Beard v. Everett Clinic: “Exercise of Judgment” Instruction Requires Evidence of Standard-of-Care-Compliant Decision-Making Process (Not Merely the Outcome)

Court: Supreme Court of Washington (En Banc)
Date: March 12, 2026
Case: Beard v. Everett Clinic, PLLC, No. 103635-3

1. Introduction

Beard v. Everett Clinic, PLLC is a Washington medical malpractice jury-instruction decision addressing when a trial court may give the Washington Pattern Jury Instruction (WPI) 105.08 “Exercise of Judgment” instruction. The dispute arose after Supak Beard, a long-term lupus patient, died following a delayed recognition of gastrointestinal tuberculosis that ultimately led to intestinal perforation.

Steven Beard (individually and as personal representative of the estate) sued Dr. Shaila H. Gala (a rheumatologist) and her clinic entities, alleging breaches of the standard of care—primarily failure to urgently refer to infectious disease, failure to order follow-up chest imaging, and failure to communicate suspected infection concerns to gastroenterology.

A jury returned a defense verdict after receiving the “exercise of judgment” instruction. The Court of Appeals affirmed (Beard v. Everett Clinic, PLLC, 32 Wn. App. 2d 833, 558 P.3d 478 (2024)). The Supreme Court granted limited review on a narrow question: what evidence is required to justify giving the exercise of judgment instruction.

Core holding (new clarification): To justify using the “exercise of judgment” instruction, the record must contain evidence that the provider’s process in selecting a course of treatment/diagnosis and the choice itself could be found to comply with the applicable standard of care; “process” may be shown through objective indicia (actions, charting, experience, observations), and need not depend on an after-the-fact narrative of internal reasoning, though notes/testimony about thought process can qualify.

2. Summary of the Opinion

The Supreme Court affirmed. It held that the trial court did not abuse its discretion in giving the instruction because the record contained sufficient evidence of Dr. Gala’s clinical decision-making process and sufficient evidence—through conflicting expert testimony and other record evidence—to allow the jury to find that her process and choices fell within the standard of care.

The court corrected an overreading of the instruction endorsed by the Court of Appeals: the phrase “in arriving at a judgment” concerns the steps and decision-making process, not merely the final selection among options. However, the Supreme Court also made the evidentiary threshold practical: “process evidence” may be established through objective record evidence and does not require a complete reconstruction of the clinician’s internal reasoning for every “little decision.”

3. Analysis

3.1 Precedents Cited

The opinion situates WPI 105.08 within a long lineage of Washington cases that have repeatedly refined “error in judgment” language into a more neutral “exercise of judgment” concept, and restricted its use to appropriate evidentiary circumstances.

  • Williams v. Wurdemann (1912) and related early cases— Nath v. Or. R.R. & Navigation Co. (1913) and Brydges v. Cunningham (1912)—reflect the early formulation that physicians were not liable for an “honest mistake or an error in judgment” when acting in accord with recognized practice.
    Influence here: historical backdrop; the modern instruction is a moderated descendant of a once physician-protective framing.
  • Dinner v. Thorp (1959) disapproved an “error in judgment” instruction to the extent it suggested “good faith” alone was enough. The court emphasized that judgment must be exercised with the skill and learning comparable to similarly situated physicians.
    Influence here: anchors the modern requirement that “judgment” never substitutes for compliance with the standard of care.
  • Miller v. Kennedy (1978) upheld a revised instruction focusing on reasonable care and skill “within the standard of care” when “arriving at that judgment,” recognizing that judgment is inherent in medicine.
    Influence here: principal modern approval of the instruction’s core concept.
  • Watson v. Hockett (1986) reaffirmed Miller, cautioned that the instruction should be given “with caution,” and directed that the word “honest” should no longer be used. It also framed the instruction’s limited use: only when evidence shows the doctor faced a choice among techniques/diagnoses and exercised reasonable care and skill within the standard of care.
    Influence here: supplies the “sparingly/with caution” theme echoed by concurrences in Beard.
  • Christensen v. Munsen (1994) reaffirmed the modified instruction and its limitations.
    Influence here: continuity of doctrinal constraints; supports the instruction’s continued legitimacy.
  • Fergen v. Sestero (2015) is the controlling framework. It articulated two requirements: (1) evidence of a choice among alternative courses of treatment/diagnoses and (2) evidence the clinician exercised reasonable care and skill within the standard of care in formulating the judgment. Critically, it held that the bar is low: evidence of “consciously ruling out” other diagnoses is not required; sufficient evidence of “use of clinical judgment” can justify the instruction.
    Influence here: Beard applies Fergen and clarifies what qualifies as evidence of the “process” in arriving at judgment.
  • Paetsch v. Spokane Dermatology Clinic, PS (2015) is cited to confirm the court’s continued acceptance of the instruction even in misdiagnosis contexts.
  • Standard-of-care evidentiary framing: Harris v. Robert C. Groth, MD, Inc. (1983) (standard is “reasonably prudent,” custom is evidence but not conclusive), Richards v. Overlake Hosp. Med. Ctr. (1990) (expert testimony generally required because standard of care is not within lay knowledge).
    Influence here: supports the opinion’s statement that expert testimony is necessary but not “conclusive.”
  • Instruction-crafting caution: Laudermilk v. Carpenter (1969) appears in the Chief Justice’s concurrence to reiterate the risk of “slanted” or “formula” instructions that emphasize one party’s theory.

3.2 Legal Reasoning

A. The governing legal standard: instruction must be supported by evidence and read with the whole charge

The court reiterated the familiar framework: a jury instruction is proper when supported by evidence, permits argument of the parties’ theories, and correctly states the law—reviewed in context of all instructions (citing Fergen v. Sestero). The trial court’s decision is reviewed for abuse of discretion.

B. The statutory standard of care remains the anchor

The “standard of care” comes from RCW 7.70.040: the degree of care, skill, and learning expected of a reasonably prudent provider in Washington acting in the same or similar circumstances. The “exercise of judgment” instruction does not change that burden; it operates only as an additional lens for cases involving clinical choices.

C. Clarifying “in arriving at a judgment”: it means the process, not merely the final selection

The Supreme Court rejected the Court of Appeals’ suggestion that “proof that Dr. Gala’s reasoning was consistent with the standard of care was not necessary.” The majority held that “in arriving at a judgment” refers to the clinician’s decision-making process—the steps taken to reach the choice.

But the court also made the evidentiary requirement workable: “process evidence” focuses on objective indicators and does not require a defendant to supply a comprehensive after-the-fact internal narrative. The court identified admissible “process evidence” categories:

  • the provider’s actions during the relevant time,
  • the provider’s experience (including with the patient/condition),
  • the patient’s medical record (including charted observations, assessments, impressions—not merely lab values), and
  • notes or testimony reflecting thought process (helpful but not indispensable in every case).

D. The “low bar” from Fergen extends to the second prong

Applying Fergen, the court treated both prongs as threshold showings. The first prong (existence of clinical judgment/choice) was not disputed. For the second prong, the court held the record need only contain evidence from which a jury could find the process and choice within the standard of care. The judge is not to decide whose expert is correct; the judge decides whether the evidence could support the finding.

E. Conflicting experts do not defeat the instruction; they create a jury question

The plaintiff argued that discrepancies between Dr. Gala’s explanations and defense expert testimony undermined the second prong. The court rejected that approach. Conflicts among experts are expected; they do not “militate against issuing the challenged instruction.” Instead, they underscore why the question is for the jury.

Importantly, the court described expert testimony as “necessary, though inconclusive,” aligning with WPI 105.01’s admonition that professional practice is evidence of prudence but not conclusive. The court thus balanced two ideas: (1) expert testimony is generally required to inform the medical standard of care (consistent with Richards v. Overlake Hosp. Med. Ctr.), and (2) the jury remains the ultimate arbiter of breach, using expert testimony as a framework rather than a binding rulebook.

F. Application to Dr. Gala’s March 1–2 care

The court pointed to chart evidence and testimony showing Dr. Gala’s clinical process: monitoring fever, evaluating flare versus infection, ordering tests (blood and urine cultures), addressing abnormal liver enzymes, adjusting prednisone, arranging gastroenterology referral, and tracking results. Defense expert testimony (Dr. Volkmann) supported that these steps and choices could be within the standard of care. That sufficed to justify the instruction.

3.3 Impact

A. Trial courts: clearer evidentiary checklist for deciding whether WPI 105.08 is “supported by the evidence”

Beard adds practical guidance missing from prior cases: the “process” prong is satisfied by objective, contemporaneous clinical evidence, not merely by post hoc testimony of subjective reasoning. This matters in cases where a defendant clinician cannot testify or cannot recall details years later.

B. Litigants: the instruction fight shifts from “internal reasoning” to “objective indicia of process”

Plaintiffs opposing WPI 105.08 will likely focus on the absence of meaningful process evidence in records (e.g., lack of assessment, differential, rationale for ordering/not ordering tests) rather than insisting on a clinician’s narrated thought process. Defendants will likely emphasize: documented assessments, sequential responses to symptoms, ordered workups, monitoring plans, and experience.

C. The instruction remains discretionary and controversial

The Chief Justice’s concurrence reiterates skepticism (rooted in the Fergen v. Sestero dissent) that the instruction is “slanted” and risks jury confusion, and stresses it is never mandatory. Justice Mungia’s concurrence urges the instruction be given “sparingly” and would require evidence of thought process plus expert support for that thought process. The majority does not adopt that stricter evidentiary prerequisite, but the separate writings signal continuing institutional unease and encourage cautious trial-level use.

4. Complex Concepts Simplified

4.1 “Exercise of judgment” instruction (WPI 105.08)

This instruction tells jurors that a physician is not liable merely because another reasonable option existed, so long as the physician used reasonable care and skill within the standard of care in choosing the course taken. It does not create immunity for mistakes; it is meant to reflect that medicine often involves uncertain choices.

4.2 “In arriving at a judgment”

In Beard, this phrase is clarified to mean the clinician’s decision-making process (what the clinician did with the available information), not solely the final decision. The process can be proved by objective evidence like chart notes, orders, assessments, and the sequence of care.

4.3 “Standard of care” under RCW 7.70.040

Washington uses a “reasonably prudent provider in similar circumstances” standard. Experts usually explain what that looks like in the specific medical context, but the jury decides whether the defendant met it.

4.4 “Expert testimony is necessary, though inconclusive”

“Necessary” means jurors generally need expert help to understand prudent medical practice. “Inconclusive” means experts do not decide the case; the jury weighs competing experts and other evidence to reach its own finding on breach.

4.5 “Substantial evidence” and “abuse of discretion” in instruction review

The trial judge is not deciding who should win. The judge decides whether there is enough evidence that a reasonable juror could find the factual prerequisites for the instruction. Appellate courts then defer unless the decision was unreasonable or based on untenable grounds.

5. Conclusion

Beard v. Everett Clinic, PLLC clarifies Washington’s Fergen v. Sestero framework for WPI 105.08 by tightening the meaning of “in arriving at a judgment”: it requires evidence of the clinician’s decision-making process—but that process may be shown through objective, contemporaneous record evidence, experience, and documented assessments, not solely a narrated internal thought process. Expert testimony remains essential to inform the standard of care, but it does not conclusively set its boundaries; the jury decides breach amid competing accounts. The result is a more administrable evidentiary standard that preserves trial-court discretion while underscoring caution about overuse of a potentially defense-leaning instruction.