opinion of the Court:
1 In this case we are asked to determine whether a physician owes nonpatients a duty to exercise reasonable care in the affirmative act of prescribing medications that pose a risk of injury to third parties We uphold such a duty, while clarifying the nature of the legal analysis relevant to duty in tort, the factors relevant to its evaluation, and its relation to matters of breach and proximate cause.
I
12 According to the allegations of the complaint, which we accept as true for purposes of our analysis, David Ragsdale received medical treatment in 2007 from Trina West, a nurse practitioner at Pioneer Comprehensive Medical Clinic in Draper, Utah.
T3 The Ragsdales' young children, who were left parentless, filed suit through their conservator against Nurse West, her consulting physician Dr. Hugo Rodier, and the medical clinic. Plaintiffs alleged negligence in the prescription of the medications that caused Mr. Ragsdale's violent outburst and his wife's death.
T4 Defendants filed a motion to dismiss under rule 12(b)(6) of the Utah Rules of Civil Procedure. The district court granted the motion, concluding that West owed no duty of care to plaintiffs because "no patient-health care provider relationship existed, at the time of the underlying events, between the plaintiffs ... and the defendants." The court further reasoned that "the non-patient plaintiffs may [not] step into David Rags-dale's shoes to pursue a malpractice lawsuit against the defendants." Plaintiffs filed this appeal, contending that the district court incorrectly concluded that defendants did not owe a duty of care to the nonpatient plaintiffs. We agree and reverse.
II
15 As every first-year law student learns, duty is one of four essential elements of a cause of action in tort.
A
' 6 A central point of the parties' disagreement in this case is whether a healthcare provider's duty requires the existence of a "special legal relationship." Defendants contend that healthcare providers owe no duty
T7 We side with the plaintiffs. The long recognized distinction between acts and omissions-or misfeasance and nonfeasance-makes a critical difference and is perhaps the most fundamental factor courts consider when evaluating duty.
18 Special relationships "arise when one assumes responsibility for another's safety or deprives another of his or her normal opportunities for self-protection." Webb,
19 We previously clarified the relationship between the nonfeasance and special-relationship factors in Webb,
[The distinction between acts and omissions is central to assessing whether a duty is owed [to] a plaintiff. In almost every instance, an act carries with it a potential duty and resulting legal accountability for that act. By contrast, an omission or failure to act can generally give rise to liability only in the presence of some external cireumstance-a special relationship.
Id. 110 (citations omitted). A special legal relationship between the parties thus acts as a duty-enhancing, "plus" factor. Even in nonfeasance cases, where a bystander typically would owe no duty to prevent harm, a special legal relationship gives rise to such a duty.
110 Webb itself was a suit against a government entity which, for policy reasons, is a rare instance where an affirmative act does not presumptively give rise to a duty. Id. 111. Under Webb, a plaintiff must demonstrate a special relationship with a government actor even if the injury arises from an
1 11 The cases cited by defendants are not to the contrary. They require a special relationship only as to nonfeasance or acts of government defendants. See Rollins v. Petersen,
112 Notably, in Rollins the plaintiff did not allege any affirmative misconduct by the hospital-Jjust that the hospital had failed to prevent the patient from engaging in harmful conduct. Thus, the court analyzed duty under the Restatement (Second) of Torts see-tions 314-20, entitled "Duties of Affirmative Action." Rollins,
113 Higgins is similar. When a mentally ill hospital outpatient stabbed a young girl, her parents alleged that the hospital owed a duty to the plaintiff to "control and/or to treat" the patient to prevent the patient from engaging in violent conduct.
I 15 Thus, Rollins, Higgins, and Wilson all stand for the proposition that a healthcare provider is not required to control its patients' independent conduct. They do not support defendants' view that a healthcare provider may-with immunity from liability to any nonpatient-negligently prescribe medication that affirmatively causes a patient to injure nonpatients.
116 The district court cited Joseph v. McCann,
T 17 The plaintiff in Joseph did not assert that the physician had a duty to exercise care in providing medical treatment. Rather, the officer claimed that the physician owed him a duty to exercise care in evaluating his suitability for his job for the purpose of giving a report to an employer. Id. 19. Thus, Joseph simply indicates that the type of harm the officer suffered-removal from the police foree-did not come within the range of harms that the physician had a duty to avoid. That does not mean that the physician lacked a duty to avoid affirmatively causing physical injury to the officer. If the physician in Joseph had used a scalpel instead of a tongue depressor to facilitate a throat examination, presumably the duty would be as obvious as the ensuing injuries.
118 Plaintiffs' allegations of duty thus steer clear of the problems identified in our nonfeasance cases and in the court of appeals' decision in Joseph. This is not a case in which the healthcare provider is charged with failing to restrain Ragsdale or with failing to warn his family about his unstable condition. Rather, plaintiffs allege that defendants' affirmative acts of preserib-ing medication caused David Ragsdale to have a violent outburst and take his wife's life. And unlike in Joseph, plaintiffs are not purporting to step into the shoes of the party who retained the physician's services. Their claim is not a derivative one for harm to their father, but a personal one for their own injuries.
€ 19 For these reasons, a special relationship or physician-patient relationship need not underlie the defendants' duty to the plaintiffs in this case. And as we explain below, the other duty factors do not justify eliminating defendants' duty to exercise care when engaging in the affirmative act of prescribing medication.
B
T20 Defendants and their amici next ask us to create a rule-primarily on policy grounds-that healthcare providers owe no duty to anyone other than a patient. We find no basis for a rule excluding all healthcare providers from lability for carelessly
T21 As a general rule, we all have a duty to exercise care when engaging in affirmative conduct that creates a risk of physical harm to others.
122 The parties in this case variously invoke each of these factors, seeking to shape them in ways that sustain their opposing positions. But many of their arguments reflect a misunderstanding of the role of duty in tort analysis, sometimes conflating duty with breach and proximate cause. Under a proper understanding of the duty factors, we affirm the existence of a duty on the part of healthcare providers to exercise reasonable care in prescribing medications that pose a risk of injury to third parties.
123 Our most basic concern with the parties' arguments is the failure to address duty at a categorical level. Plaintiffs assert (without citation) that we have "repeatedly held that whether a duty exists must be decided on a case-by-case basis." They further claim that this court has "long emphasized that duty determinations should be fact specific." This is not a proper approach to the duty analysis. Duty must be determined as a matter of law and on a categorical basis for a given class of tort claims.
1
124 Defendants challenge the imposition of a duty here on the basis of a lack of foreseeability of injury. But their arguments conflate the kind of foreseeability relevant to the duty analysis with the foreseeability inquiries significant to matters of breach and proximate cause. Defendants concede, for example, that some negligent prescription cases pose a highly foreseeable danger to nonpatients, such as those involving the prescription of powerful sedatives to a professional truck driver. Yet they still insist that this "case involves highly complex and incompletely understood possible interactions of pharmacology, general human behavior, personality traits, and troubled marital relationships," and thus that there should be no duty here because plaintiffs' injury was not foreseeable to defendants. This is a confusing infusion of the kind of foreseeability relevant to breach or proximate cause into the duty analysis.
$25 This conflation is perhaps understandable. Some variation of the notion of foreseeability is a factor in three of four elements of a tort: duty, breach, and proximate cause.
§26 Thus, defendants' foreseeability argument would be appropriately lodged as a breach or proximate cause argument. Whether-in this specific case-the drug interactions and psychological considerations at stake would lead a reasonable physician to take additional precautions because she could foresee that Mr. Ragsdale might become violent or dangerous is a question of breach. And whether the precise mixture of drugs did foreseeably cause Mr. Ragsdale's outburst is a question of proximate cause, as is whether Mr. Ragsdale's criminal conduct supersedes Nurse West's conduct as the proximate cause of Ms. Ragsdale's death. As we said in Normandeau, these questions about the foreseeability of the specific mechanism of injury fit within proximate cause, not duty. And those issues are not before us on this appeal, which deals only with the question of duty (the basis for the dismissal of plaintiffs' claims).
127 The appropriate foreseeability question for duty analysis is whether a category of cases includes individual cases in which
128 Pharmaceuticals span a scale of foreseeable risk, with innocuous drugs at the unforeseeable end and powerful narcotics at the other. Some negligent prescription cases may very well involve little foreseeable risk of injury: Imagine a patient that has a rare violent reaction to ibuprofen. Yet other cases may involve highly foreseeable risks, as where a physician mistakenly prescribes a high dose of a potent narcotic to an active airline pilot instead of the mild antibiotic the pilot needed. Because the class of cases includes some in which a risk of injury to third parties is reasonably foreseeable (as even defendants concede), the foreseeability factor weighs in favor of imposing a duty on healthcare providers to exercise care in pre-seribing medications so as to refrain from affirmatively causing injury to nonpatients. Whether in a particular case a prescription creates a risk of sufficient foreseeability that the physician should have exercised greater care to guard against injury is a question of breach. And whether the precise causal mechanism of a plaintiff's injuries was a foreseeable result of a defendant's prescriptions is a question of proximate cause. Both of those questions are case-specific and fact-intensive, and they are not before us on this appeal.
2
129 On the next factor, plaintiffs insist that physicians typically have financial resources that put them in a position to "bear the loss occasioned by the injury." Normandeau,
130 Instead, this factor considers whether the defendant is best situated to take reasonable precautions to avoid injury.
131 No such argument can be made here. Physicians-not third parties-are in a position to exercise ordinary care in prescribing medications so that patients do not pose an unreasonable risk of injury to others.
3
132 Finally, defendants offer a series of general policy arguments against the imposition of a duty on physicians to nonpatients. We find these policy concerns insufficient to sustain a categorical decision to withdraw a duty of care across the broad range of negligent prescription cases.
1 33 Defendants first assert that the recognition of a physician's duty to nonpatients will diminish the availability of preseription medications by inciting undue caution in physicians who would otherwise offer prescriptions to their patients. This argument gives undue emphasis to the benefits of prescription drugs as a whole while ignoring their costs.
1 34 As some courts have recognized, prescribed medications have significant social utility. See Burroughs v. Magee, 118 S.W.8d 328, 334-35 (Tenn.2008). But the unquestioned utility of pharmaceuticals is not enough to justify the general disavowal of a duty to use reasonable care in prescribing them. Pharmaceuticals also carry costs, including not just side effects to patients but also risks to third parties. At least in some cireumstances, the benefits of a particularly dangerous drug would clearly be outweighed by its risks. Because there are some pharmaceuticals in some cireumstances whose costs outweigh their benefits, it makes no sense to categorically eliminate a duty of care for physicians who prescribe them. When potential risks might outweigh potential benefits for a given activity, tort duties incentivize professionals-whether physi-clans, mechanics, or plumbers-to consider the potential harmful effects of their actions on both their clients/patients and third parties. And questions about which cireum-stances pose such a high degree of risk that a physician should have taken greater precautions are questions of breach of duty; they are insufficient to defeat the categorical existence of a duty.
1 35 The requirements of breach and proximate cause, moreover, counterbalance any improper incentive to withhold treatment because they pose significant barriers to plaintiffs in negligent prescription cases. A plaintiff must not only demonstrate that the providers conduct fell outside the standard of professional care, but prove that the pre-seription was the proximate cause of a patients harmful conduct. And eausation in these circumstances presents difficult questions of both empirical fact and superseding cause. Ultimately then, defendants' concern regarding decreased availability of healthcare is best dealt with on a case-by-case basis under the elements of breach and proximate cause.
1386 Defendants concerns about the impacts of a duty on malpractice insurance and ° healthcare costs falter on similar grounds. The supposed effects on insurance premiums and patient costs are speculative, as neither defendants nor their amici have presented any evidence showing that insurance costs are lower in states that do not impose this type of duty on healthcare providers. And in any event, the alternative suggested by defendants is to impose these costs on injured parties and permit negligent physicians to remain unaccountable. It seems more rea
T387 Defendants and their amici also contend that nonpatient suits will interfere with confidentiality in physician-patient relationships. In cases brought by nonpatients, defendants amici assert, providers would "nee-essarily be required to disclose" confidential medical information because "[nljonpatient plaintiffs would necessarily be given the right to demand production in discovery" of "confidential patient records." This concern seems overblown. The physician-patient privilege and medical privacy statutes are carefully designed to protect confidentiality and patient privacy, and a party concerned about confidentiality in discovery may seek refuge in a protective order. And even if the existing law on physician-patient confidentiality is imperfectly attuned to the concerns implicated in negligent prescription cases filed by nonpatients, the solution is to fine-tune that law, not to categorically foreclose the imposition of a duty.
1 38 Defendants also argue that a duty to nonpatients would conflict with the physicians duty of loyalty to her patient. Quoting Webb v. Jarvis,
T389 Along these same lines, some courts have reasoned that " 'individual treatment decisions are best left to patients and their physicians'" because "'[djoctors should not be asked to weigh notions of liability in their already complex universe of patient care.!" Burroughs,
III
1 40 Healthcare providers perform a societal function of undoubted social utility. But they are not entitled to an elevated status in tort law that would categorically immunize them from liability when their negligent pre-seriptions cause physical injury to nonpa-tients. We uphold a duty of healthcare providers to nonpatients in the affirmative act of prescribing medication, and reverse the dis-triet court's conclusion to the contrary.
Notes
. Appellees also claim on appeal that Mr. Rags-dale's guilty plea in his criminal case has a collateral estoppel effect that precludes appellants from litigating the causation issue-whether the prescribed medication caused Mr. Rags-dale's violent conduct. The district court refused to reach this issue, yet hypothesized what it would do "if [it] were to reach that alternative motion." We decline to offer an advisory opinion on the district court's hypothetical ruling.
. To assert a successful negligence claim, a plaintiff must establish that (1) defendant owed plaintiff a duty of care, (2) defendant breached that duty, and that (3) the breach was the proximate cause of (4) plaintiff's injuries or damages. Webb v. Univ. of Utah,
. AMS Salt Indus., Inc. v. Magnesium Corp. of Am.,
. See Francis H. Bohlen, The Moral Duty to Aid Others as a Basis of Tort Liability, 56 U. Pa. L. Rev. 217, 219 (1908) (describing the act/omission distinction as "deeply rooted in the common law").
. Id.
. Id.
. See Yazd v. Woodside Homes Corp.,
. Webb,
. See also Restatement (Seconp) or Torts § 302 cmt. a (1965) ("In general, anyone who does an affirmative act is under a duty to others to exercise the care of a reasonable man to protect them against an unreasonable risk of harm to them arising out of the act. The duties of one who merely omits to act are more restricted, and in general are confined to situations where there is a special relation between the actor and the other which gives rise to the duty."); Restatement (THirp) or Torts: Liasiutry ror Prysicat & Emotionat Harm § 7 cmt. a (2010) ("[AJctors engaging in conduct that creates risks to others have a duty to exercise reasonable care to avoid causing physical harm.").
. See also Restatement (SEconp) or Torts § 315 ("'There is no duty so to control the conduct of a third person as to prevent him from causing physical harm to another unless (a) a special relation exists between the actor and the third person which imposes a duty upon the actor to control the third person's conduct, or (b) a special relation exists between the actor and the other which gives to the other a right to protection.").
. Resratement (Timp) or Torts: Liasiurty ror Paysr car & Emotionat Harm § 7(a) ("An actor ordinarily has a duty to exercise reasonable care when the actor's conduct creates a risk of physical harm."); id. 7 emt. a ("[Alctors engaging in conduct that creates risks to others have a duty to exercise reasonable care to avoid causing physical harm."); Restatement (Seconp) or Torts § 302 cmt. a ("In general, anyone who does an affirmative act is under a duty to others to exercise the care of a reasonable man to protect them against an unreasonable risk of harm to them arising out of the act. The duties of one who merely omits to act are more restricted, and in general are confined to situations where there is a special relation between the actor and the other which gives rise to the duty."); see also, e.g., Turpen v. Granieri,
. Restatement (Timp) or Torts: Liasiuity ror Puysical & Emotionat Harm § 7(b) ("In exceptional cases, when an articulated countervailing principle or policy warrants denying or limiting liability in a particular class of cases, a court may decide that the defendant has no duty or that the ordinary duty of reasonable care requires modification."); see also, e.g., Webb,
. See, eg., Normandeau v. Hanson Equip., Inc.,
. Restatement (THirp) or Torts: Liasiiry ror Puysi cat & Emotionat Harm § 7 cmt. a.
. See generally Benjamin C. Zipursky, Foreseeability in Breach, Duty, and Proximate Cause, 44 Ware Forest L. Rev. 1247 (2009).
. Restatement (Trirp) or Torts: Ltasiutty ror Puysr-cat & Emotionat Harm § 7 emt. a ("When liability depends on factors specific to an individual case, the appropriate rubric is [proximate cause]. On the other hand, when liability depends on factors applicable to categories of actors or patterns of conduct, the appropriate rubric is duty.").
. See, eg., Holtz v. J.J.B. Hilliard W.L. Lyons, Inc.,
. See, e.g., Smith v. Frandsen,
. See also, eg., Nail v. Publix Super Mkts., Inc.,
