Appeal by defendant from order entered 4
September 1998 by Judge Wade Barber in Superior Court, Orange County, and from
judgment entered 7 October 1998 and order entered 31 March 1999 by Judge James
C. Spencer, Jr. in Superior Court, Orange County. Heard in the Court of Appeals
17 April 2000.
Smith, James, Rowlett & Cohen, L.L.P., by Seth
R. Cohen, and Gordon & Nesbit, P.L.L.C., by L. G. Gordon, Jr., for
plaintiff-appellee.
Pipkin, Knott, Clark
& Berger, L.L.P., by Bruce W. Berger, and Smith, Helms, Mulliss & Moore,
L.L.P., by James G. Exum, Jr., Matthew W. Sawchak and Hampton Y. Dellinger, for
defendant- appellant.
Kilpatrick Stockton,
L.L.P., by Noah H. Huffstetler, III, for North Carolina Psychiatric Association,
American Psychiatric Association, American Medical Association, North Carolina
Medical Society and North Carolina Psychological Association, amici
curiae.
TIMMONS-GOODSON,
Judge.
This case arises
out of the tragic events of 26 January 1995, when Wendell Williamson
(“plaintiff”) shot and killed two people in downtown Chapel Hill, North
Carolina. Plaintiff brought suit against Myron B. Liptzin (“defendant”), a
psychiatrist at Student Psychological Services of the University of North
Carolina at Chapel Hill (“Student Services”) who treated plaintiff, on the
grounds that he was damaged by the negligence of defendant.
The evidence presented at trial tended to show the
following. Student Services operates only on a voluntary, outpatient basis. In
May 1990, as an undergraduate student, plaintiff visited Student Services as a
“walk-in,” and received counseling for relationship issues and academic
problems. The doctor who reviewed plaintiff's intake form concluded that
plaintiff's problems were “fairly normative.”
In
September 1992, when plaintiff was a twenty-four-year-old law student at the
University of North Carolina at Chapel Hill (“UNC”), he screamed at students on
campus and struck himself about the face. Plaintiff was referred to Student
Services. As a result, Student Services further referred him to the UNC
Hospitals, where he was involuntarily committed. During his stay, plaintiff
disclosed that he had been hearing a voice talking to him for eight months and
that he believed he was telepathic. The hospital staff recorded that plaintiff
possessed a gun in his apartment.
Plaintiff refused
to voluntarily remain at the hospital and also refused medication. A court
petition was filed to have plaintiff involuntarily committed. Following a
commitment hearing, the presiding judge denied the petition and recommended that
plaintiff seek out-patient psychiatric counseling. The final primary diagnosis
was “rule/out schizophrenia.” One of plaintiff's expert psychiatrists explained
at trial that the term “rule/out schizophrenia” means that either: (a) “it's
[schizophrenia] until proven otherwise, but we haven't had enough time to prove
otherwise yet[,]” or (b) “you should keep [schizophrenia] first and foremostin
your mind until a less serious condition is shown to be causing the
problem.”
On 2 March 1994, plaintiff was again
referred to Student Services after he disrupted class at the law school by
announcing that he was a “telepath.” Plaintiff completed an intake form on which
he denied any urge “to hit, injure or harm someone” or any “[s]uicidal thoughts
or concerns.” Intake psychologists assessed that involuntary hospitalization was
“not appropriate as student denies danger to self or others.” Plaintiff was
again diagnosed with “rule/o[ut] schizophrenia.” The staff recommended treatment
and medication, which plaintiff refused. However, after a law school dean
informed plaintiff that he might not be recommended as a candidate for the bar
exam unless he received counseling, plaintiff agreed to seek
treatment.
During a ten-week period beginning on 8
March 1994, plaintiff had six counseling sessions with defendant at Student
Services, each of which lasted between twenty minutes and one hour. Defendant
prepared for the treatment by reviewing plaintiff's chart from Student Services,
which included an intake form from plaintiff's May 1990 visit to Student
Services and a “discharge summary” from his 1992 hospital stay. However,
defendant did not review the complete medical records from plaintiff's 1992
treatment. During the first session with defendant, plaintiff stated that he had
believed he was a “telepath” for two years, he consumed approximately six beers
each night, and he used marijuana occasionally. Defendant suggested that
plaintiff begin taking anantipsychotic drug, Navane, and diagnosed plaintiff
with “delusional disorder grandiose.” While defendant recognized that plaintiff
exhibited some symptoms of schizophrenia, he decided to record the more
“generous” diagnosis, so as not to deprive plaintiff of the opportunity to
practice law.
On 5 April 1994, during the fourth
counseling session, defendant informed plaintiff that defendant would be leaving
Student Services in June, and suggested that plaintiff “consider the possibility
of seeing somebody on a regular basis in therapy, and that [defendant] would be
happy to make a referral for him; that it would probably make sense to do this
sooner rather than later.”
The last counseling
session between plaintiff and defendant occurred on 25 May 1994. Plaintiff
informed defendant that he was not sure whether he would stay in Chapel Hill for
the summer or whether he would stay with his family in Clyde, North Carolina.
Defendant recorded in plaintiff's medical chart that plaintiff knew defendant
would be leaving Student Services and that plaintiff would be seeing his
replacement in the fall semester. Defendant told plaintiff that he needed to
contact defendant's replacement so that he could have his prescriptions filled.
During plaintiff's final counseling session,
defendant supplied plaintiff with a prescription for thirty Navane capsules.
Defendant recorded that plaintiff was “content to stay on[Navane].” As
plaintiff's plans for the summer were uncertain, defendant instructed plaintiff
that if he returned to Clyde, he was to visit the community health center or see
his family doctor. If, on the other hand, plaintiff remained in Chapel Hill, he
was to return to Student Services for counseling with defendant's replacement.
During the course of his treatment, plaintiff
followed virtually all of defendant's instructions concerning the regularity
with which he was to take his medication. Plaintiff testified that he did on one
occasion “voluntarily [go] off his medication,” but reported it to defendant.
Plaintiff reported that he was no longer hearing voices, his “telepathy” and
delusions were completely gone, and his hallucinations were either completely
gone or virtually gone. Although he still used alcohol and recreational drugs,
his usage had decreased. Plaintiff attended all of his classes without incident,
sat for his law school exams, improved his grades, and took part in a law school
writing competition. Friends reported that plaintiff was “more 'like his old
self.'” While he was under defendant's care, plaintiff had no thoughts of
harming or killing himself or anyone else. His first thoughts of harming others
occurred “much later” or “some number of months” after he last saw defendant.
Plaintiff believed that his mental illness was
temporary and that the medication was a short-term measure. According to
plaintiff, defendant told him “that in his opinion, [plaintiff] was probably not
really schizophrenic or psychotic.” Plaintiff furtherstated that defendant told
him that “if someday [he] wanted to go off the medication, that [he] could do
that if [he] told someone [he] trust[ed].”
Plaintiff
spent the summer at his parents' home in Clyde. He did not visit the community
health center or Student Services. Plaintiff decided to stop taking Navane for a
few days, as the drug made him susceptible to the sun and he had become
sunburned. After he discontinued his medication, plaintiff felt physically
better. He determined that he would stop taking his medication indefinitely and
informed his parents of that decision.
Plaintiff
returned to Chapel Hill in August of 1994 for the fall semester. He attended
virtually all of his classes and did not disrupt any of them. He passed all of
his courses, managed his finances, and took care of his day-to-day needs, such
as grooming, eating, and shopping. He took trips alone in his car, including
trips to Connecticut and New York City over Christmas break.
In January 1995, plaintiff returned to Chapel Hill
and began living out of his car. He stopped attending classes and purchased guns
and ammunition. In addition, plaintiff returned to Clyde to retrieve a M-1
rifle, the gun UNC Hospital staff noted he possessed. This weapon had been in
Clyde since plaintiff's hospital stay in 1992. On 26 January 1995, eight months
after his last session with defendant, plaintiff randomly fired the M-1 rifle at
unarmed people in downtown Chapel Hill, killing two of them. In an effort to
stop plaintiff, police officers shot him in the legs. Plaintiff required surgery
for the leg wounds. Plaintiffwas charged with two counts of first-degree murder.
In November of 1995, he was found not guilty by reason of
insanity.
Psychiatrist Stephen Kramer (“Dr. Kramer”)
testified as an expert witness on behalf of plaintiff.
Doctor Kramer stated that defendant violated the
standard of care for a psychiatrist with similar training and experience
practicing in Chapel Hill, North Carolina, or similar communities, in 1994.
Doctor Kramer specified that defendant failed “to pursue a proper diagnosis,
including review of old records available and assessing risk for potential
deterioration and violence[,]” failed “to develop a program for continuing care
[for plaintiff] once [defendant] retired and left the Student Health Center,”
failed to address the issue of noncompliance, and failed to properly manage the
use of antipsychotic medication. Dr. Kramer noted that the discharge summary
from plaintiff's hospital stay indicated that he had no insight into his illness
and that he had a history of noncompliance. Dr. Kramer stated that especially in
this context, if defendant advised plaintiff that he could go off his medication
if he told a responsible adult, such advice would have been improper and an
“invitation to not comply with the recommended therapy.”
According to Dr. Kramer, the correct diagnosis was
chronic paranoid schizophrenia rather than delusional disorder grandiose, and
defendant's failure to review the medical records from plaintiff's inpatient
stay at UNC Hospitals in 1992 contributed to the misdiagnosis. Dr. Kramer
further noted that there was a markeddifference between plaintiff's diagnosis of
delusional disorder and schizophrenia. Dr. Kramer explained that schizophrenia
is a long- term, lifelong illness requiring long-term care, while delusional
disorder was more intermittent in nature.
Dr. Kramer
testified that it was “harder to answer” whether defendant could have reasonably
foreseen that plaintiff would become violent to himself or others. Dr. Kramer
further
testified:
First
was, what's foreseeable is noncompliance with treatment, which would directly
lead to exacerbation or increase in the psychotic symptoms, especially that of
his thought processes. His insight and judgment would remain poor or get worse.
He would continue abusing substances . . . . That access to a gun might not be
cut off for him but might be reunited with him, and that dangerous behavior
might occur.
Those
elements regarding dangerousness may come together at a point in
time.
When asked whether he was “prepared to say . . . a part of
foreseeability would be dangerousness . . . to himself or others[,]” Dr. Kramer
answered, “I'm not sure that I can go that far with it. I can say that the
foreseeable elements are those that when they come together in time would lead
to dangerousness.” Had plaintiff received a proper diagnosis and treatment, his
delusions and acting out could have been kept under control, according to Dr.
Kramer.
James Bellard (“Dr.
Bellard”), a psychiatrist, also testified as an expert witness on behalf of
plaintiff. Dr. Bellard agreed that defendant violated the applicable standard of
care by misdiagnosing plaintiff and failing to ensure that plaintiff received
ongoing care, especially given plaintiff's history ofnoncompliance. Dr. Bellard
stated that it was foreseeable that plaintiff would again believe he was a
“telepath”. When asked where that would lead, Dr. Bellard answered, “If I may,
that's not what's foreseeable. What's foreseeable is that he would believe [he
was a “telepath”] again. But what he would do with that, I don't think --
nobody's crystal ball is that good, that they could predict that.” Dr. Bellard
further stated that if defendant had given plaintiff the name of a specific
doctor to visit during the summer of 1994, Dr. Bellard still could not predict
what would have happened. Dr. Bellard stated that “it was foreseeable that
[plaintiff] would deteriorate and eventually decompensate, that he would really
fall apart mentally, eventually.” Once he began to deteriorate, plaintiff would
certainly become dangerous to himself, according to Dr. Bellard. Both Drs.
Kramer and Bellard acknowledged that plaintiff improved under defendant's care
and stated that plaintiff made no expressions of violence and was not
committable at any point during his treatment.
Psychologist John Warren, III (“Dr. Warren”)
testified on behalf of plaintiff as an expert witness in psychology and the
treatment of paranoid schizophrenia. Dr. Warren stated that plaintiff was not
competent to take charge of his medical treatment at the time his therapy with
defendant ended. Dr. Warren testified that
there's nothing in the
record that suggests that [plaintiff] got that information that he needed in
order to make decisions about whether or not he had a major mental illness,
whether or not he needed to take medication on a long-term basis, what he needed
to do incase the symptoms got worse.
Plaintiff reported to Dr. Warren on
the day following the shootings that defendant had advised him that he could
discontinue his medication if he told someone he
trusted.
Concerning schizophrenia, Dr. Warren echoed
the testimony of Dr. Kramer stating that it was a very serious, major mental
disorder, requiring lifelong treatment. Dr. Warren also testified that “[a]s a
group, people with schizophrenia, paranoid type, are among the most likely to
hurt themselves or hurt other people.” Dr. Warren believed that because
plaintiff did not understand the seriousness of his illness, he could not make
competent decisions concerning treatment.
When asked
whether it was foreseeable that defendant “might” degenerate and become
dangerous to himself or others, Dr. Warren responded by stating that plaintiff
would become sicker, which “might” result in violence to himself or others. Both
Drs. Kramer and Warren testified that plaintiff exhibited risk factors for
dangerous behavior such as being a young male, living alone, and having access
to a gun.
Holly Rogers (“Dr. Rogers”), a
psychiatrist at Duke University's Student Counseling Center, testified as an
expert on behalf of defendant. Dr. Rogers indicated that student mental health
centers provide “short-term treatment.” Dr. Rogers stated that “[m]ost psychotic
people aren't dangerous.” Similarly, Jeffrey Janofsky (“Dr. Janofsky”), a
psychiatrist at Johns Hopkins University stated that “because the base rate of
violence is solow, and most schizophrenics aren't violent and most normal people
aren't violent either, that demographic data does not get you anywhere in
predicting dangerousness.”
Bruce Berger (“Dr.
Berger”), a psychiatrist who previously worked as a student health counselor at
East Carolina University, testified on behalf of defendant. He stated that in
the student health setting, psychiatrists are only able to work with students
for a short time “before [the students] have to make plans with or without [the
psychiatrists'] assistance to get further treatment, or at least make choices in
their life.”
Plaintiff filed suit against defendant
on 16 May 1997, alleging that defendant had been negligent and that the
negligence caused him to be shot in the legs, endure a murder trial, and be
confined indefinitely to a mental institution. Defendant moved for summary
judgment. On 4 September 1998, the trial court entered an order denying
defendant's motion, concluding that “a genuine issue of material facts exist[ed]
to show that [defendant] breached the applicable standard of care and that
[defendant's] treatment proximately caused injury to [plaintiff].” The court
further found that defendant failed to prove that there was no triable issue
concerning contributory negligence.
The case was
tried in the Superior Court, Orange County, before a jury. Defendant moved for
directed verdict at the close of plaintiff's evidence and at the close of all
the evidence. The trial court denied the motions and submitted the case to the
jury, which determined that plaintiff was damaged by the negligence ofdefendant
and that plaintiff was not contributorily negligent. Based on the jury verdict,
the trial court entered judgment ordering defendant to pay $500,000 with
interest and the court costs of the action to plaintiff. Defendant moved for a
new trial or judgment notwithstanding the verdict. On 31 March 1999, the trial
court entered an order denying the motions. Defendant appeals.
Defendant argues that the trial court
erred in denying his dispositive motions. Defendant first contends that the
trial court erred in denying his motions for directed verdict and for judgment
notwithstanding the verdict (“JNOV”).
See N.C. Gen. Stat. § 1A-1, Rule 50
(1999). A motion for JNOV is a renewal of a motion for directed verdict made
after the jury has returned its verdict. As such, a JNOV “shall be granted if it
appears that the motion for directed verdict could properly have been granted.”
N.C.G.S. § 1A-1, Rule 50(b)(1).
In deciding whether
to grant or deny either motion, the trial court must accept the non-movant's
evidence as true and view all the evidence “in the light most favorable to
[him], giving [him] the benefit of every reasonable inference which may be
legitimately drawn therefrom, with conflicts, contradictions, and
inconsistencies being resolved in the [non-movant's] favor.”
Bryant v.
Thalhimer Brothers, Inc., 113 N.C. App. 1, 6, 437 S.E.2d 519, 522 (1993)
(citation omitted),
dismissal allowed and disc. review denied, 336 N.C.
71, 445 S.E.2d 29 (1994). “If there ismore than a scintilla of evidence
supporting each element of the non-movant's claim, the motion should be denied.”
Poor v. Hill, ___ N.C. App. ___, ___, 530 S.E.2d 838, 843 (2000)
(citation omitted). An appellate court's review of a denial of these motions is
limited to a consideration of “whether the evidence viewed in the light most
favorable to [the non-movant] is sufficient to support the jury verdict.”
Suggs v. Norris, 88 N.C. App. 539, 543, 364 S.E.2d 159, 162 (1988)
(citation omitted).
To prevail on a claim of
negligence, the plaintiff must establish that the defendant owed him a duty of
reasonable care, “that [the defendant] was negligent in his care of [the
plaintiff,] and that such negligence was the proximate cause of [the
plaintiff's] injuries and damage.”
Beaver v. Hancock, 72 N.C. App. 306,
311, 324 S.E.2d 294, 298 (1985) (citation omitted). While we recognize that this
case presents a variety of novel issues concerning virtually every facet of
negligence, we have chosen to focus our discussion on the element of proximate
cause. Defendant's main contention on appeal is, in fact, that his alleged
negligence was not the proximate cause of plaintiff's injuries, and therefore he
was entitled to a directed verdict and JNOV. With this, we must
agree.
North Carolina appellate courts define
proximate cause as
a cause
which in natural and continuous sequence, unbroken by any new and independent
cause, produced the plaintiff's injuries, and without which the injuries would
not have occurred, and one from which a person of ordinary prudence could have
reasonably foreseen that such a result, or consequences of a generally injurious
nature, was probableunder all the facts as they
existed.
Hairston v. Alexander Tank &
Equipment Co., 310 N.C. 227, 233, 311 S.E.2d 559, 565 (1984) (citations
omitted). The element of foreseeability is a requisite of proximate cause.
Id. To prove that an action is foreseeable, a plaintiff is required to
prove that “in 'the exercise of reasonable care, the defendant might have
foreseen that some injury would result from his act or omission, or that
consequences of a generally injurious nature might have been expected.'”
Hart
v. Curry, 238 N.C. 448, 449, 78 S.E.2d 170, 170 (1953) (citation omitted).
Thus, the plaintiff does not have to prove that the defendant foresaw the injury
in its precise form.
Hairston, 310 N.C. at 233-34, 331 S.E.2d at 565;
see also Palsgraf v. Long Island R. Co., 162 N.E. 99, 103 (1928)
(Andrews, J., dissenting) (“It does not matter that [the actual injuries] are
unusual, unexpected, unforeseen, and unforeseeable.”) However, the law does not
require that the defendant “foresee events which are
merely possible but
only those which are reasonably foreseeable.”
Hairston, 310 N.C. at 234,
331 S.E.2d at 565 (emphasis added) (citations omitted).
A man's responsibility for
his negligence must end somewhere. If the connection between negligence and the
injury appears unnatural, unreasonable and improbable in the light of common
experience, the negligence, if deemed a cause of the injury at all, is to be
considered remote rather than a proximate cause. It imposes too heavy a
responsibility for negligence to hold the [tort-feasor] responsible for what is
unusual and unlikely to happen or for what was only remotely and slightly
possible.
Phelps v. Winston-Salem, 272 N.C. 24, 30, 157 S.E.2d
719, 723(1967) (citation omitted);
accord Sutton v. Duke, 277 N.C.
94, 108, 176 S.E.2d 161, 169 (1970) (quoting William L. Prosser,
Law of Torts
§ 50, at 303 (3d ed. 1964)) (“it is 'inconceivable that any defendant should
be held liable to infinity for all the consequences which flow from his act,'
[thus] some boundary must be set”).
Foreseeability is
but one element of proximate cause.
Wyatt v. Gilmore, 57 N.C. App. 57,
290 S.E.2d 790 (1982). Other “equally important considerations”
include:
whether the cause
is, in the usual judgment of mankind, likely to produce the result; whether the
relationship between cause and effect is too attenuated; whether there is a
direct connection without intervening causes; whether the cause was a
substantial factor in bringing about the result; and whether there was a natural
and continuous sequence between the cause and the result.
Id. at
59, 290 S.E.2d at 791 (citation omitted).
Plaintiff
alleged that he was injured as a result of defendant's actions, in that he was
wounded during the 26 January 1995 shoot-out, tried for capital murder, and
confined to a mental institution. An examination of the evidence, construed in
the light most favorable to the plaintiff, reveals that defendant could not
foresee plaintiff's injuries. There was absolutely no evidence that plaintiff
posed a threat of violence to others which would in turn lead to injury. When
asked whether dangerousness to others or to plaintiff himself was foreseeable,
plaintiff's own expert, Dr. Kramer stated, “I'm not sure that I can go that far
with it.” Another one of plaintiff's experts, Dr. Bellard, likewise
testifiedthat it was not foreseeable that plaintiff would kill others. In fact,
in the most telling testimony at trial, Dr. Bellard further responded,
“[N]obody's crystal ball is that good[.]”
Plaintiff's
own behavior prior to or at the time of defendant's retirement in no way
indicated that he would become violent. Other than striking himself about the
face, plaintiff never exhibited violent behavior. On his 2 March 1994 intake
form, plaintiff noted that he had no urge to harm others and that he had no
suicidal thoughts.
Plaintiff even noticed an
improvement in his condition. Plaintiff informed defendant that he no longer
heard voices and his hallucinations were virtually gone. Plaintiff further noted
that he had decreased his use of alcohol and recreational drugs, had attended
his law school classes without incident, and had improved his grades.
Furthermore, although plaintiff testified that he contemplated suicide in 1992,
he admitted that he never seriously thought of harming himself between the 1992
hospitalization and 1994, including the period in which he saw defendant.
Plaintiff further affirmed that thoughts of harming others only occurred “some
number of months” after his last visit with defendant. In his notes from the
last visit with plaintiff, defendant wrote that plaintiff stated “his friends
have been giving him feedback that he's more 'like his old self, and the guy
they used to know and like.'”
In addition to being
unforeseeable, plaintiff's injuries were too remote in time, and the chain of
events which lead toplaintiff's injuries was too attenuated for defendant's
actions to be the proximate cause of plaintiff's injuries. It was eight months
between plaintiff's last visit with defendant and the incident which led to his
injuries. Plaintiff was, by all accounts, functioning normally when he last
visited defendant in May 1994. Plaintiff spent the summer with his parents in
Clyde, at which time he discontinued his medication and failed to visit a mental
health center or to have his prescriptions refilled. In August 1994, plaintiff
returned to law school and began his fall classes. Plaintiff testified that his
hallucinations began to resurface gradually and achieved fruition sometime in
August or September. However, plaintiff attended virtually all of his classes
during the fall semester, without disruption, and passed every course. He
maintained his daily needs, including eating, grooming, shopping, and managing
his financial affairs. Furthermore, after completing the semester, plaintiff
took two long trips alone, after which time he returned to his parents' home in
Clyde.
In January 1995, plaintiff returned to Chapel
Hill. Only at this time did plaintiff begin living out of his car, stop
attending classes, and purchase guns and ammunition. Eight months after his last
visit with defendant, plaintiff shot and killed two individuals in Chapel Hill,
despite never expressing any intent to do so. Defendant simply could not have
foreseen that as a result of this attenuated chain of events, eight months after
his last appointment, plaintiff, who expressed no violent intentions orthreats,
would be wounded during a shoot-out, tried for capital murder, committed to a
mental institution, and not able to continue his legal studies or pursue a
possible career.
Despite this attenuated chain of
events, plaintiff contends that the testimony of his experts was tantamount to
the issue of foreseeability and was more than sufficient to establish that
“some” injury was foreseeable. With this argument, we cannot
agree.
In his testimony, Dr. Kramer expressed
difficulty in concluding that plaintiff's dangerousness to others was
foreseeable. Dr. Kramer then testified as
follows:
[W]hat's foreseeable
is noncompliance with treatment, which would directly lead to exacerbation or
increase in the psychotic symptoms, especially that of his thought processes.
His insight and judgment would remain poor or get worse. He would continue
abusing substances . . . . That access to a gun
might not be cut off for
him but
might be reunited with him, and that dangerous behavior
might
occur.
Those
elements regarding dangerousness
may come together at a point in time.
(Emphasis added.)
Dr. Kramer later testified that although he could not
go so far as to say that plaintiff's dangerousness was foreseeable, “[he could]
say that the foreseeable elements are those that when they come together in time
would lead to dangerousness.”
Dr. Bellard testified
that it was foreseeable that plaintiff
would again believe he was a
“telepath” and “it was foreseeable that [plaintiff] would deteriorate and
eventually decompensate, that he would really fall apart mentally, eventually.”
Dr. Bellardfurther testified that no one could predict “what [plaintiff] would
do with that.” Dr. Bellard stated that certain “risk factors” such as
plaintiff's “self-injurious behavior, a history of psychosis, a history of being
resistant to treatment, and an ongoing history of substance abuse,” would place
plaintiff at a “[c]onsiderably greater risk” for violence against himself. Dr.
Bellard could not definitively say that being at risk for violence to oneself
was a “risk factor” for violence to others. Both Doctors Kramer and Warren
stated that plaintiff's age, gender, his living alone, and his owning a gun were
“risk factors” for violence.
The experts' testimony
does not establish foreseeability but evinces a situation similar to those in
which our appellate courts hesitate to find an individual liable for a possible
breach of duty. In
Westbrook v. Cobb, 105 N.C. App. 64, 411 S.E.2d 651
(1992), for example, the defendant's vehicle struck a utility pole connected to
a transformer, which serviced the plaintiff's house. As a result, the
plaintiff's house caught on fire. The plaintiff, who was one and one-half miles
from his house, was alerted to the fire and arrived on the scene to assist
firefighters in controlling the blaze. The plaintiff went into his house to
retrieve some items, and in the process, injured his
back. This court found that “the chain of events
resulting in [the plaintiff's] injury [was not] reasonably foreseeable and
within the contemplation of an ordinary prudent individual.”
Id. at 68,
411 S.E.2d at 653. Thus, the court found that proximate cause did not exist.
Id. at 68-69, 411 S.E.2d at 653-54. In
Coltrane v. Hospital, 35 N.C. App. 755, 242 S.E.2d 538 (1978), the
Administratrix of the estate of a deceased patient brought an action against a
hospital for the death of the patient, who fell from a second story ledge. The
patient had been placed in restraints to prevent him from falling out of his
bed. The patient wrestled free from the restraints and was seen standing on the
second story ledge. The patient was later found dead. Our Court concluded that
any negligence which could be imputed to the hospital was not the proximate
cause of the patient's death because “there [was] no evidence that defendant
hospital could have foreseen the fall from the ledge of the second floor.”
Id. at 758, 242 S.E.2d at 540. In so concluding, this Court relied on the
testimony of the patient's doctor, who stated that the restraints were only to
keep the patient from falling out of the bed and that he did not view the
patient as suicidal.
Id.
Although not
completely analogous to the case at bar, these cases illustrate that North
Carolina courts are reluctant to hold a person liable where the chain of events
which led to the resulting injuries is unforeseeable, remote, and attenuated,
even though “some” injury to plaintiff was “possible.”
See Hairston, 310
N.C. at 234, 331 S.E.2d at 565 (citations omitted). The contemplation of what
“might” happen, which leads to what “might” or “may” potentially be the outcome,
and the consideration of “risk factors” for violence to oneself which may or may
not lead to a risk of violence to others, is simply not sufficient as a matter
of law to establish the foreseeability of plaintiff's injuries or
thecircumstances in which the alleged injuries arose. Furthermore, evidence of
“risk factors” for potential violence, such as gun ownership, being under a
certain age, or being of a certain gender, implicates a large portion of our
population and is simply insufficient in and of itself to prove foreseeability.
Given the lack of evidence of violence or any threats of violence on plaintiff's
behalf, “the connection between negligence and the injury appears unnatural,
unreasonable, and improbable.”
Phelps, 272 N.C. at 30, 157 S.E.2d at 723
(citation omitted). We therefore conclude that the expert testimony presented by
plaintiff established what was merely possible and not what was reasonably
foreseeable.
Plaintiff also argues that evidence of
foreseeability in the instant case far surpasses the evidence presented in
Hairston, 310 N.C. 227, 311 S.E.2d 559,
and in other cases in
which our appellate courts have deemed proximate cause an issue for the jury.
Plaintiff contends that like the defendant in
Hairston, defendant in the
case
sub judice should have foreseen an injury would result from his
actions. We find
Hairston distinguishable from the present case.
In
Hairston, our Supreme Court examined the
liability of a car dealership in a wrongful death suit by a deceased motorist's
wife against the dealer and a truck driver. On the same day as the accident
which led to the suit, the motorist purchased an automobile from defendant
dealer. While the motorist waited, the dealer changed the tires on the vehicle,
but failed to tighten thelug nuts on one of the wheels. The motorist drove the
car out of the dealer's lot and within minutes, the loose wheel fell off. The
motorist stopped the car, and a van pulled up behind the disabled vehicle. As
the motorist stood between his car and the van, the defendant truck driver
struck the van, killing the motorist.
Our Supreme
Court held that proximate cause existed to hold the dealer liable for the
motorist's death.
Id. at 235, 331 S.E.2d at 566. The court found that the
dealer could have foreseen the accident which led to plaintiff's injuries.
Id. The Court noted that defendant dealer was on “notice of the
exigencies of traffic, and he must take into account the prevalence of the
'occasional negligence which is one of the incidents of human life.'”
Id.
at 234, 331 S.E.2d at 565 (citations omitted).
In the
case at bar, plaintiff's violent rampage occurred eight months after his final
session with defendant, while the time between the dealer's negligence and the
motorist's harm in
Hairston was “barely six minutes.”
Id. at 238,
311 S.E.2d at 567. More importantly, treating plaintiff's mental illness and
predicting future human behavior are vastly different than maintaining an
automobile and predicting traffic. Indeed, this Court as well as courts in other
jurisdictions have previously recognized the difficulties inherit in the
treatment and diagnosis of mental illness. In
Pangburn v. Saad, 73 N.C.
App. 336, 326 S.E.2d 365 (1985), this Court
stated:
“The uncertainties
inherent in analyzing and treating the human mind, let alone the decision of
when a person is 'cured' and no longer a danger, renders the decisions ofskilled
doctors highly discretionary and subject to rebuke only for the most flagrant,
capricious, and arbitrary abuse.”
73 N.C. App. at 344-45, 326 S.E.2d at
371 (quoting
Leverett v. State, 399 N.E.2d 106, 110 (Ohio Ct. App.
1978));
see also Lee v. Corregedore, 925 P.2d 324, 338 (Haw. 1996)
(quoting
Seibel v. Kemble, 631 P.2d 173, 176-77 (Haw. 1981) (footnote
omitted)) (“'There is much uncertainty in the diagnosis and treatment of mental
illness and in the prediction of future behavior.'”);
Hicks v. United
States, 511 F.2d 407, 415 (D.C. Cir. 1975) (“A claim of negligence must be
considered in light of the elusive qualities of mental disorders and the
difficulty of analyzing and evaluating them.”);
Tarasoff v. Regents of Univ.
of California, 551 P.2d 334, 345 (Cal. 1976)(“We recognize the difficulty
that a therapist encounters in attempting to forecast whether a patient presents
a serious danger of violence.”)
The uncertainties in
diagnosing diseases of the human mind and predicting future behavior were
further hampered in the instant case by the setting in which defendant observed
plaintiff. Defendant treated plaintiff not in a hospital or private out- patient
facility, but in an out-patient student health care facility. Dr. Rogers, a
university student counseling center psychiatrist, testified that student health
centers provide only “short-term treatment.” Dr. Berger, a former counselor at a
university facility, likewise testified that a psychiatrist in a student health
care setting provides short-term care “before [the student has] to make plans
with or without [the psychiatrist's]assistance to get further treatment, or at
least make choices in his life.” There is no doubt that such a limited setting,
coupled with the few number of times defendant observed plaintiff, impeded
defendant's ability to predict and foresee plaintiff's actions eight months
after their last meeting.
Our conclusions concerning
the foreseeability of plaintiff's injuries and the unpredictability of mental
illness are further supported by public policy concerns. A court must “evaluate
[the plaintiff's] allegations in light of the goal of treatment, recovery and
rehabilitation of those afflicted with a mental disease, defect or disorder.”
Seibel, 631 P.2d at 176. Imposing liability on a psychiatrist in an
outpatient, short-term care setting for the actions of a patient that were at
most based on risk factors and not foreseeability would have adverse effects on
psychiatric care. It would encourage psychiatrists and other mental health
providers to return to paternalistic practices, such as involuntary commitment,
to protect themselves against possible medical malpractice liability. Despite
public perceptions to the contrary, the vast majority of the mentally ill are
not violent or are no more violent than the general population and thus, such
rigid measures as involuntary commitment are rarely a necessity.
See
generally John Monahan,
Mental Disorder and Violent Behavior: Perceptions
and Evidence, 47 Am. Psychol. 511, 519 (1992) (“None of the data give any
support to the sensationalized caricature of the mentally disordered served up
by the media, the shunning of former patients by employers and neighbors in the
community, or regressive'lock 'em all up' laws [based on] public fears.”); Linda
A. Teplin,
The Criminality of the Mentally Ill: A Dangerous
Misconception, 142 Am. J. Psychiatry 593, 598 (1985) ("stereotype[s] of the
mentally ill as dangerous [are] not substantiated by our data”). “If a liability
were imposed on the physician . . . each time the prediction of future course of
mental disease was wrong, few releases would ever be made and the hope of
recovery and rehabilitation of a vast number of patients would be impeded and
frustrated.”
Taig v. State, 241 N.Y.S.2d 495, 496-97 (N.Y. App. Div.
1963).
In the instant case, plaintiff functioned
well under defendant's less-restrictive outpatient care, despite having what his
experts termed a very serious mental illness. He passed all of his law school
courses, took his medication on a regular basis, and even noted his friends'
positive comments on his improved behavior. This improvement came without the
need for involuntary commitment. In fact, plaintiff's own experts' testimony
established that at the time he was being treated by defendant, plaintiff, like
the majority of the mentally ill, was not a candidate for involuntary
commitment.
Furthermore, North Carolina's policy on
the mentally ill promotes less restrictive methods of treatment and more patient
autonomy.
The policy of the
State is to assist individuals with mental illness, development disabilities,
and substance abuse problems in ways consistent with the dignity, rights, and
responsibilities of all North Carolina citizens. Within available resources,
[theState is to provide] services to eliminate, reduce, or prevent the disabling
effects of mental illness . . . through a service delivery system designed to
meet the needs of clients in the least restrictive available setting, if the
least restrictive setting is therapeutically most appropriate, and to maximize
their quality of life.
N.C. Gen. Stat. § 122C-2 (1999);
see also
Cobo v. Raba, 347 N.C. 541, 546, 495 S.E.2d 362, 366 (1998) (citation
omitted) (“a patient has an active responsibility for his own care and
well-being”). It would therefore be irrational to promote unnecessary, more
restrictive practices in affirming the judgment below.
We recognize that our jurisprudence in the area of
proximate cause is quite varied.
See generally Sutton, 277 N.C.
94, 176 S.E.2d 161; David A. Logan & Wayne A. Logan
, North Carolina
Torts, § 7.30, at 169 (1996) (“Many of the [North Carolina proximate cause]
cases could have been decided differently.”) We further recognize that it is
only in the rarest of cases that our appellate courts find proximate cause is
lacking as a matter of law.
See Hairston, 310 N.C. at 235, 311 S.E.2d at
566. However, the law of proximate cause “'cannot be reduced to absolute
rules.'”
Sutton, 277 N.C. at 108, 176 S.E.2d at 169 (quoting Prosser,
supra, § 50, at 288). This is one of those rare cases where “because of
convenience, of public policy, of a rough sense of justice, the law arbitrarily
declines to trace a series of events beyond a certain point.”
Palsgraf,
162 N.E. at 103 (Andrews, J., dissenting), quoted in
Wyatt, 57 N.C. App.
at 59, 290 S.E.2d at 791;
Westbrook, 105 N.C. App. at 68, 411 S.E.2d at
654 (citation omitted) (“proximate cause is to be determined on the facts of
each caseupon mixed considerations of logic, common sense, justice, policy and
precedent”).
We conclude that given the very specific
and novel factual scenario presented by this case, defendant's alleged
negligence was not the proximate cause of plaintiff's injuries. Therefore, the
trial court should have granted defendant's directed verdict motion made at the
close of all the evidence.
Having determined that the
trial court erred in failing to grant a directed verdict in defendant's favor
based on the issue of proximate cause, we need not address defendant's remaining
assignments of error.
Because we find that the trial
court erred in failing to grant defendant's directed verdict motion, we reverse
the order of the trial court denying a JNOV and remand with directions for the
trial court to enter judgment in defendant's
favor.
Reversed and
remanded.
Chief Judge EAGLES and Judge HUNTER
concur.
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