In this case, the Court of Appeals of North Carolina faced what it called “a variety of novel issues concerning virtually every facet of negligence.” The court, however, zeroed in on only one issue: proximate causation.
Wendell Justin Williamson stopped attending his law school classes at the University of North Carolina at Chapel Hill in January, 1995. Williamson retrieved an M-1 rifle from his family home, bought some ammunition, and moved into his car. On the night of January 26, Williamson took the rifle to downtown Chapel Hill, and fired randomly at people. He killed two before police officers shot him in the legs to stop him. Williamson, charged with two counts of first-degree murder, was found not guilty by reason of insanity.
Williamson sued his psychiatrist, Myron B. Liptzin. Dr. Liptzin attended to Williamson as a walk-in patient at the university's Student Psychological Services eight months before. Williamson alleged that Dr. Liptzin negligently treated Williamson's mental illness, and that the negligence caused Williamson to be shot in the legs, tried for murder, and confined to a mental institution.
The trial court denied Dr. Liptzin's motions for summary judgment, directed verdict, and judgment notwithstanding the verdict. A jury found against Dr. Liptzin, and the court awarded Williamson $500,000.
Treat Your Telepathy, or No Bar Exam
Dr. Liptzin appealed. He contented primarily that his negligence, if any, did not proximately cause Williamson's injuries.
The court traced Williamson's mental difficulties as far back as 1990. Williamson, then an undergraduate, sought walk-in counseling for “relationship issues and academic problems” at Student Services. The doctor who reviewed his intake form described Williamson's problems as “fairly normative.”
Two years later, Williamson was temporarily involuntarily committed, after he screamed at students, struck himself in the face, claimed that he was telepathic, and said he heard voices. He was diagnosed with “rule/out schizophrenia.” This diagnosis, an expert explained at trial, means schizophrenia should either be assumed, because time had not permitted a contrary diagnosis, or kept foremost in mind until a less serious condition otherwise proved to cause the patient's problem.
In 1994, Williamson disrupted a law school class to announce that he was telepathic. Student Services intake psychologists recommended against involuntary hospitalization, because “student denies danger to self or others.” Williamson refused to permit the staff to treat or medicate him—until the law school dean informed Williamson that if he did not seek treatment, the school might not recommend him as a candidate for the bar exam.
A More “Generous” Diagnosis
Dr. Liptzin counseled Williamson six times, for up to an hour per session, over the next ten weeks. Dr. Liptzin recognized some schizophrenia symptoms, and recommended the antipsychotic drug Navane. But he recorded a diagnosis of “delusional disorder grandiose,” which he called a more “generous” diagnosis, to avoid hampering Williamson's legal career.
In their fourth session, Dr. Liptzin notified Williamson that he intended to retire from Student Services in about two months, and that he could refer another psychiatrist to continue regular therapy.
In their last session, Dr. Liptzin instructed Williamson either to visit the community health center or family doctor, or to see Liptzin's replacement. Dr. Liptzin recorded in Williamson's medical chart that Williamson was content to stay on Navane, that he knew Liptzin was leaving Student Services, and that Williamson would see Liptzin's replacement in the fall semester.
Williamson claimed that Dr. Liptzin also said “that in his opinion, [Williamson] was probably not really schizophrenic or psychotic” and that “if someday [Williamson] wanted to go off the medication, that [he] could do that if [he] told someone [he] trusted.”
Williamson responded well to the treatment. The telepathy and delusions were “completely gone”; the hallucinations, nearly so. His friends reported that he was more “like his old self.”
He spent the summer at his parents' home. He did not, though, visit the community health center or another doctor. When he temporarily stopped taking the Navane, he seemed to feel better and less susceptible to sunburn. He told his parents he would discontinue the medication altogether. Williamson returned to school in the fall, completed the semester successfully without disrupting classes, and drove to Connecticut and New York over Christmas break.
When he returned, though, Williamson began to reside in his car. He gathered his gun and ammunitions. Soon he fired randomly on people in downtown Chapel Hill.
“No Crystal Ball That Good”
Dr. Liptzin argued on appeal that he was entitled to a judgment notwithstanding the verdict, because he did not proximately cause the injuries Williamson claimed.
To establish the foreseeability element of proximate cause, the plaintiff must 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.”[1]
“However,” the court elaborated, “the law does not require that the defendant ‘foresee events which are merely possible but only those which are reasonably foreseeable.'”[2]
Psychiatrist Stephen Kramer testified for Williamson that the defendant misdiagnosed Williamson's illness. The proper diagnosis was chronic paranoid schizophrenia, not delusional disorder grandiose. The defendant, Kramer testified, did not “pursue a proper diagnosis, including review of old records available and assessing risk for potential deterioration and violence” nor did the defendant “develop a program for continuing care” beyond his retirement. Moreover, if the defendant told Williamson he could discontinue his medication if he informed a responsible adult, that would be an “invitation to not comply with the recommended therapy.”
When counsel asked whether the defendant could have reasonably foreseen that Williamson would become violent, however, Kramer testified that was “harder to answer”:
“I'm not sure that I can go that far with it,” Kramer said. “I can say that the foreseeable elements are those that when they come together in time would lead to dangerousness."
Psychiatrist James Bellard also testified for the plaintiff that the defendant violated the applicable standard of care. But when questioned on the foreseeability of dangerousness, Dr. Bellard said, “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.”
“Absolutely No Evidence” of Threat
The court held that the evidence, in the light most favorable to Williamson, “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.”
Moreover, Williamson's own experts, Drs. Kramer and Ballard, hedged on whether his dangerousness was foreseeable. The court described Dr. Ballard's testimony that “[n]obody's crystal ball is that good” as “the most telling testimony at trial. . . .”
“The uncertainties inherent in analyzing and treating the human mind,” quoted the court, “let alone the decision of when a person is ‘cured' and no longer a danger, renders [sic] the decisions of skilled doctors highly discretionary and subject to rebuke only for the most flagrant, capricious, and arbitrary abuse.”[3]
Footnotes:
Hart v. Curry, 78 S.E.2d 170, 170 (1953).
Quoting Hairston v. Alexander Tank & Equipment Co., 311 S.E.2d 559, 565 (1984).
Quoting Leverett v. State, 399 N.E.2d 106, 110 (Ohio Ct. App. 1978).
 | Lawrence Levine, J.D. Professor of Law University of the Pacific |
Levine: Williamson presents an all-too-familiar fact pattern in an unusual legal context. Since the famous Tarasoff case,[1] most courts have come to impose a legal obligation on psychotherapists to warn foreseeable victims of credible threats made to psychotherapists by their patients. In coming to this conclusion and in deciding the appropriate parameters of such a legal obligation, courts have spoken about the existence of a legal duty on the part of the psychotherapist. Duty is the first element of a negligence claim. To establish the existence of a duty the plaintiff must persuade a judge that the law imposes some obligation on the part of the defendant to act other than arbitrarily toward the plaintiff. Because the decision whether to impose a duty is often policy driven, it is reserved as a question of law for a judge.
“Williamson could have been dealt with as a duty case.”
Williamson could have been dealt with as a duty case, a judge determining if public policy favors imposing a legal obligation under the facts of the case. The plaintiff in Williamson is the patient himself, suing the psychotherapist for not following customary medical standards that would have prevented the plaintiff from engaging in the conduct that led to a murder prosecution. The court could have determined, for example, that, while a duty is owed to foreseeable third parties, no such obligation is owed the patient himself; there are public policy interests that can support such a distinction.[2]
Proximate Cause: The Most Nebulous Element
The Williamson court decided to take another path, however. Instead of treating the issue as one of duty, the court opted to focus on proximate cause, a most nebulous element of a negligence cause of action. Both duty and proximate cause can serve to limit a defendant's liability in appropriate circumstances, but there are significant differences between them. In fact, it is these differences that gave rise to what is probably the most famous of all torts cases: Palsgraf v. Long Island Railroad.[3]
In Palsgraf, Judge Cardozo determined for the majority of the New York high court that duty was the proper element to limit liability, finding a duty extending only to foreseeable plaintiffs. Judge Andrews for the dissenters argued instead that proximate cause was the brake on liability, that “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.” Ultimately, both judges have prevailed to some degree with duty and proximate cause both serving as potential ways to limit a defendant's scope of liability.
By selecting proximate cause as the focus, the Williamson court necessarily focused on the foreseeability of the harm, as that is often a central component of proximate cause. A defendant is not liable for unforeseeable types of harm arising from the defendant's negligence. The court explained: “If the connection between negligence and the injury appears unnatural, unreasonable, and improbable in the light of common experience, the negligence . . . is to be considered remote rather than proximate.” “Common experience” is not the proper focus here though. The question is whether in light of professional medical knowledge the result is too unexpected and attenuated.
A “key aspect of proximate cause is that the type of harm suffered by the plaintiff must be the kind of harm that made the defendant's conduct negligent in the first place.”
Narrow View of Anticipated Harm
In determining the lack of proximate cause as a matter of law here,[4] the court noted the passage of time between the plaintiff's last appointment with the defendant and the killings as well as the general unforeseeability of the type of harm. Both are appropriate considerations. In fact, a key aspect of proximate cause is that the type of harm suffered by the plaintiff must be the kind of harm that made the defendant's conduct negligent in the first place.
The debate is about how broadly or narrowly this expected type of harm is to be defined, however, with the Williamson court opting for an arguably narrow view of the anticipated harm. Here there was no doubt that the plaintiff exhibited “risk factors.” The question was what the foreseeable result of those risk factors would be. In finding a lack of foreseeability in this case, the court stated:
[T]he 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 the circumstances in which the alleged injuries arose. . . . Given the lack of evidence of violence or any threats of violence on plaintiff's behalf, “the connection between the negligence and the injury appears unnatural, unreasonable and improbable.”
If the court reached this determination based on science the result is probably a sound one, but if based only on its own general notions of foreseeability, the decision is problematic. The expert testimony seemed to conflict, suggesting that it was a call for the jury.
Ultimately the court raises several public policy arguments to support its result. The court expressed concerns about “the difficulties inherit [sic] in the treatment and diagnosis of mental illness” and noted that the defendant was seeing the plaintiff as an outpatient. The court also discussed the adverse effects a contrary ruling would have on psychiatric care in the state as it would lead to an increase in involuntary commitments and other steps contrary to the state's policy to treat those with mental illness with respect and dignity. These public policies are important, but they are the same ones that were raised and rejected by the court in Tarasoff.
Footnotes:
Tarasoff v. Regents of the Univ. of Cal., 551 P.2d 334 (Cal. 1976).
Cf. Bellah v. Greenson, 146 Cal. Rptr. 535 (Cal. App. 1978), in which the court determined
Tarasoff did not apply where the patient's threats are of “self-inflicted harm or property damage.”
A key difference between duty and proximate cause is that the latter is viewed as a question for the jury unless the evidence is so strong that no reasonable jury could disagree about the outcome. The court in
Williamson determined that the only reasonable conclusion a jury could make is that proximate cause did not exist under these facts.
