulting€in€paralysis.ÌÌà àIn€his€brief,€the€defendant€takes€the€following€position:ÌÓÓà8 àà àThis€case€law€highlights€the€confusion€that€exists€inÏthe€body€of€law€regarding€informed€consent€in€theÏmedical€arena€and€whether„„or€when„„a€claim€sounds€inÏbattery€or€negligence.€€Dr.€Stroup€respectfully€submitsÏthat€a€distinction€must€be€made€between€two€potentialÏkinds€of€informed€consent€claims:Ìà8 àà à1.€€When€the€physician€utterly€fails€to€inform€theÏpatient€of€the€nature€of€the€procedure€and€the€significantÏrisks€most€likely€associated€with€it;€and€Ìà8 àà à2.€€When€the€physician€fails€to€inform€the€patient€of€aÏremote€(even€though€consequential)€risk€of€the€procedure,Ïbut€otherwise€obtains€the€patient's€informed€consent.Ìà8 àà àOtherwise,€a€no„fault€analysis€will€prevail€and€allowÏa€patient€to€recover€damages€when€that€patient€has€beenÏunfortunate€enough€to€experience€a€very€remote€risk€thatÍoccurred€in€the€absence€of€negligence.€€If€the€patientÏconsents€to€the€touching,€but€a€remote€yet€undisclosed€riskÏis€realized,€the€jury€should€be€allowed€to€determineÏwhether€that€patient,€or€a€reasonable€patient,€would€haveÏnonetheless€consented€òòeven€if€the€remote€risk€had€beenÏdisclosed€as€part€of€the€informed€consent€discussionóó.Ìà8 àà àOtherwise,€the€fear€expressed€in€òòShadrickóó€and€othersÏwill€be€realized.€€Healthcare€providers€will€feel€requiredÏto€disclose€risks€"that€are€extremely€unlikely€to€occur€.€.€.;Ïrisks€that€are€unforeseeable€or€unknowable;€or€where€theÏpatient's€medical€condition€renders€discussion€of€the€risksÏand€benefits€of€the€treatment€and€procedure€impossible€orÏmedically€inadvisable,€.€.€.,€or€where€full€disclosure€wouldÏbe€detrimental€to€the€patient's€total€care,€i.e.,€the€patient€isÏunduly€alarmed€or€apprehensive€to€start€with€an€additionalÏinformation€would€overload€the€patient€and€jeopardize€hisÏor€her€physical€or€emotional€well„being."€€(Slip€Op.,€at€p.Ï11.)€€In€the€present€climate€of€experts„for„hire,€anyÏphysician€would€be€foolhardy€to€exercise€discretion€andÏavoid€so„called€"full€disclosure"€even€if€the€patient'sÏinterests€may€require€it.ÌÌÓ€ÓÌà àOn€July€13,€1998€the€Supreme€Court€released€its€opinion€inÏòòò òFrances€Blanchard€v.€Arlene€Kellum,€D.D.S.ó óóó,€No.€02„S„01„9709„CV„00083.€€The€court€therein€makes€the€distinction€asserted€by€the€defendant€inÏthis€case.€€Says€the€Supreme€court€in€òòò òBlanchardó óóó:ÌÓÓà8 àà àThe€plaintiff€has€alleged€that€she€did€not€give€Dr.ÏKellum€permission€to€pull€thirty„two€teeth€during€theÏoffice€visit€giving€rise€to€this€litigation.€€The€plaintiffÏcontends€that€her€claim€on€appeal€is€predicated€upon€aÏtheory€of€"a€violation€of€plaintiff's€person"€or€"anÏactionable€battery"€and€is€not€"related€to€medical€orÏprofessional€negligence."€€She€argues€that€expertÏtestimony€should€not€be€required€merely€to€show€whetherÏDr.€Kellum€procured€permission€to€perform€theÏextractions.ÌÌà8 àà àWe€believe€that€there€is€a€distinction€between:€€(1)Ïcases€in€which€a€doctor€performs€an€unauthorizedÏprocedure;€and€(2)€cases€in€which€the€procedure€isÏauthorized€but€the€patient€claims€that€the€doctor€failed€toÏinform€the€patient€of€any€or€all€the€risks€inherent€in€theÏprocedure.€€Performance€of€an€unauthorized€procedureÏconstitutes€a€òòmedical€batteryóó.€€A€simple€inquiry€can€beÏused€to€determine€whether€a€case€constitutes€a€medicalÏbattery:€€(1)€was€the€patient€aware€that€the€doctor€wasÏgoing€to€perform€the€procedure€(i.e.,€did€the€patient€knowÏthat€the€dentist€was€going€to€perform€a€root€canal€on€aÏspecified€tooth€or€that€the€doctor€was€going€to€performÏsurgery€on€the€specified€knee?);€and,€if€so€(2)€did€theÏpatient€authorize€performance€of€the€procedure?€€AÏplaintiff's€cause€of€action€may€be€classified€as€a€medicalÏbattery€only€when€answers€to€either€of€the€above€questionsÏare€in€theà à€negative.€€If,€however,Ïanswers€to€the€above€questions€are€affirmative€and€if€theÏplaintiff€is€alleging€that€the€doctor€failed€to€inform€of€anyÏor€all€risks€or€aspects€associated€with€a€procedure,€theÏpatient's€cause€of€action€rests€on€an€informed€consentÏtheory.ÌÓ  Ó.€.€.ÌÌÓ  Óà8 àà àLack€of€informed€consent€in€a€medical€malpracticeÏaction€under€Tenn.€Code€Ann.€ðð€29„16„118€operates€toÏnegate€a€patient's€authorization€for€a€procedure€therebyÏgiving€rise€to€a€cause€of€action€for€battery.€€òòCardwell€v.ÏBechtolóó,€724€S.W.2d€739,€750„51€(Tenn.€1987).€€There€is,Ïhowever,€no€prior€authorization€or€consent€in€a€medicalÏbattery€case€to€be€negated€by€expert€testimony.€€TheÏprimary€consideration€in€a€medical€battery€case€is€simplyÏwhether€the€patient€knew€of€and€authorized€a€procedure.€ÏThis€determination€does€not€require€the€testimony€of€anÏexpert€witness.ÌÌò òòòœFrances€Blanchard€v.€Arlene€Kellum,€D.D.S.ó óóó,€No.€02„S„01„9709„CV„00083,€slip€op.€at€4„6€(Tenn.€July€13,€1998)€(emphasis€added).ÌÌÓ€Ó›Ìà àIn€the€case€at€bar€there€is€no€assertion€of€a€"medical€battery"€case€asÏdefined€in€ò òòòBlanchardó óóó€since€not€only€was€the€radiation€therapy€authorized€byÏthe€plaintiff€but€in€fact€was€"dress€rehearsed"€before€the€procedure€wasÏundertaken.€€We€are€dealing€here€only€with€lack€of€informed€consent€underÏT.C.A.€ðð€29„16„118€and€not€with€a€ò òòòBlanchardó óóó€defined€"medical€battery"Ïœcase.€€Thus€we€refer€to€the€rule€in€òòò òShadrickó óóó.›ÌÌà8 àThe€à àsupreme€court€has€stated:ÌÓÓà8 à[5]€€A€cause€of€action€based€on€the€lack€of€informedÏconsent€stems€from€the€premise€that€a€competent€patientÏshould€be€allowed€to€formulate€an€intelligent,€informedÏdecision€about€surgical€or€other€treatment€procedures€theÏpatient€undertakes.€€òòHoush€v.€Morrisóó,€818€S.W.2d€39,€41Ï(Tenn.App.1991).€€The€basic€policy€consideration€whichÏsupports€the€recognition€of€the€cause€of€action€for€lack€ofÏinformed€consent€has€been€explained€as€follows:Ìà àà8 àThe€root€premise€is€the€concept€fundamental€inÏAmerican€jurisprudence€that€'every€humanÏbeing€of€adult€years€and€sound€mind€has€a€rightÏto€determine€what€shall€be€done€with€his€ownÏbody€.€.€.€.'€€True€consent€to€what€happens€toÏone's€self€is€the€informed€exercise€of€a€choice,Ïand€that€entails€an€opportunity€to€evaluateÏknowledgeably€the€options€available€and€theÏrisks€dependant€upon€each.€€The€average€patientÏhas€little€or€no€understanding€of€the€medicalÏarts,€and€ordinarily€has€only€his€physician€toÏwhom€he€can€look€for€enlightenment€with€whichÏto€reach€an€intelligent€decision.€€from€theseÏalmost€axiomatic€considerations€springs€theÏneed,€and€in€turn€the€requirement,€of€aÏreasonable€divulgence€by€[the]€physician€to€[the]Ïpatient€to€make€such€a€decision€possible.€ÏòòCanterbury€v.€Spenceóó,€464€F.2d€772,€780Ï(D.C.Cir.1972).ÌÌà8 àà à[6„8]€€Accordingly,€the€law€recognizes€that€a€healthÍcare€provider,€such€as€a€physician€or€surgeon,€whoÏproposes€a€treatment€or€surgical€procedure€has€a€duty€toÏprovide€the€patient€with€enough€information€about€theÏnature€of€the€treatment€or€procedure€involved€to€enableÏthe€patient€to€make€an€intelligent€decision€and€therebyÏgive€an€informed€consent€to€the€treatment€or€procedure.€ÏòòSee€Cardwell€v.€Bechtolóó,€724€S.W.2d€739,€750Ï(Tenn.1987).€€ò òòòÌœShadrickó óóó›€at€731.ÌÌÓ€ÓÌà àThe€position€of€the€plaintiff€that€there€is€no€causation€issue€exceptÏthe€cause€and€effect€relationship€between€the€radiation€therapy€and€the€spinalÏinjury€might€well€be€correct€in€a€Blanchard€defined€'medical€battery'€action.€ÏIt€likewise€finds€support€in€Pennsylvania€Gouse€v.€Cassell,€615€At.2d€331Ï(Penn.€1992)€but€little€support€elsewhere.€€In€a€lack€of€informed€consent€caseÏunder€T.C.A.€ðð€29„16„118,€Tennessee€has€not€so€limited€the€causationÏœinquiry.€€Nor›€have€Tennessee€cases€articulated€a€causation€standard€directlyÏencompassing€the€effect€of€lack€of€informed€consent€on€the€preoperativeÏdecision„making€of€the€patient.€€The€only€hint€comes€from€ò òòòLongmire€v.ÏHoeyó óóó,€512€S.W.2d€307,€309€wherein€the€court€of€appeals€observes:€Ï"Although€not€of€itself€necessarily€controlling,€we€can€not€help€but€note€thatÏplaintiff€never€claimed€that€she€would€have€made€any€other€choice€than€theÏone€she€made,€even€if€she€had€been€advised€of€the€possibility€of€a€fistulaÏdeveloping."€€This€hints€at€a€subjective€causation€standard.ÌÌà àProfessor€Joseph€H.€King,€Jr.€in€his€1977€article:€€"The€standard€ofÏcare€and€informed€consent€under€the€Tennessee€Medical€Malpractice€Act"Ïvol.€44€Tenn.€Law€Review€2€observed:ÌÓÓà8 àAnother€aspect€of€the€causation€requirement€deals€with€theÏquestion€of€whether€the€required€disclosure€would€haveÍmade€any€difference€in€the€decision€to€proceed€with€theÏtreatment.€€Most€courts€and€legislatures€that€haveÏaddressed€the€question€apply€an€objective€standard,€whichÏrequires€that€plaintiff€prove€that€a€reasonable€person€inÏplaintiff's€position€would€have€declined€the€therapy€had€heÏbeen€adequately€informed.€€A€few€courts€have€adopted€aÏsubjective€standard€that€would€inquire€whether€theÏparticular€plaintiff€would€have€consented€had€theÏappropriate€disclosure€been€made.ÌÌ44€Tenn.€Law€Review€2€at€p.€295.€€Footnotes€omitted.ÌÌÌÓ€Óà àRecognizing€the€reliance€of€òòò òLongmire€ó óóóand€ò òòòShadrickó óóó€onÏpreeminent€authority€of€the€near€encyclopedic€decision€in€ò òòòCanterbury€v.ÏSpenceó óóó,€464€F.2d€772€(1972);€and€lacking€further€guidance€from€theÏappellate€courts€in€Tennessee,€we€adopt€the€objective€causation€standardÏstated€therein:ÌÓÓà8 àà à[31]€€A€causal€connection€exists€when,€but€only€when,Ïdisclosure€of€significant€risks€incidental€to€treatmentÏwould€have€resulted€in€a€decision€against€it.€€The€patientÏobviously€has€no€complaint€if€he€would€have€submitted€toÏthe€therapy€notwithstanding€awareness€that€the€risk€wasÏone€of€its€perils.€€On€the€other€hand,€the€very€purpose€ofÏthe€disclosure€rule€is€to€protect€the€patient€againstÏconsequences€which,€if€known,€he€would€have€avoided€byÏforegoing€the€treatment.€€The€more€difficult€question€isÏwhether€the€factual€issue€on€causality€calls€for€an€objectiveÏor€a€subjective€determination.Ìà8 àà àIt€has€been€assumed€that€the€issue€is€to€be€resolvedÏaccording€to€whether€the€factfinder€believes€the€patient'sÏtestimony€that€he€would€not€have€agreed€to€the€treatmentÏif€he€had€known€of€the€danger€which€later€ripened€intoÏinjury.€€We€think€a€technique€which€ties€the€factualÏconclusion€on€causation€simply€to€the€assessment€of€theÏpatient's€credibility€is€unsatisfactory.€€To€be€sure,€theÏobjective€of€risk„disclosure€is€preservation€of€the€patient'sÏinterest€in€intelligent€self„choice€on€proposed€treatment,€aÍmatter€the€patient€is€free€to€decide€for€any€reason€thatÏappeals€to€him.€€When,€prior€to€commencement€ofÏtherapy,€the€patient€is€sufficiently€informed€on€risks€andÏhe€exercises€his€choice,€it€may€truly€be€said€that€he€didÏexactly€what€he€wanted€to€do.€€But€when€causality€isÏexplored€at€a€post„injury€trial€with€a€professedlyÏuninformed€patient,€the€question€whether€he€actuallyÏwould€have€turned€the€treatment€down€if€he€had€knownÏthe€risks€is€purely€hypothetical:€€"Viewed€from€the€pointÏat€which€he€had€to€decide,€would€the€patient€have€decidedÏdifferently€had€he€known€something€he€did€not€know?"€ÏAnd€the€answer€which€the€patient€supplies€hardlyÏrepresents€more€than€a€guess,€perhaps€tinged€by€theÏcircumstance€that€the€uncommunicated€hazard€has€in€factÏmaterialized.Ìà8 àà àIn€our€view,€this€method€of€dealing€with€the€issue€onÏcausation€comes€in€second„best.€€It€places€the€physician€inÏjeopardy€of€the€patient's€hindsight€and€bitterness.€€ItÏplaces€the€factfinder€in€the€position€of€deciding€whether€aÏspeculative€answer€to€a€hypothetical€question€is€to€beÏcredited.€€It€calls€for€a€subjective€determination€solely€onÏtestimony€of€a€patient„witness€shadowed€by€the€occurrenceÏof€the€undisclosed€risk.Ìà8 àà à[32]€€Better€it€is,€we€believe,€to€resolve€the€causalityÏissue€on€an€objective€basis:€€in€terms€of€what€a€prudentÏperson€in€the€patient's€position€would€have€decided€ifÏsuitably€informed€of€all€perils€bearing€significance.€€IfÏadequate€disclosure€could€reasonably€be€expected€to€haveÏcaused€that€person€to€decline€the€treatment€because€of€theÏrevelation€of€the€kind€of€risk€or€danger€that€resulted€inÏharm,€causation€is€shown,€but€otherwise€not.€€€TheÏpatient's€testimony€is€relevant€on€that€score€of€course€butÏit€would€not€threaten€to€dominate€the€findings.€€And€sinceÏthat€testimony€would€probably€be€appraised€congruentlyÏwith€the€factfinder's€belief€in€its€reasonableness,€the€caseÏfor€a€wholly€objective€standard€for€passing€on€causation€isÏstrengthened.€€Such€a€standard€would€in€any€event€ease€theÏfact„finding€process€and€better€assure€the€truth€as€itsÏproduct.ÌÌò òòòCanterbury€v.€Spenceó óóó,€464€F.2d€at€790„791€(1972).ÌÌÓ€ÓÌÓÓIII.à8 àòòIf€in€addition€to€radiation„paralysis€causation€plaintiff€à8 àmust€further€prove€causation€in€a€consent€context,€doesÏthe€"rule€of€cancellation"€justify€a€directed€verdict€againstÏheróó.€€€€€€Ìà àà àà àà àà àÌÌÓ€Óà àSince€the€objective€standard€we€adopt€renders€the€testimony€of€theÏplaintiff€but€one€of€the€factors€to€be€considered,€the€"rule€of€cancellation"€ofÏò òòòTayloró óóó€does€not€apply.€€Since€this€rule€formed€the€sole€basis€for€the€trialÏcourt's€directed€verdict,€the€action€of€the€trial€court€in€this€respect€isÏreversed.€ÌÌà àThe€discrepancies€between€the€testimony€of€Mrs.€Ashe€at€herÏdeposition€and€her€testimony€at€trial€go€to€her€credibility€as€a€witness€andÏmust€be€considered€along€with€all€other€evidence€presented€to€the€trier€ofÏfact€on€the€causation€issue€under€an€objective€person€standard.ÌÌà àAppellee€asserts€error€in€the€failure€of€the€trial€court€to€grant€itsÏmotion€for€a€directed€verdict€on€the€issue€of€professional€negligence€in€thisÏcase.€€The€jury€was€unable€to€reach€a€decision€and€a€mistrial€was€declared€asÏto€this€issue.ÌÌà àThe€order€granting€the€motion€of€the€defendant€for€a€directedÏverdict€on€the€informed€consent€issue€provides:ÌÓÓà8 àAfter€considering€the€argument€of€counsel,€the€pleadingsÏsubmitted€by€the€parties,€and€otherwise€being€sufficientlyÏadvised,€the€court€denies€the€plaintiff's€motion€for€newÏtrial€and€motion€for€partial€summary€judgment,€andÏgrants€the€defendant's€motion€to€make€the€directed€verdictÏfinal.Ìà8 àAccordingly,€it€is€hereby€ordered€that€the€plaintiff'sÏinformed€consent€claim€is€dismissed€with€prejudice.€€AllÏother€claims€by€the€plaintiff€are€reserved€and€the€case€isÏhereby€stayed€pending€the€plaintiff's€expected€appeal€ofÏthe€directed€verdict.Ìà8 àThis€order€as€to€the€directed€verdict€on€the€informedÏconsent€claim€is€final€and€there€is€no€just€cause€for€delay.ÌÌÌÓ€Óà àThe€only€notice€of€appeal€is€that€filed€by€the€plaintiff€which€isÏpursuant€to€rule€54.02€of€the€Tennessee€Rules€of€Civil€Procedure€andÏeffectively€brings€before€this€court€only€the€informed€consent€issue.€ÌÌà àThe€action€of€the€trial€court€in€directing€a€verdict€in€favor€of€theÏdefendants€on€the€issue€of€informed€consent€is€reversed€and€the€case€isÏremanded€for€a€new€trial€along€with€the€negligence€issue€still€pending€in€theÏtrial€court.ÌÌà àCosts€of€this€appeal€are€assessed€to€the€appellees.ÌÓӜ̛à àà àà àÔ€$XÔ_____________________________________ÌœCONCUR:›à àà àWILLIAM€B.€CAIN,€JUDGEÌœ›Ì__________________________________ÌHENRY€F.€TODD,€PRESIDING€JUDGEÌœÌ__________________________________›ÌBEN€H.€CANTRELL,€œJUDGE›