2010 QCCA 2180, 2010 QCCA 2180

R.K. c. Ackman (Succession d') 2010 QCCA 2180 COURT OF APPEAL CANADA PROVINCE OF QUEBEC REGISTRY OF MONTREAL No: 500-09-019242-080 (500-17-015575-031) DATE: 29 NOVEMBRE 2010 CORAM: THE HONOURABLE MARC BEAUREGARD, J.A. MARIE-FRANCE BICH, J.A. NICOLE DUVAL HESLER, J.A. R. K. and H. T. and L. T. and J. T. and B. T. APPELLANTS / Plaintiffs v. THE ESTATE OF THE LATE DR.

DOUGLAS ACKMAN and GÉRARD MOHR RESPONDENTS / Defendants and CALVIN MELMED Defendant JUDGMENT [ 1 ] THE COURT: On appeal from a judgment of the Superior Court, district of Montreal (Madam Justice Christiane Alary), rendered on December 16, 2008, that dismissed the appellants’ action in damages; [ 2 ] For the reasons of Bich, J.A., with which Beauregard and Duval Hesler, JJ.A. agree; [ 3 ] DISMISSES the appeal, with costs; [ 4 ] DISMISSES the appellants' motion for a publication ban and for confidentiality of the medical records, without costs. MARC BEAUREGARD, J.A. MARIE-FRANCE BICH, J.A. NICOLE DUVAL HESLER, J.A.

Mtre H. T. [...] Mtre Gilles Poulin Gilles Poulin Avocat For the appellants Mtre David Everett Platts Mtre Simon Chamberland McCarthy Tétreault For the respondents Date of hearing: October 20, 2010 REASONS OF BICH, J.A. [ 5 ] Following a surgical operation performed in June 2000 in order to untether her spinal cord, appellant R. K.'s lower body functions were severely and permanently impaired.

Needless to say, this seriously disrupted her life, both personal and professional, which in turn affected her spouse and children. [ 6 ] The appellants sued the estate of Douglas Ackman (urologist) and also sued Calvin Melmed (neurologist) and Gérard Mohr (neurosurgeon), solidarily, claiming more than one million dollars in damages.

Appellant K. also asked that her right to apply for additional damages be reserved for a period of three years following the date of the judgment (art. 1615 C.C.Q. ). [ 7 ] On December 16, 2008, the Superior Court, district of Montreal (Madam Justice Christiane Alary), dismissed the action. [ 8 ] The trial judge decided that neither Dr. Ackman nor Dr.

Melmed had committed any fault, and, at any rate, none that could have made them liable for the prejudice suffered by the appellants. [ 9 ] On the other hand, she decided that respondent Gérard Mohr, who performed the June 2000 operation and did so in accordance with good medical practice, nevertheless committed a fault by failing to inform appellant K. of the risks of the surgery that he was recommending and would later be carrying out. Those risks were significant and indeed materialized in the case of the appellant. Applying the principles established in Chouinard v. Landry, [1] Pelletier c.

Roberge [2] and Drolet c. Parenteau , [3] the trial judge concluded however that there was no causal link between respondent Mohr's fault and the prejudice suffered by appellant K.. In her opinion, the evidence clearly established that even if appellant K. had been fully informed of the risks associated with the surgery, she would have agreed to it, considering her past attitude in matters of health and health care and considering that her condition actually left her with no other realistic course of treatment. [ 10 ] The appellants basically challenge all findings of fact of the trial judge with regards to Drs.

Ackman and Mohr, and they most vigorously dispute the finding that appellant K. would have consented to surgery if she had been properly informed of the serious risks of the operation. [ 11 ] No appeal was lodged against the findings and conclusions exonerating Dr. Melmed. * * [ 12 ] The trial judge correctly identified all applicable legal principles and, indeed, the appellants do not seriously contend that she committed any error of law, except — and I will address that question later — in relation to the burden of proof regarding the causal link between Dr.

Mohr's fault and the damages suffered by appellant K.. Suffice it to say for the moment that the appellants have failed in this assertion. [ 13 ] Neither have they established that the trial judge committed any error of fact that would warrant the intervention of the Court. [ 14 ] In P. L. c. Benchetrit , [4] the Court, per Morissette, J.A., recently commented that: [24] Cette réponse, qui n’est pas fausse, est cependant ambiguë et incomplète. « Étudier le dossier » ne signifie pas refaire le procès.

Dans le domaine des faits, les rôles respectifs d’une juridiction de première instance et d’une juridiction d’appel sont dictés en grande

partie par des considérations institutionnelles. Un juge de première instance, tout le monde le sait, a l’avantage de scruter la preuve documentaire ou matérielle, de voir et d’entendre les témoins, et d’assister au déroulement linéaire de la preuve, au rythme auquel les parties l’administrent. Un juge d’appel a l’avantage d’être saisi longtemps avant l’audience d’un dossier qui, en principe, contient déjà toute la preuve, ou du moins tout ce qui est pertinent au pourvoi.

Il peut donc d’emblée demander aux avocats des éclaircissements sur le contenu du dossier et, comme il travaille avec les transcriptions des témoignages (ce qui est rarement le cas en première instance), il peut faire des recoupements pour confronter les informations contradictoires ou divergentes que contiennent presque tous les dossiers litigieux.

Mais il ne voit ni n’entend les témoins et, surtout, les contraintes de temps que lui impose sa fonction ne lui permettent pas de refaire ce que l’on attend d’un juge de première instance, c’est-à-dire un examen minutieux de la preuve au rythme auquel elle fut présentée par les parties au procès. Hors les cas qui ne laissent pas de place au doute, il est donc mal placé pour réévaluer la crédibilité des témoins. Il lui faut par ailleurs compter sur l’assistance des avocats pour repérer et évaluer les prétendues erreurs de fait sur

lesquelles se fonde une partie. D’où il suit qu’affirmer sans plus de précision qu’une conclusion de fait « est contraire à l’ensemble de la preuve » n’est d’aucune utilité en appel. Et prétendre qu'une chose est « manifeste » ne suffit pas à la rendre telle . À mon avis, c'est dans ce sens que doivent se comprendre les propos du juge Fish quand il écrivait ce qui suit dans H.L. c. Canada (Procureur général) [renvoi omis] : … en plus de sa résonance, l'expression « erreur manifeste et dominante » contribue à faire ressortir la nécessité de pouvoir « montrer du doigt » la faille ou l'erreur fondamentale.

Pour reprendre les termes employés par le juge Vancise [TRADUCTION] « [l]a cour d'appel doit être certaine que le juge de première instance a commis une erreur et elle doit être en mesure de déterminer avec certitude l'erreur fatale » ( Tanel , p. 223, motifs dissidents, mais pas sur ce point). « Montrer du doigt » signifie autre chose qu'inviter la Cour à porter un regard panoramique sur l'ensemble de la preuve : il s'agit de diriger son attention vers un point déterminé où un élément de preuve univoque fait tout simplement obstacle à la conclusion de fait attaquée.

Si cette conclusion de fait, dont a ainsi démontré qu'elle était manifestement fausse, compromet suffisamment le dispositif du jugement, l'erreur sera qualifiée de déterminante et justifiera la réformation du jugement . [Emphasis added.] [ 15 ] Earlier, in Regroupement des CHSLD Christ-Roy (Centre hospitalier soins de longue duré

e) c. Comité provinciale des malades , [5] the Court observed that: [54] L’appel, rappelons-le encore une fois, n’est pas une occasion de refaire le procès . [55] Lorsqu’une preuve de quelque complexité prête à interprétation et requiert de la part du juge de première instance l’appréciation individuelle puis globale de multiples éléments, dont certains sont divergents ou contradictoires, il ne suffit pas de sélectionner aux fins du pourvoi tout ce qui aurait pu être interprété différemment, à l’exclusion de tout le reste, afin de réitérer une thèse déjà tenue pour non fondée par le juge qui a entendu le procès.

Une erreur dans la détermination d’un fait litigieux n’est manifeste que si son caractère évident ou flagrant se dégage avec netteté du réexamen de la

partie pertinente de la preuve et qu’une conclusion différente sur ce fait litigieux s’impose dès lors à l’esprit. Une erreur n’est déterminante que si elle prive le jugement entrepris d’une assise nécessaire en fait, faussant ainsi le dispositif de la décision rendue en première instance et commandant réformation de ce dispositif pour cette raison . Cette question pourtant importante en appel n’est nulle part abordée par les appelants privés conventionnés pour qui, semble-t-il, toutes les erreurs ou prétentions d’erreur se valent.

Il leur revenait d’identifier spécifiquement et de circonscrire dans leur mémoire ce en quoi le jugement souffrait d’une telle faiblesse et ils ne l’ont pas fait. [Emphasis added.] [ 16 ] Admittedly, the appellants do not simply allege that the trial judge misapprehended the whole of the evidence and they seek to identify and pinpoint a variety of specific mistakes, none of which, however, results from a univocal proof (“élément de preuve univoque”, see Benchetrit , supra ) that the trial judge would have ignored or misconstrued.

Relying on a series of carefully chosen elements that should in their opinion have been interpreted differently by the judge, the appellants ignore or downplay in their argument most of what is incompatible with their viewpoint.

In reality, they ask the Court to re-evaluate the evidence and conclude in a manner different from that of the trial judge, without demonstrating the unreasonableness of the latter's findings and conclusions. [ 17 ] In fact, the judgment is particularly careful and meticulous, the trial judge's analysis of the situation being altogether rigorous, coherent and nuanced, and, in my opinion, entirely consistent with the evidence, on the balance of probabilities. * * [ 18 ] As far as Dr.

Ackman is concerned, I agree with the judge that he committed no professional misconduct and no fault in his treatment of appellant K.. [ 19 ] According to the appellants, when he examined and treated Ms. K. in 1994 and in early 1995 for urinary problems, Dr. Ackman should have investigated her condition more thoroughly and aggressively. The possibility of a neurogenic bladder had occurred to him at that time (as well as the possibility of multiple sclerosis) and he should have referred his patient to a neurologist instead of simply reporting to her family physician.

Had he done so, the source of her symptoms would have been detected earlier ( i.e. an untethered spinal cord, which is a congenital defect complicated here by the presence of a lipoma in her lower back). She could then have taken the necessary precautions and measures in order to avoid or prevent the deterioration of her condition over the next five years, which would have reduced the risks associated with the surgery.

Alternatively, she could have chosen to undergo at that time the surgery that was only performed in 2000, after her condition had deteriorated. [ 20 ] With due respect, this argument is purely speculative. The evidence is clear that after he examined and treated appellant K. in October 1994, Dr. Ackman met with her again in January 1995, for a follow-up examination. The symptoms that had afflicted her previously had been relieved by then (a fact that her family physician noted as well) and she did not complain again for more than three years afterwards.

According to the expert evidence, [6] there was at the time no medical reason for Dr. Ackman to pursue the investigation further by referring his patient to a neurologist. Had he done so, the course of events might have been changed, [7] but has he committed a professional fault by not sending her to a neurologist nor suggesting that she seek the opinion of a neurologist? This is the only question that the trial judge had to answer and she answered it in the negative. There is no mistake in that conclusion, and, certainly, no palpable and overriding error. * * [ 21 ] Dr.

Mohr's fault — he breached his duty to inform his patient of the known risks of the surgical operation — is indisputable and there is no reason to review the finding of the trial judge in this respect. That being so, the only remaining question is the following: would appellant K. have agreed to the operation if she had been fully apprised of the nature and extent of the risks thereof?

[ 22 ] On the basis of the judgment of the Court in Marcoux c. Bouchard , [8] the appellants first contend that the trial judge erred in law by imposing upon them the burden to demonstrate that Ms. K. would not have consented to the operation. They argue that it was Dr. Mohr's burden to demonstrate that her patient would have consented to the operation had she known of the risks involved and that he did not discharged himself of this burden. [ 23 ] With respect, I believe that the appellants are confusing the question of the ultimate burden of proof pursuant to

article 2804 C.C.Q. with that of the reversal which may result from the establishment of facts leading to a presumption (art. 2847 et 2849 C.C.Q. ) that will stand as conclusive evidence if not rebutted (see: Gburek c.

Cohen , [9] at. p. 2439-2440). [ 24 ] In the present case however, without regard to the burden of proof, the evidence upon which the trial judge relied overridingly established that appellant K. is, indeed, a reasonable and prudent person (as illustrated by her medical history and itinerary), who tends to actively seek diagnosis of her health problems and to follow punctiliously and with great discipline the medical advice that she receives, and who would have accepted the surgery even if she had been properly informed of its objectives, risks and potential consequences. [ 25 ] The relevant test in this respect is well-known (for instance, see: Chouinard c.

Landry , [10] Lefebvre c. Madore , [11] Pelletier c. Roberge , [12] Lacasse c. Lefrançois , [13] Ferland c. Ghosn , [14] Baum c.

Mohr [15] ) and the judge applied it correctly: [193] Ainsi, il ne s'agit pas de se demander si la personne raisonnable placée dans les mêmes circonstances aurait agi de la même façon, mais si le patient particulier qui a subi le traitement aurait agi de même s'il avait été dûment informé [renvoi omis] : On peut, en premier lieu, tenter d'évaluer ce qu'aurait été la décision du demandeur, par comparaison à celle d'une personne raisonnablement prudente et diligente, placée dans les mêmes circonstances. C'est alors utiliser un test objectif.

On peut, en second lieu, apprécier le comportement du patient d'une façon subjective par rapport donc à la décision qu'aurait rationnellement prise ce patient particulier dans les circonstances de l'espèce. C'est ce dernier test subjectif qui est adopté, à l'heure actuelle, par une

partie de la jurisprudence. Celle-ci utilise cependant davantage désormais un troisième test, qui est en fait une combinaison des deux premiers, qualifié de test de « subjectivité rationnelle » ou de « rationalité subjective ». [194] Bref, la recherche de la causalité doit se faire par l'analyse du comportement du patient.

Par ailleurs, la version du patient pouvant être colorée par les malheurs qui lui sont arrivés, sans mettre de côté le test subjectif, les tribunaux sont appelés à évaluer la crédibilité du patient en s'interrogeant sur ce qu'aurait été la décision du patient prudent et diligent, face à l'information complète [renvoi omis] : La responsabilité civile du médecin n'est toutefois pas automatiquement engagée de la seule constatation d'une faute dans le devoir d'information.

Selon notre jurisprudence, il faut alors appliquer un test qui à mon avis, est essentiellement un test subjectif et qui consiste à évaluer si la patiente, dans les circonstances particulières, aurait accepté l'intervention quand même si elle avait été convenablement informée. Cette évaluation se fait d'habitude surtout en prenant en compte les témoignages du patient. Ce témoignage doit cependant pour des raisons évidentes, être évalué avec prudence, et d'autres facteurs doivent être considérés.

C'est pour cette raison que souvent les tribunaux se posent aussi la question de savoir ce qu'une personne normalement prudente et diligente aurait décidé en espèce, test dit « objectif », mais qui, à mon avis, s'attache essentiellement à la crédibilité de ce témoignage. Ce test objectif ne se substitue donc pas au test subjectif. Il ne fait que le compléter. Je suis donc loin d'être sûr, comme on nous l'a plaidé, qu'il existe véritablement, au sein de notre Cour, deux écoles distinctes sur la question. Je pense plutôt que le test subjectif est désormais bien reconnu.

Toutefois, en l'absence d'autres preuves que les témoignages de la victime, venant après coup affirmer qu'elle n'aurait jamais consenti, notre Cour se demande, pour évaluer sa crédibilité, quelle aurait été la conduite d'une personne raisonnablement prudente dans les circonstances (test objectif) . ( Le Tribunal souligne ) [195] Le Tribunal doit donc se demander quelle aurait été la décision de Mme K… si Dr Mohr lui avait indiqué que l'opération risquait de provoquer, dans 5 % à 6 % des cas, une aggravation des fonctions déjà atteintes, que dans 90 % des cas, chez les adultes, ces fonctions continuent de se détériorer malgré l'opération, qu'une atteinte aux chevilles et aux pieds était risquée dans 5 % à 6 % des cas et enfin qu'il existait une possibilité de devoir être opérée à nouveau dans le cas d'écoulement du liquide céphalorachidien. [ 26 ] As we know, the trial judge concluded that appellant K. would have agreed to undergo the operation.

Her conclusion rests on the fact that, absent the surgery, the appellant's condition, had it followed its natural course, would have deteriorated to the point where she most likely would have been in the same situation that she is today after the risks of the surgery materialized. The appellants' own expert, [16] John Ratliff, does not say otherwise in his report [17] and the testimony of Dr.

Jean-Pierre Farmer, neurosurgeon, is very clear to that effect. [18] Both experts even agree that the surgery had to be performed within a short period of time, albeit not on an emergency basis, in order to prevent any further deterioration of appellant K.'s condition. In his report, Dr. Ratliff states that: […] I believe surgery in this patient's case is inevitable, however, and I would personally have recommended early surgery secondary to the severity of the patient's bladder dysfunction and to my fear of further loss of function.

However, surgery was not an emergency and should not have been presented as such. The tethered cord is a congenital abnormality meaning it has been present for the patient's entire life. Her bladder dysfunction had been present for years. While I believe surgery would be necessary, a brief period of clinical follow-up probably would not have adversely affected the patient's outcome. [19] [ 27 ] We understand from this report and from Dr. Farmer's testimony that both experts would not have recommended that surgery

be delayed for years and that it was the only viable option, to be performed in the short term. [ 28 ] The evidence also indicates unambiguously that had appellant K. sought a second medical opinion after having consulted Dr. Mohr, the recommendation would have been identical. Surgery is indeed the only possible treatment for the appellant's congenital condition, consisting in the untethering of the spinal cord and the removal of the lipoma.

This surgery has no curative effect (functions that have already been damaged cannot be restored, or only marginally so), but has a preventive effect, essentially. [ 29 ] Confronted with the likelihood of the important deterioration of her natural condition, which would have caused problems similar to those that resulted from the operation, appellant K., had she been fully informed, would have chosen to undergo the surgery, even if she expresses today her preference for the “conservative management” of her situation.

Such conservative management however would imply nothing but a period of further observation and, in time, surgery would necessarily have had to be performed, hopefully before the occurrence of a serious degradation of the patient's situation (most notably paralysis of the lower limbs).

It is conceivable, of course, that Ms K. would have chosen to undergo the operation later, but not considerably later, due to the risks of a natural aggravation of her condition compared to those of the surgery. [ 30 ] It must also be noted that appellant K., although claiming that she would not have accepted the surgery in 2000 if she had known the risks thereof, claimed at the same time that she would have undergone the operation in 1994 or 1995, a possibility which she was deprived of because Dr. Ackman neglected to refer her to a neurologist, which could have led to the early detection of her condition.

Considering that the risks of the operation, whether in 1994 or 2000, are basically the same, this element justifiably reinforced the judge's determination that the appellant would have accepted the surgery even if she had been properly informed by Dr. Mohr. [ 31 ] In conclusion, the trial judge could reasonably infer from the evidence that appellant K. would have consented to the surgery had she been properly informed of the risks and potential consequences thereof.

There is of course no absolute certainty in that finding, but on a balance of probabilities, which is the applicable standard, her conclusion appears unchallengeable.

The appellants, although they propose another narrative, have not discharged themselves of the burden to establish the existence of a palpable and overriding error in this respect. * * [ 32 ] In their written and oral argument, the appellants raise the following question: Even if this Honourable Court would answer the previous question affirmatively, is Appellant K. entitled to damages for the emotional shock of finding herself in such a situation with no previous warning that it was a risk of the surgery? [20] [ 33 ] This question was not debated at trial, nor was it specifically alleged in the motion to institute proceedings.

It is of such a nature that the respondents might have wanted to adduce evidence in the matter, most notably by cross-examining appellant K.. [ 34 ] That being so, according to the principles expounded in Pitre et Durand inc. (Syndic de) [21] and constantly applied by our court [22] , the matter cannot be argued for the first time in appeal. * * [ 35 ] The appellants ask for a publication ban of their names, to be effective both in our court and in the Superior Court.

At the hearing, they also required the confidentiality of the medical records of appellant K.. [ 36 ] As far as anonymity is concerned, considering the judgments of our court in Marcovitz c. Bruker [23] and Métromédia CMR Montréal inc. c. Johnson , [24] the appellants' motion must be dismissed. It is to be noted however that the principal publishers (at least in Quebec) of judgments (SOQUIJ and REJB) follow a voluntary, self-imposed policy of anonymity in cases such as this one. [ 37 ] As far as the confidentiality of medical records is concerned, no special order is required, the matter being taken care of by

section 3 of the Rules of practice of the Superior Court of Québec in civil matters : 3. Dossier médical et rapport d'expertise. Dans toute demande en justice, le dossier médical et tout rapport d'expertise préparé par un médecin, un psychologue ou un travailleur social, versé au dossier, sont conservés sous enveloppe scellée et personne, sauf les parties et leurs avocats, n'y a accès sans la permission du tribunal ou d'un juge. L'accès à un tel document comporte le droit d'en prendre copie à ses frais. 3. Medical record and experts' reports.

In every legal action, a medical record or any report prepared by a physician, a psychologist or a social worker that is filed of record shall be kept in a sealed envelope and only the parties and their attorneys may have access thereto without authorization from the Court or a judge. Access to such a document includes the right to make copies thereof at one's own expense. [ 38 ] In the Court of Appeal, although there is no rule to that effect, the practice is similar and the parties simply have to draw the attention of the Clerk to the matter.

Measures will then be taken to ensure the confidentiality of the medical information on record (i.e. medical records and medical expert reports). * * [ 39 ] For these reasons, I would dismiss the appeal, with costs. The motion for a publication ban with respect to the names of the appellants and for confidentiality of the medical records will also be dismissed, but without costs.

MARIE-FRANCE BICH, J.A.