AppellateDivision,SecondDepartment
CaseNo.2012-10336June17,2015,Decided
亲爱的听众朋友们，新年好！希望美国法律讲堂在2017年能够继续为大家传递有用的普法知识。
今日讲题
本期讲解美国纽约州上诉法院
二零一五年裁判案例
InformedConsent知情同意
I.本期语音讲解(全文)
II.本期内容提要及KeyIssue(焦点)
签了就等于“知情同意”吗？(Whether“signed”=“informedconsent)
第九讲·知情同意（InformedConsent）
概念定义
医护人员通常要求患者签署同意书。同意书上详细列举和说明拟议治疗方法和步骤的风险。但是患者仅仅签署了同意书并不一定证明患者给予了知情同意。医护人员必须真正地与患者讨论拟议治疗方法和步骤的风险，以确定患者必须尽可能地对他或她所面临的风险有所了解和明白。
案件事实陈述
原告患者自2004年9月因为超声波检查时发现骨盆处有肿块而在LAZAR医生处进行治疗。2005年LAZAR医生为原告患者制定了几项治疗方案，其中包括经腹部全子宫切除术。原告患者曾多次告诉LAZAR医生她不想接受手术治疗。2007年原告患者在得知她的骨盆肿块可能是恶性肿瘤后再次去找LAZAR医生就诊。LAZAR医生还是建议原告患者进行手术治疗，有可能包括子宫切除术等。原告患者明确拒绝了LAZAR医生的手术治疗建议。之后，原告患者决定接受腹腔镜手术。
根据LAZAR医生所说，原告患者“同意有可能做子宫切除手术”。在手术之前，原告患者签署了同意书，该同意书显示她同意“接受腹腔镜手术…可能的探索性剖腹术、全子宫切除术、PAP涂片、可能的分期手术…去除病变组织“。根据LAZAR医生所说，子宫切除术的决定是在行腹腔镜手术中做出的，因为肿块太大了，十分异常，以及“像是已显病变”。原告患者在她的证词中证实她签署了同意书，但是宣称她没有机会阅读同意书就被强迫签署了，而且在签署的时候她是处于被麻醉的状态下。
根据原告患者的证词，她当时躺在手术室内，手术即将开始，在不知道是否已经接受麻醉的情况下一个护士跑进来递给她同意书。原告患者声称LAZAR医生当时质问手术室内的其他人，为什么知情同意书没有在之前就让原告患者签署。原告患者宣称自己没有带眼镜，她没有也无法阅读同意书。LAZAR医生也没有与她讨论同意书的内容。相反，据原告患者所诉，LAZAR医生告诉她，她别无选择，需要签这份同意书，因为她可能患有癌症。
LAZAR医生给出的证词与原告患者的相反。她表示同意书是在原告患者进入手术室前签署的，并且所有的内容都已经解释给了原告患者。LAZAR医生之后进行了腹腔镜手术，并在手术操作过程中决定改行开放性手术以及子宫切除术。LAZAR医生的证词还表明，尽管原告患者一直坚持自己不想进行子宫切除术，但她明白也同意，如果在行腹腔镜手术时，发现有癌变的可能，是有可能行子宫切除术的。但是，相反，原告患者在证词中表明，她在整个治疗过程中坚持不做子宫切除术并且LAZAR医生从未告诉过她腹腔镜手术可能转换为开放性手术，包括子宫切除术。
在这些事实爭议中，有一个事实是无可爭议的，那就是原告患者在她手术的那天，的确是亲自签署了同意书的。该同意书表示[原告患者]同意腹腔镜手术和可能的子宫切除术。
司法程序及初审法庭裁决
地方初审法庭依据原告患者签署的同意书，及原告患者承认她的确签署了同意书，为理由，撤销了原告患者对被告LAZAR医生的“人身侵犯”(Assault&Battery)及“缺乏知情同意”(LackofInformedConsent)的两个指控。
原告患者上诉。
上诉法院面临的裁决/法律焦点
地方初审法庭基于原告患者签署了同意书而撤销原告患者对被告LAZAR医生的“人身侵犯”(Assault&Battery)及“缺乏知情同意”(LackofInformedConsent)的指控的裁决是否正确合理？
上诉法院的意见分析及裁判
这里原告患者的庭外传讯的证词显示她没有被充分地告知手术或治疗的风险（包括可能的全子宫切除术或肠穿孔等风险）以及手术或治疗的益处和可替代的方法。地方初审法庭也没有依据法律程序来确定裁判，如果原告患者得到了充分的披露，对手术或治疗的风险充分“知情”，她也许仍然会同意手术。被告也没有针对原告患者的“未完全告知且知情”的证词提出反驳证据。
因此，上诉法院认为地方初审法庭仅仅因为原告患者签署了同意书而撤销原告患者对被告LAZAR医生“缺乏知情同意”(LackofInformedConsent)的指控的裁决是不正确的。地方初审法庭应当要求原被告双方提供事实证据，以此裁判被告是否充分地告知手术或治疗的风险以及原告患者是否在充分知情的情况下签署了同意书并同意手术。借此，上诉法院推反了地方初审法庭撤销对被告LAZAR医生“缺乏知情同意”(LackofInformedConsent)的指控的裁决，要求地方初审法庭针对“缺乏知情同意”(LackofInformedConsent)的指控依据事实证据进行重新审理。
总结
总之，这个法案告诉我们，即使患者签署了同意书，并不一定表明患者“知情”。医护人员应当充分告之所可能的风险，益处，可替代诊治方法等，并且确定备录患者在完全“知情”“自愿”“清醒”“未受任何药物影响”的状态下签署的同意书。
III.本期参考文献Reference
1.ThawvNorthShoreUniv.Hosp.,129A.D.3d937
Englishversion
“InformedConsent”isaprocesswhereboththedoctorandpatientshouldtakeanactiverole,andwherethedoctorhasanobligationandresponsibilitytoprovidethepatientwithessentialinformationaboutaparticulartreatmentorprocedureandgetthepatient'sagreementtoacertainmedicalprocedureortreatmentafterthepatientisfullyinformedandunderstood.Patientshavealegalrighttobeadvisedofkeyrisksassociatedwithaproposedmedicalprocedure,andadoctor'sfailuretoadequatelyinformthepatientcanformthebasisofamedicalmalpracticecase.
Doctorstypicallyrequirepatientstosignaconsentformdetailingtherisksofanygiventreatmentorprocedure.Butsigningaformalonedoesnotnecessarilyprovethatthepatientgaveinformedconsent.Thedoctormustactuallydiscusstheprocedureandriskswiththepatient.Andthepatientmustunderstand,totheextentpossible,therisksheorshefaces.
FactualBackground
TheplaintiffbeganseeingLazarinSeptember2004,inconnectionwithamassdetectedonapelvicultrasound.In2005,LAZARofferedtheplaintiffseveraltreatmentoptions,includingatotalabdominalhysterectomy(hereinafterahysterectomy).TheplaintiffadvisedLazarthatshedidnotwanttoundergosurgery.TheplaintiffreturnedtoLazarin2007,afterreceivingdiagnostic[MRI]testresultsthatraisedaconcernthattheplaintiff'spelvicmassmightbemalignant.Lazarrecommendedthattheplaintiffundergo,amongotherthings,ahysterectomy,andtheplaintiffexpresslyrejectedthatrecommendation.Thereafter,itwasdecidedthattheplaintiffwouldundergoacertainlaparoscopicprocedure.
However,accordingtoLazar,theplaintiff'agreedtothepossibilityofahysterectomy.'Beforetheoperation,theplaintiffsignedaconsentform,whichstatedthatshewasconsentingto'[o]perativelaparoscopy.Possibleexploratorylaparotomy.Totalabdominalhysterectomy.PAPsmear.Possiblestaging...Removalofdiseasedtissue.'AccordingtoLazar,thedecisiontoperformthehysterectomywasmadeduringtheoperation,becausethepelvicmasswasverylarge,wasatypicalinappearance,and'appear[ed]diseased.'Theplaintifftestifiedatherdepositionthatshesignedtheconsentform,butclaimedshehadnoopportunitytoreadit,wasbulliedintodoingso,andwasundertheinfluenceofanesthesiawhenshesignedit.
Accordingtotheplaintiff,shewaslyingintheoperatingroom,theprocedurewasabouttostart,andanesthesiamayormaynothavebeenstartedwhenanurse'camerunningin'withtheconsentform.TheplaintifftestifiedthatLazar'yelled'atotherstaffintheroom,questioningwhytheconsentformhadnotbeensignedearlier.Theplaintiffassertedthatshedidnothaveherglasses,thatshedidnotandcouldnotreadtheform,andthatLazardidnotdiscussitwithher.Rather,accordingtotheplaintiff,Lazartoldhertosigntheformandstatedthatshehadnochoicebecauseshemighthavecancer.
Lazardisputedthisversionofevents,testifyingthattheconsentformwassignedbeforetheplaintiffwastakenintotheoperatingroom,andthatsheexplainedtheformtotheplaintiff.Lazarthereafterbeganthelaparoscopicprocedureanddetermined,intraoperatively,toconvertthelaparoscopicproceduretoanopenprocedureandtoperformahysterectomy.
Lazartestifiedatadepositionthat,althoughtheplaintiffcontinuouslymaintainedthatshedidnotwantahysterectomy,theplaintiffunderstoodandagreedthatthisproceduremightbeperformedif,inthecourseofperformingthelaparoscopicprocedure,amalignancywassuspected.Incontrast,theplaintifftestifiedatherdepositionthatshewasadamantthroughouthercourseoftreatmentwithLazarthatshedidnotwantahysterectomyandthatLazarneverdiscussedwithherthepossibilitythatthelaparoscopicproceduremightbeconvertedtoanopenprocedure,includingahysterectomy.
Itisundisputedthat,onthedayofhersurgery,theplaintiffsignedaconsentform,authorizingthelaparoscopicprocedureandapossiblehysterectomy.
LegalProcedures
Theplaintiffsueddefendant,allegedthatonApril27,2007,Lazarperformedanunauthorizedhysterectomyuponher,constitutingassaultandbattery.Theplaintiffalsoassertscausesofactionbasedon,interalia,lackofinformedconsentandmedicalmalpractice.
Thetrialcourtdismissedtheplaintiff’sassaultandbatteryclaimsbecause,notwithstandingthepatient'sallegationsandtestimonythatshenevergavepermissionfortheperformanceofahysterectomy,hersignedconsent
formclearlyauthorizedsuchaprocedure,andsheadmittedthatshesignedtheconsentform;
Forthesamereasoning,thetrialcourtalsodismissedtheplaintiff’s“lackofinformedconsent”claims.
Plaintiffappealed.
LegalIssuesBeforetheAppellateCourt
Whetherthetrialcourtproperlydismissedboth“assaultandbattery”and“lackofinformedconsent”claimswhentheplaintiffsignedtheconsentform;
Whethertheplaintiff’ssignedconsentprovidesundisputedfactsforherauthorizedand/orinformedconsentforhysterectomy.
AppellateCourtLegalAnalysis
1)Forthe“assaultandbattery”claim,theAppellatecourtneedstodecidewhethertherewerenotriableissuesoffactsona)whetherdefendants’actconstitutes“intentionalphysicalconductplacingtheplaintiffinimminentapprehensionofharmfulcontact”(Assault);orb)“bodilycontactmadewithintent,offensiveinnature”(Battery);
Notwithstandingtheplaintiff'sallegationsandtestimonythatshenevergavepermissionfortheperformanceofahysterectomy,thesignedconsentformclearlyauthorizedsuchaprocedure,andsheadmittedthatshesignedtheconsentform.Therefore,dismissaloftheassaultandbatterycauseofactionwasproper。
2)For“lackofinformedconsentandmedicalmalpractice”claim,theAppellatecourtneedstodecidewhethertherewerenotriableissuesoffactsona)whetherDr.Lazarfailedtodisclosetherisks,benefits,andalternativestotheprocedureortreatmentthatareasonablepractitionerwouldhavedisclosedatthetimetheplaintiffsignedtheconsentform;andb)areasonablepersonintheplaintiff'sposition,fullyinformed,wouldhaveelectednottoundergotheprocedureortreatment.
Here,theplaintiff'sdepositiontestimonyindicatesthatshewasnotfullyadvisedoftherisks,benefits,andalternativestotheprocedureortreatment,includingthefactthatoneoftheriskswasatotalhysterectomyand/orperforationofthebowel,norwasitestablishedasamatteroflawthatiftheplaintiffreceivedfulldisclosure,shestillwouldhaveconsentedtotheprocedure.Sincethedefendants'submissionsincludedtheplaintiff'sdepositiontestimony,theyfailedtoestablish,primafacie,thattherewerenotriableissuesoffactwithrespecttothecauseofactionalleginglackofinformedconsent.
AppellateCourtRuling
Accordingly,theSupremeCourtshouldhavedeniedthatbranchofthedefendants'motionwhichwasforsummaryJudgmentdismissingthecauseofactionalleginglackofinformedconsent.