Lead Opinion
This medical-malpractice case ultimately requires an answer to the following question: Who must bear the legal burden for the death of Gwendolyn Rozier when Rozier, because of her religious convictions, refused to accept a blood transfusion that likely would have saved her life, but Rozier’s doctors, through their assumed breach of the applicable standard of care and acting with knowledge of her religious convictions, placed Rozier in the position to need the blood transfusion? This is a difficult case because of both the complex legal issues this question presents and the tragic loss incurred by Rozier’s family.
The trial court concluded that plaintiff, Eric Braver-man, as personal representative of the Estate of Gwendolyn Rozier, is barred as a matter of law by the doсtrine of avoidable consequences from recovering damages for Rozier’s death. Thus, the court granted summary disposition under MCR 2.116(C)(10) in favor of defendants Darla K. Granger, M.D., Heung K. Oh, M.D., Ivan G. Olarte, M.D., St. John Hospital and Medical Center, and St. John Health (collectively the “St. John defendants”); and defendants Robert Provenzano, M.D., Mohamed A. El-Ghoroury, M.D., and St. Clair Specialty Physicians (collectively the “St. Clair defendants”). Plaintiff now appeals as of right. For reasons discussed further in this opinion, we agree with the trial court that the doctrine of avoidable consequences, when applied in a purely objective manner to comply with the First Amendment’s requirement of government neutrality toward religion, precludes plaintiff from recovering damages for Rozier’s death. Therefore, we affirm.
According to the Jehovah’s Witness faith, no blood, blood product, or any derivative of any kind of blood are allowed for medical treatment. Every Jehovah’s Witness consciously determines what he or she accepts in blood management. Rozier was a Jehovah’s Witness and would not accept whole blood or blood products in medical treatment.
On August 15, 2007, Rozier was suffering from end-stage renal disease and received a kidney transplant at St. John Hospital. Dr. Oh and surgical resident Dr. Olarte performed the surgery. Rozier was discharged on August 18, 2007, but returned to St. John Hospital on August 24, 2007, with complaints of abdominal pain.
The documentary evidence illustrates that on August 25, Rozier’s hematocrit level was 41.6%, and her hemoglobin level was 13.7 grams per deciliter of blood (g/dl).
Rozier was taken to the operating room immediately after the CT-scan finding. The intended procedure, risks, and complications, including bleeding from the transplant wound and possible death because of Rozier’s refusal to accept any blood product, were explained to Rozier’s husband, Gregory. Dr. Oh explained to Gregory that Rozier’s hemoglobin was unacceptably low and that she needed a blood transfusion. Gregory responded, “Well, that’s unacceptable, Dr. Oh, as you well know.” The Roziers had previously discussed with Dr. Oh that they were Jehovah’s Witnesses and had explained that they would not accept whole blood or whole blood products. Further, Rozier had signed a document stating that she refused to permit “blood and/or blood components to be administered[.]” Rozier consented to defendants doing anything they thought was appropriate for her, except for the “blood situation.”
According to Dr. Oh’s operative report, the fascia of the kidney was “found to have a large amount of blood clots, as well as fresh blood.” The kidney was completely decapsulated. And the “lower pole of the kidney showed there was a small pumper from what seemed to be a biopsy site.” The bleeding site was sutured. However, the fate of the transplant kidney was found to be “doomed because [they] were not able to give [Rozier] anymore treаtment for vascular rejection due to her bleeding tendencies, as well as [her] refusal to receive any blood product so it was decided to remove the transplant to give her a chance to survive . . . .” The kidney transplant was removed without incident. Upon inspecting the transplant wound, there were still some clots in Rozier’s retroperitoneum. Although the operation was completed and Rozier was taken to recovery, she died on August 29, 2007, at the age of 55.
On November 30, 2009, plaintiff initiated the instant medical-malpractice suit against defendants. Plaintiff alleged various breaches of the standard of care, including improper prescription of various blood-thinning medications and daily plasmapheresis,
After a hearing to address the motions, the trial court issued an opinion and order, granting defendants’ motions for summary disposition under MCR 2.116(0(10). The court opined that after “thorough research,” it would use an objective standard—as opposed to a case-by-case approach that would inject religion into the case—when applying the doctrine of avoidable consequences. Relying on caselaw from the United States Court of Appeals for the Fifth Circuit, the trial court was persuaded by and adopted the view that an objective approach did not violate the First Amendment. Applying the doctrine of avoidable consequences using the objective approach, the court opined, in pertinent part, as follows:
Rozier had a duty to exercise reasonable care to minimize her damages. .. . [I]t is uncontested that the medical procedure, i.e., a blood transfusion, would have saved her life and stood a high probability of being successful had it been accepted by Ms. Rozier. Although the record indicates genuine issues of material fact regarding whether defendants breached the standard of care by prescribing various blood thinning medications, daily plasmapheresis, and failing to timely recognize signs of internal bleeding, the record further indicates that after defendants’ alleged wrongful conduct Ms. Rozier had the opportunity to mitigate her damages but instead mаde the decision to refuse the blood transfusion.
Under these circumstances, once Ms. Rozier’s religious beliefs are removed from the equation, a reasonable trier of fact could not conclude that the refusal to accept a lifesaving procedure, i.e., a blood transfusion, was a reasonable choice under the objective person approach. The proposed blood transfusion was reasonable, since there were no remaining alternatives, a high probability of a positive outcome, and the transfusion was not a serious operation or medical procedure. Since it is uncontested that Ms. Rozier would have lived if she had accepted a blood transfusion, under an objective standard it was unreasonable to refuse thе life-saving treatment.
The damages which plaintiff seeks to recover did not occur as a result of the personal injuries suffered by Ms. Rozier but as a result of her death, which she could have avoided with reasonable acts. Accordingly, defendants have no legal obligation to pay damages for Ms. Rozier’s death because her death was avoidable and the refusal of the blood transfusion by Ms. Rozier was objectively unreasonable. [Citations omitted.]
Plaintiff moved the trial court for reconsideration, which the court denied.
II. ANALYSIS
Plaintiff argues that the trial court erred by granting summary disposition in favor of defendants under the doctrine of avoidable consequences. We disagree.
We review the trial court’s decision to grant a motion for summary disposition de novo. Maiden v Rozwood,
As an initial matter, plaintiff argues for the first time on appeal that the doctrine of avoidable consequences was extinguished through the abolition of contributory negligence and the adoption of comparative negligence. “Issues raised for the first time on appeal are not ordinarily subject to review.” Booth Newspapers, Inc v Univ of Mich Bd of Regents,
The doctrine of avoidable consequences, which includes the principle of mitigation of damages, is a common-law doctrine. See Pulver v Dundee Cement Co,
In this case, plaintiff invites this Court to deem the doctrine of avoidable consequences implicitly abrogated by the adoption of comparative negligence. However, plaintiff has demonstrated neither that the Legislature has abrogated the doctrine “in no uncertain terms,” nor that our Supreme Court has done so expressly, see, e.g., Placek,
Our Supreme Court has explained the doctrine of avoidable consequences as fоllows:
Where one person has committed a tort, breach of contract, or other legal wrong against another, it is incumbent upon the latter to use such means as are reasonable under the circumstances to avoid or minimize the damages. The person wronged cannot recover for any item of damage which could thus have been avoided. [Shiffer,393 Mich at 197 (citation, quotation marks, and emphasis omitted). See also Morris v Clawson Tank Co,459 Mich 256 , 263-264;587 NW2d 253 (1998)(stating the same); Talley v Courter, 93 Mich 473 , 474;53 NW 621 (1892) (“A party against whom a trespass is committed has no right... by neglecting the obvious and ordinary means of preventing or lessening the damages, to make them more than they otherwise would have been....”).]
Thus, stated differently, the doctrine of avoidable consequences prevents parties from recovering damages that could have been avoided by reasonable effort. Tel-Ex Plaza, Inc v Hardees Restaurants, Inc,
Negligence subsequent to the injury is distinguished from contributory negligence, which is negligence which contributed proximately to cause the injury. If plaintiff fails to use due care to prevent or reduce damages subsequent to the injury complained of, he or she may not recover the enhanced damages. While the amount of damages may be reduced by such action or inaction, the action itself will not be barred. Thus, this doctrine of “avoidable consequences” is distinguished from contributory negligence and, in effect limits the latter dоctrine to events which cause the original injury, even though plaintiffs action or inaction in aggravating the injury may result in damage out of all proportion to the original event. [Emphasis omitted.]
In the instant case, defendants contend that reasonable efforts were not made to avoid plaintiffs damages resulting from Rozier’s death because the blood transfusion recommended to save Rozier’s life was refused. Thus, the dispositive question is whether the blood transfusion was an objectively reasonable means to avoid or minimize damages following Rozier’s original injury given the circumstances of this case. The parties dispute whether Rozier’s religion should be considered when answering this question. Defendants argue that the trial court properly abstained from considering the subjective reason for the refusal of the blood transfusion. Plaintiff argues that the trial court should have considered the fact that Rozier’s religion did not permit her to accept a blood transfusion when it was determining whether a question of fact exists regarding whether Rozier failed to undertake reasonable efforts under the circumstances to avoid the damages plaintiff seeks to recover in this case. This is a complex issue with First Amendment implications.
The First Amendment of the United States Constitution states that “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof. . . .” US Const, Am I. “The protections provided by the First Amendment. .. have been ‘incorporated’ and extended to the states and to their political subdivisions by the Fourteenth Amendment.” Greater Bible Way Temple of Jackson v City of Jackson,
There is no binding authority in Michigan addressing the application of the doctrine of avoidable consequences in the context of a patient’s refusal of lifesaving medical treatment and the interplay of the religion clauses of the First Amendment. However, there are a limited number of cases from other jurisdictions that address the issue. See, generally, Anno: Refusal of Medical Treatment on Religious Grounds, 3 ALR5th 721, 727-745, §§ 2-9.
In Munn v Algee, 924 F2d 568, 574-575 (CA 5, 1991), the United States Court of Appeals for the Fifth Circuit addressed whether an “objective approach,” which does not consider religion as a factor, or a “case-by-case approach,” which permits consideration of a plaintiffs religious beliefs, should be used when determining whether a plaintiff failed to mitigate damages. In Munn, the plaintiff, Ray Munn, and his wife, Elaine Munn were involved in a car accident with the defendant. Id. at 570-571. Elaine was taken to a hospital to receive treatment for a variety of injuries, but her condition deteriorated. Id. at 571. She died after she refused to accept a blood transfusion because she was a Jehovah’s Witness. Id. The defendant asserted that the doctrine of avoidable consequences precluded an award of damages for Elaine’s death. The trial court used the case-by-case apprоach, and a jury concluded that Elaine would not have died had she accepted the blood transfusion and, therefore, awarded no damages on the plaintiffs wrongful-death claim. Id. at 571.
On appeal, the plaintiff argued that the application of the doctrine of avoidable consequences violated the Free Exercise and Establishment Clauses of the First Amendment by burdening his wife’s exercise of the Jehovah’s Witness faith and inviting the jury to consider the reasonableness of her religious beliefs. Id. at 574. The Fifth Circuit held that the application of the case-by-case approach would arguably violate the Establishment Clause but was nevertheless harmless error in the case before it. Id. at 574-575. The court determined that application of the doctrine did not violate the Free Exerсise Clause under either the objective or the case-by-case approach because “generally applicable rules imposing incidental burdens on particular religions do not violate the free exercise clause.” Id. at 574. The court emphasized that “[t]he more compelling problem with the application of the doctrine in this case is that it potentially invited the jury to judge the reasonableness of the Jehovah’s Witnesses’ religion.” Id. The court explained the constitutional problem as follows:
Application of the case-by-case approach allows a jury to consider the religious nature of a plaintiffs refusal to avoid the consequences of a defendant’s negligence. Accordingly, otherwise unreasonable conduct may be deemed reasonable. However, the question of whether a jury decides to label such conduct as reasonable may depend upon its view of the religious tenet that motivated the plaintiffs failure to mitigate damages.
If the jury finds the religion plausible, it will more likely deem the conductreasonable; on the other hand, if the particular faith strikes the jury as strange or bizarre, the jury will probably conclude that the plaintiffs failure to mitigate was unreasonable. Because the plaintiff’s religion is the only basis upon which otherwise unreasonable conduct can be deemed reasonable, the jury undoubtedly assesses the plaintiff’s religion in reaching its conclusion. A strong case can be made that the first amendment forbids such an assessment. [Id. at 575 (citation omitted; emphasis added).]
Notwithstanding the constitutional problem, the court concluded that application of the case-by-case approach was harmless error. Id. The court explained that the plaintiff injected religion into the case; had the court prohibited the plaintiff from doing so (through the application of the objective standard), the jury would have undoubtedly deemed Elaine’s refusal of the blood transfusion unreasonable; therefore, the jury’s assessment of Elaine’s religion did not harm the plaintiffs case. Id. The court encouraged trial courts to apply the objective standard in the future to religiously motivated refusals to mitigate damages because the approach does not violate the Free Exercise or Establishment Clauses of the United States Constitution.
In Williams v Bright,
You have to accept as a given that the dictates of her religion forbid blood transfusions.
And so you have to determine ... whether she ... acted reasonably as a Jehovah’s Witness in refusing surgery which would involve blood transfusions.
Was it reasonable for her, not what you would do or your friends or family, was it reasonable for her given her beliefs, without questioning the validity or the propriety of her beliefs? [Id. at 551 (quotation marks omitted).]
The appellate court held that this jury instruction constituted government endorsement of thе Jehovah’s Witness faith in violation of the First Amendment. Id. at 553-554. The court explained that “[t]he trial court, in accepting
In determining the properjury instruction to be used on remand, the appellate court first noted that “[v]irtually all of the handful of jurisdictions to have considered the question have adopted the test of the reasonably prudent person instead of the formulation employed here.” Id. at 552, citing Munn, 924 F2d 568; Corlett v Caserta, 204 Ill App 3d 403, 413-414; 149 Ill Dec 793;
“In considering whether the plaintiff acted as a reasonably prudent person, you may consider the plaintiffs testimony that she is a believer in the Jehovah’s Witness faith, and that as an adherent of that faith, she cannot accept any medical treatment which requires a blood transfusion. I charge you that such belief is a factor for you to consider, together with all the other evidence you have heard, in determining whether the plaintiff acted reasonably in caring for her injuries, keeping in mind, however, that the overriding test is whether the plaintiff acted as a reasonably prudеnt person, under all the circumstances confronting her.” [Id. at 556-557.]
The appellate court emphasized that the trial court was “not to permit the introduction of any ‘theological’ proof, by way of either expert or lay testimony, as to the validity of religious doctrine, nor should the court issue any instructions whatsoever on that score.” Id. at 557. The court noted that its supplemented instruction “has found some support in other jurisdictions.” Id., citing Lange v Hoyt,
While we respect and appreciate the desire to strike a balance between the competing interests of the parties in a situation such as this, we find Williams to be flawed in that it inescapably entails a jury’s assessment of the reasonableness of one’s religious beliefs. We conclude that the adoption of a purely objective approach—which eliminates from consideration all subjective reasons and, thus, only incidentally burdens religious beliefs—is the only way to avoid running afoul of the
The purely objective approach, employed by the trial court in this case and recommended in Munn, does not suffer the same constitutional shortcoming. Under the objective approach, the proper inquiry is not whether the person’s subjective reasons for refusing the transfusion were reasonable. Rather, the proper inquiry is whether the blood transfusion was an objectively reasonable means to avoid or minimize damages following the person’s original injury given the circumstances of the case, circumstances that may include the gravity of the original injury, the intrusiveness of the proposed medical treatment and the risk of complications, the feasibility of alternative medical treatments, the expense of the proposed medical treatment, and the increased likelihood of recovery if the proposed medical treatment had been accеpted by the patient. See generally Corlett, 204 Ill App 3d at 413-414. If the blood transfusion was an objectively reasonable means of avoiding or minimizing damages, then the refusal to accept the transfusion means the individual unreasonably failed to mitigate his or her damages. This is a neutral approach that does not treat anyone disparately because it eliminates all subjective factors
Applying the objective standard to the instant case, we conclude that there is no genuine issue of material fact that the blood transfusion was a reasonable procedure to minimize damages following Rozier’s original injury under the circumstances of this case. The documentary evidence illustrates that after the biopsy and the initiation of plasmapheresis, there were strong indications that Rozier began
Therefore, because the blood transfusion was refused under these circumstances, reasonable minds could not disagree that reasonable efforts were not made to avoid Rozier’s death and the resulting damages. The trial court did not err by concluding that the doctrine of avoidable consequences precluded plaintiff from recovering damages for Rozier’s death.
Finally, plaintiff argues that the trial court improperly invoked the doctrine of avoidable consequences to bar plaintiff from compensation for damages other than those stemming from Rozier’s death. We conclude that plaintiff has waived this issue.
It is well established that “[a] party who waives a right is precluded from seeking appellate review based on a denial of that right because waiver eliminates any error.” The Cadle Co,
The representations by plaintiffs counsel in the trial court establish that plaintiff voluntarily and intentionally abandoned any right to pursue damages other than those stemming from Rozier’s death, such as for any pain and suffering that Rozier may have experienced because of the аlleged malpractice before she died. On December 14, 2011, the trial court held a hearing to address defendants’ motions for summary disposition. During the hearing, the following exchange occurred between the court and plaintiffs counsel regarding the damages plaintiff was seeking:
The Court: You’re not — you’re not suing for damages short of her dying, though, right? You’re, suing for what happened after that point in time?
[Plaintiff’s Counsel]: Exactly.
Plaintiffs counsel and the court also had the following exchange at the conclusion of
[Plaintiff’s Counsel]: I just want — the only thing I want to let the Court know is that — it’s essentially a motion for summary disposition because there are no economic claims in this case. She wasn’t working and she — she died, you know, on — on the table. So if — if that motion’s granted, that’s dispositive on the entire case, not partially dispositive. I just want the Court to be clear on that.
The Court: All right.
Plaintiff is seeking to reopen a door to recover damages unrelated to the death, a door that he intentionally closed at the trial court level. Plaintiff has waived this issue.
Accordingly, we conclude that the trial court did not err by granting summary disposition in favor of defendants.
Affirmed.
Notes
Plaintiff is not critical of the actual transplant surgery. Further, plaintiff acknowledges that there was a known risk that Rozier’s hody might reject the transplanted kidney because it came from her daughter, and her body could have developed antibodies during pregnancy that would cause her system to recognize the transplanted kidney as a foreign hody.
Plasmapheresis removes blood from the body, separates blood cells from plasma in order to filter out antibodies, and returns the blood cells to the body’s circulation. The patient usually receives replacement plasma, hut in a situation such as Rozier’s, in which the patient refuses to accept blood products, saline solution is used.
A hematocrit test determines the percentage of the volume of a blood sample taken up by cells. The test indicates whether a person has too many or too few red blood cells. The normal range is 34.9% to 44.5% for women. Mayo Clinic, Hematocrit Test <http://www.mayoclinic.org/ tests-procedures/hematocrit/basics/definition/prc-0015009?p=l>[http:// perma.cc/4EDN-HQ3X] (accessed January 8, 2014). Hemoglobin is a protein in red blood cells that carries oxygen; normal results vary, but in general range between 12.1 and 15.1 g/dL for women. MedlinePlus, Hemoglobin http://www.nlm.nih.gov/medlineplus/ency/article/003645.htm [http://perma.cc/A2Q3-BV33] (accessed January 8, 2014).
Plaintiff contends that while initial findings were consistent with Rozier experiencing antibody-mediated vascular rejection, the findings were inconclusive and did not rule out cell mediated rejection or a combination of both. Plaintiff argues that even if the rejection is determined to be antibody-mediated vascular rejection, the first line of treatment is IVIG and Solu-Medrol, a corticosteroid treatment, with plasmapheresis to follow only if such treatment efforts prove unsuccessful.
It is noteworthy that the court also considered the propriety of the trial court’s instruction to the jury that in determining whether the refusal of the blood transfusion was reasonable, the jury could consider Elаine’s “ ‘religious beliefs and related teachings,... if you find that to be a factor in her decision.’ ” Munn, 924 F2d at 578. The court concluded that the instruction, while not purely objective because it permitted the jury to consider Elaine’s religious beliefs, comported with state law that permitted courts to consider personal attributes in determining reasonableness. Id. at 579. However, the court emphasized that the state’s law allowing the jury to consider personal attributes when determining reasonableness “does not in any way undermine our observation that jury consideration of religious beliefs may violate” the Establishment Clause. Id. at 579 n 20.
Such other subjective reasons might include a heightened fear of blood transfusions (unrelated to objective data) due to the risk of contracting bloodborne infections such as Hepatitis or HIV
In his deposition testimony, Dr. Nasimul Ahsan agreed with defense counsel that Rozier “would have survived had she accepted blood products.” In his deposition testimony, Dr. Harold Yang similarly agreed with defense counsel that Rozier’s life “could have been saved” and that she “likely would have survived” had she been transfused with blood.
We reject plaintiffs contention that this issue is not waived because counsel’s statements were ambiguous and counsel did not have an opportunity to fully express himself during the motion hearing due to repeated interruption by the court and opposing counsel. Our review of the transcript from the motion hearing reveals that counsel, although often interrupted, had ample opportunity to express himself on his client’s behalf. Counsel’s statements were not ambiguous. Finally, counsel had ample opportunity to express himself on behalf of plaintiff in the written responses to defendants’ motions for summary disposition. At no point did plaintiff argue that that application of the doctrine of avoidable consequences would only entitle defendants to partial summary disposition.
Concurrence Opinion
(concurring). I fully concur in the majority opinion and in its excellent analysis. I write separately to emphasize that our opinion should not be interpreted as reflective of any viewpoint regarding religion generally or any particular religious belief or expression. To the contrary, it is reflective of the spirit of the First Amendment of the United States Constitution and its guarantee of every person’s right to freely exercise and express the religious beliefs of his or her choice, without governmental interference.
That said, however, it bears noting that every person bears responsibility for the decisions and choices that he or she makes in life. People make decisions and choices in all aspects of their lives, and for untold hosts of reasons. But regardless of the reasons, decisions and choices have consequences. It is the essence of personal responsibility that the makers of decisions and choices, relative to their own lives, bear the consequences that flow from those decisions and choices. Our recognition of that fact is in no respect a criticism or indictment (or endorsement, for that matter) of any person’s decision or choice (or of the reasons for which it was made). It is merely an acknowledgеment of the principle of personal responsibility.
In this sad case, Gwendolyn Rozier and her family made a choice, and decided to forgo a blood transfusion that likely would have saved her life. In her particular case, and while the reasons could have been many, the reason for doing so was based on her religious beliefs. But the reason simply does not matter. The choice was hers to make, whether for reasons of religion, or for altogether different reasons entirely, or in fact for no reason at all. But as in any aspect of life, in which choices result in consequences, Ms. Rozier’s
However unfortunate the nature of that consequence, it does not provide a basis for shifting responsibility for the consequence of Ms. Rozier’s choice to others.
For these additional reasons, I concur in the majority opinion.
In this case, that shifting of responsibility would place Ms. Rozier’s medical professionals in the untenable position of having to choose between bearing legal responsibility for the consequences of Ms. Rozier’s religion-based choices or, alternatively, opting not to treat her. In either event, they likely would face legal action, of different sorts. The First Amendment does not require that medical professionals be placed between such a rock and hard place.