Wrongful Death Noneconomic Damages Cap Unconstitutional

An Air Force dependent received prenatal medical care at a United States Air Force clinic. She opted for the Air Force's family practice department to provide primary prenatal care and delivery services throughout her pregnancy. She had a healthy and normal pregnancy until the last trimester. Test results revealed that her blood pressure was high and that she was suffering from severe preeclampsia. Her serious condition required that labor be induced immediately.


Instead of transferring her to the OB/GYN department, the family practice department continued to provide medical care. The Air Force hospital was temporarily unavailable for obstetric and delivery services, so members of the family practice department transferred her to a local medical center instead. There, Air Force family practice doctors treated her for hypertension, and induced labor. When she dilated to five centimeters, her contractions slowed and became weaker. The Air Force family practice doctors treating her called an Air Force obstetrician and asked if he could perform a cesarean section. The obstetrician reported that he was performing another surgery and would not be available to perform a cesarean section on the woman until after he finished that surgery. The Air Force family practice doctors prepared her for a cesarean section but did not call any other obstetricians to determine if one was available to provide immediate medical care.


The following day the obstetrician finally arrived to perform the cesarean section, but the woman's contractions had resumed and the Air Force family practice doctors decided to allow her to deliver vaginally. The obstetrician left the medical center. The following morning the woman delivered a healthy baby boy. Family members who visited her after the delivery expressed concerns about the amount of blood she had lost during delivery. Medical personnel assured these family members that she was stable.


Thirty-five minutes later, when the placenta had not delivered as expected, two family practice doctors from the family practice department tried without success to manually extract the placenta. An Air Force nurse anesthetist administered additional epidural pain relief and gave her two separate doses of Morphine intravenously. About 70 minutes after delivery, the family practice department doctors called the obstetrician for assistance when they could not remove the placenta manually.


The woman's blood pressure began to drop rapidly and remained dangerously low over the next two and a half hours. The Air Force nurse anesthetist monitoring her vital signs did not notify the family practice doctors of the drop in her blood pressure. The obstetrician arrived ten minutes later and removed the placenta within five minutes. The family practice department doctors informed the obstetrician that the woman had not lost much blood during delivery. The obstetrician, however, noticed severe vaginal lacerations and worked to repair them over the next hour. During that time, the Air Force nurse anesthetist monitored the woman's vital signs, reported to the obstetrician that they were stable, and failed to inform him that the woman's blood pressure was dangerously low and continuing to drop. The obstetrician never checked the vital signs himself and relied exclusively on the nurse to inform him of any blood pressure changes or problems.


Sixty-five minutes after he arrived, when the obstetrician finished his work, he requested an immediate blood count and, if needed, a transfusion to compensate for the blood the woman lost during the procedure. Forty minutes later, the family practice department physician ordered the blood count test. Another forty minutes later, and over an hour after the obstetrician had requested immediate blood work, a nurse attempted to draw blood from the woman. She was unresponsive. She had gone into shock and cardiac arrest as a result of severe blood loss. It is not clear how long she had been in this state, since no one had monitored her or checked her status for the hour following the obstetrician's procedure. The woman never regained consciousness and was removed from life support five days after giving birth.


The woman’s family filed an action against the United States under the Federal Tort Claims Act (FTCA), 28 U.S.C.A. §§ 1346(b), 2671 to 2680. Following a bench trial, the United States District Court for the Northern District of Florida found the United States liable. The district court determined that the family’s economic damages, or financial losses, amounted to $980,462.40. The district court concluded that their noneconomic damages, or nonfinancial losses, totaled $2 million, including $500,000 for her son and $750,000 for each of her parents. However, the district court limited the recovery of wrongful death noneconomic damages to $1 million upon application of section 766.118(2), Florida Statutes (2005), Florida's statutory cap on wrongful death noneconomic damages based on medical malpractice claims.


The woman’s family appealed. The United States Court of Appeals for the Eleventh Circuit affirmed the application of the statutory cap. The circuit court held that the statute did not constitute a taking in violation of article X, section 6, of the Florida Constitution and also held that the cap did not violate either the Equal Protection Clause or the Takings Clause of the United States Constitution. The court then certified questions of state constitutional law with regard to the cap.


The Supreme Court of Florida held that the statutory cap on wrongful death noneconomic damages recoverable in medical malpractice actions violated the right to equal protection under Article I, Section 2 of the Florida Constitution. Applying the rational basis test, the court reasoned that the cap imposed unfair and illogical burdens on injured parties when an act of medical negligence gave rise to multiple claimants. In these circumstances, medical malpractice claimants did not receive the same rights to full compensation because of arbitrarily diminished compensation for legally cognizable claims. Aggregate caps or limitations on noneconomic damages violated equal protection guarantees under the Florida Constitution when applied without regard to the number of claimants entitled to recovery.


The court reasoned that the plain language of this statutory plan irrationally impacted circumstances that have multiple claimants/survivors differently and far less favorably than circumstances in which there was a single claimant/survivor. The cap also exacted an irrational and unreasonable cost and impact when, as here, the victim of medical negligence had a large family, all of whom have been adversely impacted and affected by the death. Three separate noneconomic damage determinations were assessed by the federal district court based on the evidence presented. The damages suffered by the woman's parents were determined to be $750,000 each, and her surviving son sustained damages determined to be $500,000. Applying the cap, the federal court then reduced the amounts of damages so each claimant would receive only half of his or her respective damages. Yet, if the woman had been survived only by her son, he would have recovered the full amount of his noneconomic damages: $500,000. Here, the cap limited the recovery of a surviving child (and surviving parents) simply because others also suffered losses. In a larger context, under the statutory cap, the greater the number of survivors and the more devastating their losses were, the less likely they would be fully compensated for those losses.


In addition to arbitrary and invidious discrimination between medical malpractice claimants, the court also held that the cap on noneconomic damages also violated the Equal Protection Clause of the Florida Constitution because it bore no rational relationship to a legitimate state objective, thereby failing the rational basis test. The cap did not bear a rational relationship to the stated purpose that it was purported to address: the alleged medical malpractice insurance crisis in Florida. Equal protection analysis under the rational basis test required the court to determine: (1) whether the challenged statute serves a legitimate governmental purpose, and (2) whether it was reasonable for the legislature to believe that the challenged classification would promote that purpose. The Florida Legislature attempted to justify the cap on noneconomic damages by claiming that Florida was in the midst of a medical malpractice insurance crisis of unprecedented magnitude. The legislature asserted that the increase in medical malpractice liability insurance premiums had resulted in physicians leaving Florida, retiring early from the practice of medicine, or refusing to perform high-risk procedures, thereby limiting the availability of health care. The legislature relied heavily on a report prepared by the Governor's Select Task Force on Healthcare Professional Liability Insurance (Task Force), which concluded that actual and potential jury awards of noneconomic damages (such as pain and suffering) are a key factor (perhaps the most important factor) behind the unavailability and unaffordability of medical malpractice insurance in Florida.


The court held that findings of fact made by the legislature were not entitled to the presumption of correctness if they are nothing more than recitations amounting only to conclusions, and they are always subject to judicial inquiry. The court found that during this purported crisis, the numbers of physicians in Florida were actually increasing, not decreasing. For example, in a 2003 report, the United States General Accounting Office found that from 1991 to 2001, Florida's physician supply per 100,000 people grew from 214 to 237 in metropolitan areas and from 98 to 117 in nonmetropolitan areas, or percentage increases of 10.7 and 19, respectively. Available data indicated the Task Force's finding that noneconomic damage awards by juries were a primary cause of the purported medical malpractice crisis in Florida was questionable. A study indicated that jury trials constituted only a small portion of noneconomic damages payments of $1 million or more. Medical malpractice insurance had been subject to sudden jolts, both in availability of coverage and cost, due to insurance underwriting profits, unrelated to jury awards.


The Supreme Court of Florida answered the certified question in the affirmative and held that the cap on wrongful death noneconomic damages provided in section 766.118, Florida Statutes, violated the Equal Protection Clause of the Florida Constitution.


See: Estate of McCall v. U.S., 2014 WL 959180 (Fla., March 13, 2014) (not designated for publication).