Introduction

BERNARD v. CHAR is a landmark case adjudicated by the Supreme Court of Hawaii on October 6, 1995. This dental malpractice lawsuit centered around the doctrine of informed consent, specifically examining the standards for risk disclosure and causation in medical procedures. The plaintiff, Noah Phillip Bernard, III, alleged negligence against his dentist, John K. Char, D.D.S., claiming that insufficient risk information led to adverse medical outcomes following a tooth extraction.

The key issues in this case revolved around:

• Whether the standard for a physician's disclosure of risks should be assessed from the patient's perspective rather than the physician's.
• Whether, to establish causation, the plaintiff must demonstrate that he would not have undergone the procedure if properly informed of the risks.

Summary of the Judgment

The Supreme Court of Hawaii affirmed the decisions of the Intermediate Court of Appeals (ICA), which had previously upheld the trial court's judgment in favor of Bernard. The ICA had applied a "modified objective standard" for causation in informed consent cases, assessing from the viewpoint of the actual patient acting rationally. However, the Supreme Court overruled this approach, reinstating the traditional objective standard.

The Court concluded that:

• The standard for disclosure should indeed be patient-oriented, focusing on what a reasonable person in the patient's position would require.
• The causation element should be evaluated using an objective standard, determining whether a reasonable person would have consented to the treatment had they been properly informed.

Consequently, the Supreme Court upheld the judgments and orders of the First Circuit Court in favor of Bernard.

Analysis

Precedents Cited

The judgment extensively referenced pivotal cases that have shaped the doctrine of informed consent and causation standards:

• NISHI v. HARTWELL (1970): Established earlier standards for informed consent in Hawaii.
• CRAFT v. PEEBLES (1995): Addressed aspects of informed consent but was distinguished in light of newer precedents.
• LEYSON v. STEUERMANN (1985): Introduced the "modified objective standard" for causation.
• CANTERBURY v. SPENCE (1972): Advocated for an objective standard based on what a reasonable person would decide.
• SCOTT v. BRADFORD (1979): Supported the subjective standard, emphasizing patient self-determination.
• FAIN v. SMITH (1985): Reinforced the objective standard while acknowledging patient-specific factors.

Notably, the Supreme Court in CARR v. STRODE (1995) played a crucial role by adopting the patient-oriented standard, effectively overruling earlier cases like Nishi and distinguishing Craft.

Legal Reasoning

The Court's legal reasoning focused on reinforcing the objective standard for causation while acknowledging the necessity of patient-oriented disclosure. The "modified objective standard" introduced by the ICA was deemed overly complex and not widely adopted, with difficulties in consistent application.

Key points in the Court’s reasoning included:

• Uniformity and Simplicity: The objective standard offers a more uniform and straightforward approach compared to the modified objective standard, which introduces unnecessary complexity.
• Consistency with Negligence Law: Aligning the causation standard with general negligence principles ensures coherence within the legal system.
• Preservation of Patient Autonomy: The objective standard still accommodates individual patient characteristics without relying solely on subjective testimony, thereby respecting patient self-determination.

The Court emphasized that the objective standard allows for consideration of the patient's unique circumstances while maintaining an objective framework, ensuring fairness and practicality in legal proceedings.

Impact

This judgment has significant ramifications for future medical malpractice cases in Hawaii and potentially influences broader legal interpretations of informed consent:

• Standardization of Causation: By reaffirming the objective standard, the Court ensures a consistent approach in evaluating causation, reducing ambiguity and fostering predictability in legal outcomes.
• Guidance for Medical Practitioners: Healthcare providers are now clearly guided to disclose risks based on what a reasonable patient would require, enhancing patient-provider communication and safeguarding against litigation.
• Legal Precedent: This decision serves as a binding precedent in Hawaii, influencing how courts interpret informed consent and causation in similar cases.
• Balancing Objectivity and Individuality: The judgment strikes a balance between objective legal standards and individual patient circumstances, promoting fairness without overcomplicating legal analysis.

Complex Concepts Simplified

Informed Consent

Informed consent is a fundamental principle in medical law requiring healthcare providers to disclose pertinent information about treatments, including risks and benefits, allowing patients to make knowledgeable decisions about their care.

Objective vs. Modified Objective Standard

The objective standard assesses whether a reasonable person in the patient’s position would have consented to the treatment if properly informed. It emphasizes an impartial perspective, focusing on general reasonableness rather than individual circumstances.

The modified objective standard, previously adopted by the ICA, attempted to blend objective analysis with the patient's unique situation by assessing causation from the viewpoint of the actual patient acting rationally. However, this approach was criticized for its complexity and limited adoption.

Causation in Informed Consent

Causation in informed consent cases requires demonstrating that the lack of adequate risk disclosure directly led to the patient’s decision to undergo a treatment, which then caused harm. Establishing this link is crucial for a successful malpractice claim.

Conclusion

The Supreme Court's decision in BERNARD v. CHAR solidifies the application of the objective standard in assessing causation within informed consent cases. By rejecting the modified objective standard, the Court promotes a more streamlined and consistent approach aligned with general negligence principles. This ruling not only clarifies the legal expectations for risk disclosure by healthcare providers but also ensures that patients' rights to make informed decisions are upheld through an objective and equitable framework.

Moving forward, medical practitioners in Hawaii must adhere to the objective standard in their informed consent processes, meticulously disclosing all significant risks in a manner that aligns with what a reasonable patient would need to know. This decision enhances legal clarity, supports patient autonomy, and reduces potential litigation ambiguities in medical malpractice cases.