Personal Practice, a Different Perspective.

Below is an article I wrote that looks very briefly at ethical approaches when dealing with expert testimony, primarily in the area of medical malpractice, and personal practice.

***please note, although an appendix is attached below, due to formating issues the endnotes throughout the article were not properly linked.

A look at the ethical dilemma faced when establishing the standard of care through an expert’s testimony although it conflicts with the experts’ own personal practice.

Preface to the Preface

Before undertaking the pleasure of reading this article and postulating one’s own theories, it is helpful to understand the foundations of medical malpractice and the influence of an expert witness in U.S. system of law. As such, the preface to this article attempts to crudely summarize the two.

Preface

October 10th, 1794 arguably marked the nation’s first medical malpractice claim. In Cross v. Guthery , the Tolland County Circuit Court of Connecticut sent a rogue wave across the nation. This wave was in the form of a specialized area of law sought to encompass the negligence of medical professionals arising from actions during their duty of care to a patient. In Cross v. Guthery the plaintiff’s wife had developed, in modern day what is referred to as breast tuberculosis, a scrofulous humor. The diseased area of the breast required amputation, thus Dr. Guthery performed an operation to remove the tissue. During the procedure the operation, “contrary to all the well-known rules and principles of practice in such cases; and that after said operation, the plaintiff's wife languished for about three hours and then died of the wound given by the hand of the defendant.” The case was brought forth under a theory of contracts for failure to provide the requisite skill and safety to the wife of the plaintiff during the operation as contracted. A decision was made and the plaintiff was released of his debt to the physician and additionally recovered forty pounds (£40.00) for the great cost and expenses he incurred as well as the deprivation of the service, company and consortship of his wife.

Fast forwarding slightly over two centuries, today’s theory of medical malpractice rests in the area of tort law, whereby a physician with a duty to provide a standard of care, breached that duty to a patient, caused injury as it related to that breach, which ultimately led to damages incurred by the patient. The cases are heavily controversial as they typically involve complex matters which are brought to the attention of a jury panel whose duty is to determine whether or not to find the defendant is liable for, in a simple sense, negligence. Among the various facts alleged and agreed, the jury is introduced to expert testimony. As William L. Foster put it, “Gentleman of the jury, there are three kinds of liars: the common liar, the dammed liar, and the scientific liar.” Here, Foster refers to the expert witness as the “scientific liar.” Expert testimony is commonly governed by a form of Federal Rule of Evidence 702 which states,

If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise, if (1) the testimony is based upon sufficient facts or data, (2) the testimony is the product of reliable principles and methods, and (3) the witness has applied the principles and methods reliably to the facts of the case.

Because the burden of proof lies with the plaintiff he or she must in large part utilize his or her hired expert witness to establish, by a preponderance of the evidence , their case is more plausible than that of the defendant. By rigorously reviewing the medical records surrounding the case, as well as the testimony of the plaintiff and defendant, the plaintiff’s expert witness opines what standard of care would have been proper by a physician to a patient in the same or similar circumstance. As the plaintiffs expert witness and the defendants expert witness each take turn in efforts to establish what they attest to as the standard of care, they are cooperatively engaged in what is commonly known as the “Battle of the Experts.” After testimonies are presented to the jury, a person’s well being, large sums of damages, and difficult ethical dilemmas are deliberated upon after which a decision, often times subject to appeal, is made.

Introduction

Medical malpractice seems simple right? Well, in theory yes, however since Cross v. Guthery medical malpractice has evolved. In fact, it continues to evolve as its roots in contract law are dilapidated then restored in tort law. However, with these evolutions in medical malpractice come new challenges. One new challenge is deciding how to deal with the ethical dilemma faced when establishing the standard of care through an expert’s testimony although it conflicts with the experts own personal practice. More specifically, is the personal practice of an expert witness an issue or not as it relates to the standard of care in medical malpractice actions? This brief article discusses the evidentiary evolution of “personal practice” through not only a utilitarian approach of ethics, but a common-good approach, rights approach, virtue approach, and justice approach.

Case Law

We delve into the issue of personal practice, using three major cases in the seventh circuit to identify the specific issue at hand. In Schmitz v. Binette , Mary Schmitz filed a complaint against Dr. Steven Binette. She alleged that:

Dr. Binette was negligent (1) in causing an obstruction in Mary's right ureter with a suture, (2) in failing to adequately monitor Mary in the peri-operative period to ascertain the presence of any damage or obstruction to her right ureter, (3) in failing to adequately monitor Mary in the postoperative period to ascertain the presence of any damage or obstruction to her right ureter, and (4) in failing to exercise the appropriate degree of skill and care in treating Mary. As a result of this negligence, the complaint alleged (1) that Mary developed hydro-uretal nephrosis of the right kidney, (2) that multiple subsequent procedures were required, (3) that her kidney became infected and lost all function, and (4) that the kidney ultimately had to be removed.

In establishing her case Mary elicited Dr. Samir Hajj, an obstetrician / gynecologist, as her expert witness. Dr. Hajj, opined that, Dr. Binnette deviated from the applicable standard of care by failing to perform an indigo carmine dye test, which would have identified an obstruction. The defendant then brought testimony from Dr. Lane Mercer who opposed Dr. Hajj’s testimony stating that, “the standard of care does not require gynecologists to perform a cytoscopy and use indigo carmine dye after an MMK procedure. ” However in a contradictory fashion, Dr. Mercer also testified , during depositions, it was his personal practice to routinely perform the indigo carmine dye tests after bladder suspension surgeries even though it increased the risk of altercations during the procedure and had a statistically significant fail rate. Dr. Mercer also added that he conducted the indigo carmine test because he was a compulsive SOB who had been in depositions for too long and too afraid not to. Similarly in Gallina v. Watson , plaintiff Vtio Gallina appealed a lower court’s decision against defendant Dr. Michael Watson alleging that he was negligent in failing to operate on a “type II” fracture. The plaintiff was brought to the hospital after being involved in a head on vehicle collision at over eighty-five miles per hour. Vito was presented to the hospital staff with a fractured jaw, left femur, pelvis, hand, and both ankles. This was in addition to his ruptured spleen. “Dr. Watson testified he did not operate on Gallina’s right ankle because it was acceptable not to do so and another surgery could have threatened Galina’s life due to the multiple surgeries already performed that night.” He further testified that, he acknowledged he agreed with his resident and knew he was dealing with a “type II” fracture when he chose not to operate on plaintiff. In an effort to provide testimony that he met the standard of care, Dr. Watson introduced his expert witness Dr. Joeseph Whalen. The expert testified that Dr. Watson met the standard of care. Yet, Dr. Watson also stated that it was his own personal practice to operate on all type II fractures. After this testimony defendant then argued that Dr. Whalen identified plaintiffs fracture as a “type I” fracture, thus the standard of care was met. The court did not agree with the last minute attempt at a cover up. Accordingly they were convinced that although the “…testimony did not prove Dr. Watson breached the standard of care by not performing an open reduction on the plaintiff, Dr. Whalen’s testimony goes to the credibility and persuasive value of Dr. Whalen’s opinion Dr. Watson’s actions were within the standard of care.” The expert testimony of personal practice was deemed acceptable to allow the jury to use it to discredit that very experts own opinion as to the standard of care.

In another instance, plaintiff Dorthy Rush brought suit against defendant Dr. Mostafa Hamdy. She alleged she suffered damages sustained when he perforated her esophagus while performing an esophageal dilation. In 1986 Dorthy was determined to have 1.5-centimeter Schatzki’s ring which was dilated with a 1.8-centimeter dilator. However after the procedure the Schatzki’s ring returned. For that reason, Dorthy sought the assistance of Dr. Hamdy who only obtained records of a two year old barium swallow test. Although Dr. Hamdy testified he knew that Dorthy had an esophageal dilation procedure before, he failed to provide records that indicated this. According to the facts, Dr. Hamdy scheduled Dorthy for another dilation procedure, and with multiple dilators available; he chose to use a 4-centimeter dilator! After maintaining five millimeters of mercury for five seconds , “Dorthy complained of pains, and the procedure was terminated.” After the termination, Dorthy had nausea, dry heaves, and chest pain. Dr. Hamdy then altered medical records, “changing the measurement of the opening of the Schatzki’s ring from 1.5-centimeteres to 2.5 centimeters and changing the pressure maintained from 500 millimeters mercury to 5 pounds per square inch.” Dr. Stehpen Holt, a specialist in internal medicine and gastroenterology testified Dr. Hamdy did not meet the standard of care because he did not determine the proper placement of the dilator, he did not use radiology to determine the proper measure of the Schatzki’s ring, he used an achalasia dilator , and using a dilator measuring four centimeters was inappropriate. The defendant’s introduced expert witness Dr. Michael Shekleton, a practicing gastroenterologist, testified that an achalasia dilator to treat a Schatzki’s ring would be appropriate. Contrary to this testimony, Dr. Shekleton testified that he had never heard of an achalasia dilator being used on a Schatzki’s ring prior to the matter between Dorthy Rush and Mostafa Hamdy. Even more so Dr. Shekleton stated had Dorthy been his patient, he would have treated her with a savary dilator .

All of the above cases present a conflict which arises when an expert witness establishes that the standard of care is one thing, yet, for various reasons, their own personal practice is to provide care that varies from what they just testified as the standard of care. Furthermore the prevailing decision in the seventh circuit, as well as the nation, is to allow the testimony of the physician’s personal practice as it allows the jury to weigh the expert’s testimony against their credibility prior to deliberations. As convincing as this may seem, on the ethical front the arguments and opinions can be far different and even more difficult to discern.

Ethical Approaches

Often times the decisions of judges are strictly based on a set facts and rules. The method allows for a stricter standard, a more black and white approach . Ethical approaches, while important, create grey areas which are often times avoided. In fact they are especially avoided when dealing with cases of first impression. Although the area of medical malpractice is not any new area of law, as time progresses, new challenges are brought forth. The personal practice of a physician has traditionally been barred from testimony. The point of judgment on a case of medical malpractice is the standard of care and whether or not it was breached, however when an expert witness identifies a standard of care but in his own personal practices does more than their own standard of care, some attorneys argue that the credibility of an expert must be allowed into consideration. In an effort to navigate through these waters, this ethical analysis will focus generally on two consequential, two normative, and one deontological approach. More specifically the analysis will focus on the utilitarian, common good, rights, virtue, and justice approach.

Consequential Approaches:

Consequentialism is a theory of ethics where the approach judges the quality of the act by the end it achieves. If it maximizes some goal, it is the appropriate choice . Essentially, the end justifies the means.

Utilitarian Approach:

The first ethical approach when delving into this matter is known as the utilitarian approach. For this frame work we, “[f]irst identify the various courses of action available to us. Second, we ask who will be affected by each action and what benefits or harms will be derived from each. And third, we choose the action that will produce the greatest benefits and the least harm. ”

In accordance with the analysis above when exploring this approach the action available to us is that the judge may either allow or not allow the testimony of the experts’ personal practices to be heard by the jury.

Next we explore who is affected when the testimony is allowed. In one respect the permission to allow the testimony of personal practice affects the defendant physicians adversely while being favorable to plaintiffs. The testimony creates another angle of holding an expert responsible to their testimony. If their preaching deviates from their practice, they face being perceived less credible by the jury, which in effect may deter attorneys from obtaining experts who would testify on the basis of any interest other than justice. In another respect plaintiffs can implicitly drive physicians to increase the standard of care. When the jury hears the testimony, it will likely create a negative impression on the jury. The jury could potentially accept the higher degree of care performed by the expert physician and, while not realizing it, create a newer and higher standard of care. Almost instantly the defendant’s practices are implicitly discredited, even though they may have been within the standard of care. Essentially each time this sequence of events would occur, plaintiffs force a higher standard on physicians practicing in the medical arena. Similarly this sequence of events could work adversely for the plaintiffs. Although at first the standards would increase, physicians could potentially decrease their standards of practice and uniformly practice medicine via a set standard. In a sense medicine could possibly be practiced at a general level, rather than an individual specific level. The fear could direct physicians in the future to follow a strict standard operating procedure based on their check of the patients’ symptoms. Without doubt this has the potential of severely and adversely affecting patients nationwide.

On the other hand, not allowing the testimony creates, a potential for various standards of care in terms of individual procedures. However, this is what the medical industry prefers, as medicine is not uniform practice. Rather medicine is an individualistic art, which patients with unique symptoms require individual observations, assessments, and prognoses. This directly benefits the defendants as it allows physicians to practice medicine to the best of their ability. Conversely it gives physicians room to negotiate if for any reason they did not provide the proper standard of care. Perhaps, providing physicians with too much flexibility and freedom from accountability? Arguably the human life is invaluable, and one of the greatest benefits is maintaining life over death. Those who acknowledge the responsibility of a human life must be required to meet those strict standards however the lack of pressure can create a venue of escape from responsibility.

In this light allowing the testimony of the expert witnesses personal practice projects a compelling interest. Not allowing the testimony also projects an equally compelling interest, however the human life is a benefit that carries great weight and in light of the cases mentioned above, the courts using a utilitarian approach would have ascertained a result that agreed with their legal analysis.

Common Good Approach:

The common good approach to ethical analysis focuses on ensuring that the social policies, social systems, institutions, and environments on which we depend are beneficial to all.

With the great weight of human life, the issue of personal practice testimony, in terms of social policy, would be encouraged. The testimony would likely provide an increase in the knowledge to the multiple approaches available to the patients. This implicitly creates a higher sense of accountability within physicians because it forces the physician to ask themselves, “what other approaches are available, and what are the ramifications of my actions with this procedure?” Personal practice testimony will also act to defend a physician who may have appropriately dealt with the patient as well as bring scrutiny to the practices of those physicians who allegedly did not meet the standard of care. However, they equally and unduly burden physicians. A physician can only be held to the standard that they should know of. Expecting a physician to practice the standard of care and then above and beyond practice what another physician might do, although idealistic, is not realistic. If anything it is the beginnings to a recipe for disaster. The effect could also cause a standardization of medical practice as measured above, where at first the standards would increase, physicians could potentially decrease their standards of practice and uniformly practice medicine via a set standard. In a sense medicine could possibly be practiced at a general level, rather than an individual specific level. Additionally under this ethical outlook, one could tenuously argue if the personal practice testimony was allowed, insurance costs as well as medical institution costs could eventually rise due to the added potential liabilities that each physician would have to seek protection against thereby shifting the disadvantage to the patients again. The argument suggest a chain of events which only return the system as a whole to the same point it was at before, except the difference is that the costs would be notably more.

Although the weight of personal practice testimony is high, it is outweighed by what is beneficial to all. Initially it may seem beneficial to all but, it would be difficult to find the happy medium when choosing to accept the personal practice testimony. Further the long term effects of allowing personal practice testimony would be more adverse to all than beneficial.

Normative Approaches:

Normative approaches to ethics are focused on studying what make actions right and conversely what makes those actions wrong.

Rights Approach:

The rights approach simply asks, “Does the action respect the moral rights of everyone? ” Actions are wrong to the extent that they violate the rights of individuals; the more serious the violation, the more wrongful the action.” As simple as the question is, the application of it can be very difficult to discern if broadly analyzed, thus we will narrowly focus the analysis.

In evaluating the moral rights, the permission to allow the testimony of the expert we address the rights of the participants in the proceedings. First, the plaintiffs’ rights are addressed as the experts personal practice can aid in making their claim. It also provides them the ability to protection from expert witnesses that are motivated by anything other than the interest of justice. Second, the defendants’ rights are addressed as the experts personal practice will either corroborate their actions or contradict them. Morally speaking, the interest of justice is what is morally right, the fact that the defendant maybe seen in an adverse light does not influence this perspective. Third, the rights of attorneys are respected when allowing the testimony the experts’ personal practice. Each attorney has the right to protect their client vigilantly, and must be able to inform the jury as to the standard of care. The personal practices are helpful for to the attorney to convey what the standard of care really is. Similarly, as stated above, morally speaking, the interest of justice is what is morally right; the fact that the defendant may be seen in an adverse light does not influence this perspective. Lastly we consider the jury’s rights. The jury is faced with unquestionably the most difficult task in the matter, which is to decide what will be the outcome of the trial. The jury members must, in order fulfill their moral rights, be able to hear the full testimony, including the discrediting testimonies to make a proper deliberation.

Using the rights approach, it is highly probable one would confer the use of the rights approach would lead to the admissibility of an experts personal practice in order to maintain the majority of moral rights of the majority people.

Virtue Approach:

The virtue approach is another approach under the normative view of ethics. This view establishes the task of not only doing what is right but also what will encourage right. It solicits the inquirer to ask, “what kind of person should I be, what will promote the development of character within myself and my community? ”

Using this approach, similar to a consequentialist approach, asks the individual to assess the outcome. It guides the individual to promote the development of character with one’s self and the community. In this sense it is likely that the one using this approach would allow the personal practice testimony as it would encourage the best of one’s self as well as the community. As discussed in prior approaches the testimony would implicitly drive physicians to increase the standard of care out of fear of not doing “enough”. The jury could potentially accept the higher degree of care performed by the expert physician and, while not realizing it, create a newer and higher standard of care due to their dismissal of the actual standard of care. The virtue approach in a nutshell views the experts personal practice as informative as it would likely yield other to those higher standards.

Thus accepting the personal practice testimony of an expert using a virtue view of ethics creates a “better person” and promotes the development of character within one’s self and their community.

Deontological Approach:

The deontological approach of ethics is the most common form of ethics characterized in the field of law, as it focuses on the duty of a person while weighing together their moral obligations and rules the individuals must adhere by. It is sometimes described as "duty" or "obligation" or "rule" based ethics, because rules "bind you to your duty"

Justice Approach:

Under the broader form of deontology, is the justice approach. It asks, “[h]ow fair is an action? Does it treat everyone in the same way, or does it show favoritism and discrimination?” Thereafter it weighed against the interest of justice.

In analyzing how fair or just allowing the testimony of the personal practice of a witness is, we decipher whether it shows favoritism or discrimination. On one hand to allow the personal practice testimony of a physician would show favoritism for the benefit of the plaintiff. It could allow the personal practice testimony of a physician who may have been superseding the standards of care for various reasons, thereby making it seem that, in the context of the cases mentioned above, as if the defendant did not meet the standard of care. On the other hand the barring of the experts personal practice testimony could likely hinder the ability for the plaintiff to plead their case, thereby creating a discriminatory effect for the plaintiff.

The approach seems equally compelling on each side, however in light of justice, the scales tip to the side of allowing the personal practice testimony of an expert physician. This specifically provides protection to the plaintiff from those few expert witnesses who may be motivated by anything other than the interest of justice. The justifying reason itself is to ensure justice, thus this approach would allow the jury to hear the testimony and surmise their own opinion. However without hearing the testimony the jury could potentially be misled, or pointed in a direction of a decision rather than deliberating their decision.

Thus the interest of justice prevails over the disadvantages it may bring forth.

Conclusion

The ethical dilemma faced when establishing the standard of care through an expert’s testimony although it conflicts with the experts own personal practice is without doubt, a difficult analysis. Although one approach leads the ethicist to one conclusion, another approach could likely have a different conclusion. Recently the trend has been established in the interest of justice, thereby creating a reason to allow the experts personal practices as relevant testimony. As medical malpractice continues to evolve the need for various analyses become ever important in identifying the proper decision going forward. Although ethics may not definitively provide the proper decision going forward, it does substantially provide a means of making that decision.

Appendix

[1] 1794 Conn. App. LEXIS 20; 2 Root 90, February, 1794, Decided

[1] Id.

[1] Id at 2.

[1] William L. Foster, Expert Testimony: Prevalent Complaints and Proposed Remedies, 11 HARV. L. REV. 169, 169 (1897).

[1] Rule 702. Testimony by Experts http://www.law.cornell.edu/rules/fre/rules.htm

[1] Party's duty to prove a disputed assertion or charge. The burden of proof includes both the burden of persuasion and the burden of production. Black's Law Dictionary (8th ed. 2004), burden of proof

[1] The greater weight of the evidence, not necessarily established by the greater number of witnesses testifying to a fact but by evidence that has the most convincing force; superior evidentiary weight that, though not sufficient to free the mind wholly from all reasonable doubt, is still sufficient to incline a fair and impartial mind to one side of the issue rather than the other. Black's Law Dictionary (8th ed. 2004)

[1] [T]he degree of care that a reasonable person should exercise. Black's Law Dictionary (8th ed. 2004), standard of care

[1] Categorically simplified the following paper describes the evidentiary issue of personal practice through three overarching ethical approaches. They are, in order of discussion, consequential theory, normative theory, and deontological theory.

[1] Schmitz v. Binette, 857 N.E.2d 846 (Ill. App. 2006).

[1] Id. at 848.

[1] See Schmitz v. Binette, 857 N.E.2d 846, 848 (Ill. App. 2006).

[1] MMK is and abbreviation for, Marshall-Marchetti-Krantz. It is a procedure to surgically restore the bladder to its normal physiological position.

[1] Schmitz v. Binette, 857 N.E.2d 846, 850 (Ill. App. 2006).

[1] At this point the case was on appeal as a result of foregoing testimony by Dr. Mercer. Prior to the appeal, the plaintiffs had filed a motion in limine, requesting permission to ask questions pertaining to Dr. Mercer’s personal practice on cross examination. The plaintiffs argued that the personal practices of Dr. Mercer were relevant, and would allow the jury to question the expert witness credibility and diminish the weight the jury would give to the testimony. However, prior to this case, personal practice testimony were deemed irrelevant to expert testimony. According, to the majority of opinions they did not carry weight. However, the higher court in this case overturned the decision citing precedential case history (See Infra) that, “an expert’s personal practices may well be relevant to that expert’s credibility, particularly when those practices do not entirely conform to the expert’s opinion as to the standard of care.” Schmitz v. Binette, 857 N.E.2d 846, 858 (Ill. App. 2006).

[1] See Schmitz v. Binette, 857 N.E.2d 846, 858 (Ill. App. 2006).

[1] Id. at 850

[1] Gallina v. Watson, 821 N.E.2d 326 (Ill. App. 2004).

[1] Gallina v. Watson, 821 N.E.2d 326, 327 (Ill. App. 2004).

[1] See id. at 327.

[1] See id. at 327.

[1] Id. at 327.

[1] Id. at 331.

[1] Id. at 328.

[1] Id. at 331.

[1] Perforation of the esophagus is a common result of a forceful dilation. (Wichern WA . Perforation of the esophagus. Am J Surg 1970; 119:534-536.)

[1] Esophageal perforation is a true emergency. Prompt diagnosis, in less than 24 hours, is vital to good outcomes. There is a mortality of 10% with early diagnosis and that mortality goes up to 50% with late diagnosis. (Allen Lue, M.D. (2001, May 31). Baylor College of Medicine. Retrieved April 28, 2010, from http://www.bcm.edu/oto/grand/05_31_01.htm)

[1] Rush v. Hamdy, 627 N.E. 1119, 1121-22 (Ill. App. 1993).

[1] Schatzki’s ring is a narrowing of the lower esophagus (typically due to an abnormal layer of tissue). Those who suffer from the disorder often face difficulty eating passing food and liquids from the mouth to the stomach. The difficulty is often times accompanied by pain and discomfort as the globules descends down the esophagus. In some patients the discomfort leads to phagophobia, in other words the fear of swallowing. Parker C, Power M, Hamdy S, Bowen A, Tyrrell P, Thompson DG (2004). "Awareness of dysphagia by patients following stroke predicts swallowing performance". Dysphagia 19 (1): 28–35. doi:10.1007/s00455-003-0032-8. PMID 14745643

[1] Rush v. Hamdy, 627 N.E. 1119, 1121 (Ill. App. 1993).

[1] Id.

[1] Id.

[1] Standard unit when measuring pressure.

[1] Dr. Hamdy initially recorded that the pressure was at five millimeters mercury, however the facts are unclear as to how many times the records were altered.

[1] Rush v. Hamdy, 627 N.E. 1119, 1121 (Ill. App. 1993).

[1] See Rush v. Hamdy, 627 N.E. 1119, 1122 (Ill. App. 1993).

[1] Rush v. Hamdy, 627 N.E. 1119, 1122 (Ill. App. 1993).

[1] An achalasia dilator is a balloon dilator typically used cases where a patient suffers from, you guessed it, achalasia. Achalasia is disorder of the esophagus, in which the patient has difficulty moving food from the mouth to the stomach.

[1] Rush v. Hamdy, 627 N.E. 1119, 1122 (Ill. App. 1993).

[1] Id.

[1] Id.

[1] A savary dilator is a thin, flexible, and hollow cylinder which is narrow at one end and then expands to a measured thickness. They are guided along a wire to dialate (expand) a target region. Savary dilators are available in multiple sizes and are a common tool when presented with a Schatzki’s ring. Savary dilators have statistically been shown to be more effective and simpler to use as compared to balloon dilators (achalasia dilators).

[1] Id. at 1126.

[1] See Schmitz v. Binette, 857 N.E.2d 846 (Ill. App. 2006) (Ruled that an expert’s personal practices may well be relevant to that expert’s credibility, particularly when those practices do not entirely conform to the expert’s opinion as to the standard of care, and Gallina v. Watson, 821 N.E.2d 326 (Ill. App. 2004) (same), Rush v. Hamdy, 627 N.E. 1119 (Ill. App. 1993) (same), and Smethers v. Campion, 108 P.3d 946 (Ariz. App. 2005) (same), Wallbank v. Rothenberg, 74 P.3d 413 (Colo. App. 2003) (same), and Condra v. Atlanta Orthopaedic Group, 681 S.E.2d 152 (Ga. 2009) (same).

[1] A perspective in which there is definite positive and contra positive.

[1] An ill-defined area of activity that does not readily conform to an existing category or set of rules. (Oxford Dictionary. (n.d.) Ask Oxford. Retrieved April 22, 2010, from http://www.askoxford.com/concise_oed/greyarea?view=uk

[1] Barry R. Furrow, T.L. (2008). Bioethics: Health Care Law and Ethics, 6th ed., pg. 5, St. Paul: Thomson / West.

[1] Barry R. Furrow, T.L. (2008). Bioethics: Health Care Law and Ethics, 6th ed., pg. 5, St. Paul: Thomson / West.

[1] Manuel Velasquez, C. A. (1996, Winter). Thinking Ethically: A Framework for Moral Decision Making. Retrieved April 22, 2010, from http://www.scu.edu/ethics/practicing/decision/thinking.html

[1] Id.

[1] Id.

[1] Id.

[1] Id.

[1] Id.

[1] Waller, Bruce N. 2005. Consider Ethics: Theory, Readings, and Contemporary Issues. New York: Pearson Longman: 23

[1] Manuel Velasquez, C. A. (1996, Winter). Thinking Ethically: A Framework for Moral Decision Making. Retrieved April 22, 2010, from http://www.scu.edu/ethics/practicing/decision/thinking.html