Georgia M. Rathje, Kelly Rathje And Richard Rathje Vs. Mercy Hospital, Cedar Rapids, Iowa, And Dwight J. Schroeder ( 2008 )

IN THE SUPREME COURT OF IOWA
No. 115 / 04–2081
Filed February 22, 2008
GEORGIA M. RATHJE, KELLY RATHJE and RICHARD RATHJE,
Appellants,
vs.
MERCY HOSPITAL, CEDAR RAPIDS, IOWA, and
DWIGHT J. SCHROEDER,
Appellees.
Appeal from the Iowa District Court for Linn County, Thomas M.
Horan, Judge.
District court granted summary judgment for defendants in a
medical malpractice action. REVERSED AND REMANDED.
James P. Hayes and Karen A. Lorenzen of Hayes Lorenzen Lawyers
PLC, Iowa City, and Richard H. Doyle of Galligan, Doyle & Reid, PC,
Des Moines, for appellants.
David A. Elderkin and Robert M. Hogg of Elderkin & Pirnie, P.L.C.,
Cedar Rapids, for appellees.
2
CADY, Justice.
In this appeal, we must decide if the district court correctly
granted summary judgment in a medical malpractice action based on a
claim that the plaintiffs failed to file their petition within the statute of
limitations. Although the district court relied on our line of prior cases in
reaching its decision, we now conclude the statute of limitations for
medical malpractice actions does not begin to run until discovery of both
the injury and its factual cause. On our review, we reverse the decision
of the district court and remand for further proceedings.
I. Background Facts and Proceedings.
On March 19, 1999, Kelly and Richard Rathje admitted their
sixteen-year-old daughter, Georgia, to an outpatient alcohol abuse
treatment center at Mercy Hospital in Cedar Rapids. Part of the
treatment plan developed for Georgia called for the administration of a
drug called Antabuse. This drug causes the body to produce an alcohol
sensitivity that results in a highly unpleasant reaction to the ingestion of
beverages containing alcohol. The treatment plan called for Georgia to
receive a liquid dose of Antabuse, administered by a nurse at the
treatment center, twice each week.
Around a week later, Georgia began to feel sick and nauseated.
She also began to experience cramps and was constipated. Georgia
reported these symptoms to the nurse who administered the Antabuse at
the treatment center, and the nurse suggested she consume food prior to
taking Antabuse in the future.
On April 5, Kelly contacted the family’s physician, Dr. Jerome
Janda, to report Georgia was nauseated and frequently expelled an acid-
like fluid from her stomach. Dr. Janda subsequently examined Georgia,
and ordered an upper gastrointestinal test. The results of the test were
3
consistent with peptic disease and duodenitis, but revealed no definite
ulcer or reflux disease. Dr. Janda prescribed medication for Georgia’s
stomach pain.
On April 20, Georgia would not eat or drink. She was suffering
from abdominal pain and was vomiting a green substance. She was also
fatigued. Kelly reported these symptoms to a nurse in Dr. Janda’s office.
On April 23, Georgia was seen by Dr. Janda with continued
complaints of nausea and constipation. Dr. Janda ordered x-rays,
together with a liver function test, a blood test, and a test used to
diagnose various intestinal diseases and problems. The x-rays were
taken, but the other tests were not performed due to a mix-up.
On April 26, Georgia returned to Dr. Janda’s office. She had been
bedridden for most of the time since the previous office visit on April 23.
She was nauseated, vomiting, and constipated. At this visit, Dr. Janda
noticed Georgia’s skin color was “mildly yellow or jaundiced and the
whites of her eyes were yellowish or icteric.” He again ordered the prior
tests and added a test to determine the presence of any inflammation.
Georgia had blood drawn for testing at Mercy Hospital. The blood
tests were performed by the hospital lab, with abnormal results.
Dr. Janda informed Kelly of the test results, and Georgia was admitted to
St. Luke’s Hospital on April 27.
Dr. Janda consulted with a surgeon about his concern that
Georgia could have gallbladder stones. A CAT scan revealed some
enhancement of the gallbladder wall and some fluid around the
gallbladder, but no other abnormalities. The surgeon then consulted
with a gastroenterologist.
The gastroenterologist determined the jaundice and elevated liver
enzymes experienced by Georgia were secondary to hepatitis. He
4
believed Georgia’s condition might be a “drug-induced hepatitis
secondary to Antabuse.” He recommended Georgia stop taking all prior
medications.
Georgia was discharged from St. Luke’s Hospital, but promptly
readmitted on April 29. She still appeared jaundiced, and her condition
continued to deteriorate over the passing days. On May 5, she was
transferred to the University of Iowa Hospitals and Clinics Pediatric
Intensive Care Unit. She later received a liver transplant as a result of
end-stage liver disease secondary to Antabuse.
On April 26, 2001, Georgia and her parents filed a petition against
numerous health care providers, including Mercy and Dr. Dwight
Schroeder, the medical director at the Alcohol Treatment Center at
Mercy. The lawsuit claimed Dr. Schroeder and the hospital were
negligent in prescribing Antabuse and in their treatment of Georgia for
alcohol abuse, and this negligence was the cause of her irreversible liver
damage and transplant. The Rathjes eventually dismissed all defendants
from the lawsuit except Mercy Hospital and Dr. Schroeder.
Mercy Hospital and Dr. Schroeder filed answers to the petition and
later were permitted to amend their answers to claim the statute-of-
limitations defense. They both then subsequently moved for summary
judgment based on the two-year statute of limitations.
Mercy Hospital and Dr. Schroeder claimed the statute of
limitations began to run when Georgia began to experience symptoms of
her injury prior to April 26, 1999. Georgia and her parents claimed the
statute of limitations began to run when Georgia learned after April 26,
1999, her liver was irreversibly damaged, or, at the earliest, when her
condition worsened on April 26, 1999, to include symptoms of jaundice.
5
The district court granted summary judgment for Mercy Hospital
and Dr. Schroeder. It found the facts were undisputed that Georgia’s
injury had physically manifested itself well prior to April 26, 1999, more
than two years before the Rathjes filed suit. Consequently, it concluded
the lawsuit filed by the Rathjes was barred by the statute of limitations
contained in Iowa Code section 614.1(9)(a) (2001).
The Rathjes appealed. They argue the district court erred in
allowing Mercy to amend its answer to include a statute-of-limitations
defense and further argue the district court erred in granting summary
judgment for Mercy Hospital and Dr. Schroeder.1
II. Standard of Review.
We review a district court ruling granting a motion for summary
judgment for correction of errors at law. Kragnes v. City of Des Moines,
714 N.W.2d 632, 637 (Iowa 2006).
III. Statute of Limitations for Medical Malpractice Actions.
This case requires us once again to visit the medical malpractice
statute of limitations and apply it to the facts of a particular case. We
have done this on a number of occasions since the special statute was
enacted in 1975, and have developed a body of interpretative law in the
process. Yet, this law has raised some questions about the fairness of
1We conclude the district court did not abuse its discretion in allowing the
hospital and Dr. Schroeder to amend their petitions. See Rife v. D.T. Corner, Inc., 641
N.W.2d 761, 766 (Iowa 2002) (“We afford district courts considerable discretion in
ruling on motions for leave to amend pleadings. Consequently, we will reverse only if
the record indicates the court clearly abused its discretion.” (Citations omitted.)). The
Rathjes raised two primary arguments in support of their claim that the district court
erred in granting summary judgment. In addition to arguing their lawsuit was filed
within two years of the date the injury was discovered, the Rathjes claimed their lawsuit
should survive the statute of limitations under the continuing treatment and
continuum of negligent treatment doctrines. We only address the issue concerning the
date of discovery of the injury in this appeal. Our resolution of this issue in favor of the
Rathjes makes it unnecessary to address their claim that the district court erred in
failing to adopt the continuing treatment and continuum of negligent treatment
doctrines.
6
the outcome of a number of these cases. This perception has not gone
unnoticed by us, for we have freely acknowledged the statute can
“severely restrict[] the rights of unsuspecting patients.” Schlote v.
Dawson, 676 N.W.2d 187, 194 (Iowa 2004). Nevertheless, we have
declined to change course, recognizing it is the role of the legislature to
“address this problem.” Id.
It is, of course, the role of the legislature to write statutes, and it is
our role to interpret them based on their application in the course of
litigation. Moreover, the legislature can rewrite a statute to reflect its
intent when it does not believe our interpretation in a particular case has
accomplished this goal. Yet, these general principles of separation of
powers and fundamental duties do not totally absolve us from our
continued responsibility to interpret applicable statutes in each case
and, more importantly, to revisit our past interpretations if we are
convinced they have not clearly captured the intent of our legislature.
We adhere to precedent, but also remain committed to clarifying the law
as we work with our precedent. When our interpretation of a statute has
created problems in the application of the statute to subsequent cases,
we should be willing to reexamine our precedent to see if our
understanding of the legislative intent can be better articulated. See
Ruth v. Dight, 453 P.2d 631, 634 (Wash. 1969) (reexamining past
interpretation of statue of limitations in light of “constant intellectual
bombardment”).
We begin the task of revisiting our interpretation of section
614.1(9) by returning to the original statute of limitations for personal
injury actions enacted by our legislature in the Nineteenth Century. This
journey is necessary to put the issue we face today in perspective and to
help understand the intent of our legislature in choosing the language it
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used to write the statute of limitations for medical malpractice actions.
As originally enacted, the statute of limitations provided:
“The following actions may be brought within the times
herein limited, respectively, after their causes accrue, and
not afterwards, except when otherwise specially limited: (1)
Actions founded on injuries to the person . . ., whether based
on contract or tort, . . . within two years.”
Fadden v. Satterlee, 43 F. 568, 568–69 (S.D. Iowa 1890) (quoting Iowa
Code § 2529). Thus, our legislature selected the prescriptive period of
time to bring a personal injury action based on tort and used the accrual
of the claim as a starting point for the limitation period. In doing so, the
legislature determined a two-year period was sufficient for a reasonably
diligent person to file a claim with the judicial system.2 See Estate of
Kuhns v. Marco, 620 N.W.2d 488, 491 (Iowa 2000) (“Statutes of
limitations establish a reasonable period of time for plaintiffs to file their
claims.”). The statute was designed primarily to protect the courts and
defendants from the multitude of problems that can occur in dealing
with stale claims. Id.; see Schulte v. Wageman, 465 N.W.2d 285, 286
(Iowa 1991) (recognizing the burdens of defending a claim after memories
have faded, witnesses have died or disappeared, and evidence is lost).
While the legislature prescribes the period of limitation, courts
have generally been called upon to determine when a claim accrues to
start the running of the statute of limitations. See Roberts v. Sw. Cmty.
Health Servs., 837 P.2d 442, 446 (N.M. 1992) (recognizing that, absent
instructions from the legislature, courts must determine when a cause of
2Allstates have enacted a statute of limitations for tort victims and nearly all
such statutes require the action to be filed within one to three years of the accrual of
the action. David W. Feeder II, When Your Doctor Says, “You Have Nothing to Worry
About,” Don’t Be Sure: The Effect of Fabio v. Bellomo on Medical Malpractice Actions in
Minnesota, 78 Minn. L. Rev. 943, 950 (1994). The vast majority of states, like Iowa,
have adopted a two-year limitation period. Id.
8
action accrues under a statute of limitations); see also Developments in
the Law of the Statute of Limitations, 63 Harv. L. Rev. 1177, 1203–05
(1950). This task has been formidable, largely due to the manifold
sequences in which the elements of a tort action can unfold and become
discernible to a plaintiff as a signal to pursue a legal remedy for a wrong.
See Ruth, 453 P.2d at 634 (recognizing that the application of statutes of
limitation in medical malpractice cases has been a vexing and
continuous source of judicial uncertainty).3
The first rule to emerge from our early statute-of-limitations cases
was that a claim accrued when the injured party had a “right to institute
and maintain a suit.” Chrischilles v. Griswold, 260 Iowa 453, 461, 150
N.W.2d 94, 99 (1967), superseded by statute, 1975 Iowa Acts ch. 239,
§ 26, as recognized in Langner v. Simpson, 533 N.W.2d 511 (Iowa 1995);
see Dean v. Iowa-Des Moines Nat’l Bank & Trust Co., 227 Iowa 1239,
1242, 281 N.W. 714, 717 (1938) (explaining a cause of action does not
“accrue” until the plaintiff is entitled to sue). This approach meant the
statute was triggered when the commission of a tortious act caused a
legally recognized injury. See Schnebly v. Baker, 217 N.W.2d 708, 721
(Iowa 1974) (“The general rule in tort cases is that the period of
limitations commences when the tort is committed.”), overruled on other
grounds by Franke v. Junko, 366 N.W.2d 536 (Iowa 1985). It reflected
the general rule of law around the country. Id.
We also observed early on that the tortious act committed by a
defendant was not always immediately followed by the resulting injury.
3“Like most general rules of law,” the rules “pertaining to ‘limitations’ become
less than profound when an attempt is made to apply them to specific cases.” Mattingly
v. Hopkins, 253 A.2d 904, 907 (Md. 1969). This complexity primarily results when the
elements of a cause of action unfold sequentially (rather than simultaneously) and can
be further compounded by additional factors unique to professional malpractice. Id.
9
Ogg v. Robb, 181 Iowa 145, 155–56, 162 N.W. 217, 220–21 (1917); see
also United States v. Kubrick, 444 U.S. 111, 122, 100 S. Ct. 352, 359, 62
L. Ed. 2d 259, 269 (1979) (noting “[t]hat [the plaintiff is] injured in fact
may be unknown or unknowable until the injury manifests itself” and
thus recognizing, at least implicitly, that the tortious act does not always
temporally coincide with the injury); Hansen v. A.H. Robins, Inc., 335
N.W.2d 578, 580 (Wis. 1983) (“Although the negligence and resulting
injury are often simultaneous, occasionally an injury will not be
sustained until a subsequent date.”). Thus, in response to a number of
statute-of-limitations cases in which the injury did not occur until long
after the wrongful act, our general rule for the accrual of a claim was
more specifically described to commence the running of the statute of
limitations for personal injury actions at the time the injury occurred.
Ogg, 181 Iowa at 155–56, 162 N.W. at 220–21; Gustin v. County of
Jefferson, 15 Iowa 158, 160 (1863) (declaring the statute of limitations
commences to run from the time the injury is done); see also Fadden, 43
F. at 568–69 (concluding Iowa’s statute of limitations in malpractice
cases begins to run at the time of the injury).
This approach was logical because the injury would not always
occur at the same time as the wrongful act, but no cause of action could
accrue until the injury occurred. Ogg, 181 Iowa at 155–56, 162 N.W. at
220–21 (recognizing a cause of action accrues when damages are
sustained in those cases in which the wrongful act itself does not cause
an immediate legal injury, but when damages subsequently occur as a
result of the act); see also Hansen, 335 N.W.2d at 580 (holding the injury
is the triggering event because the injury may occur after the negligent
act). Thus, we transformed the general rule to more accurately describe
that a claim did not accrue under the statute of limitations until the
10
injury occurred. Of course, there was no change in the rule that the
statute of limitations began to run even if the plaintiff had not discovered
the injury or its cause. The early case of Ogg illustrates this approach.
In Ogg, the plaintiff suffered burns on his arms as a result of x-
rays taken by the doctor after he broke his wrist. 181 Iowa at 147, 162
N.W. at 218. This event occurred in 1901. Id. In 1912, the plaintiff
developed cancer in his arm, resulting in amputation. Id. In 1915, he
brought a negligence action against the doctor, alleging the x-rays
caused the cancer. Id. at 147, 162 N.W. at 219. After finding no
evidence of fraudulent concealment of the tort by the physician, the court
concluded the cause of action accrued at the time of the burn in 1901,
and the action was therefore barred by the statute of limitations. Id. at
155–65, 162 N.W. at 220–21. This approach reaffirmed the bright-line
rule, but frequently left victims who were unable to discover their injuries
within the statute-of-limitations period, through no fault of their own,
without any remedy.
Application of the general statute of limitations based on the
occurrence of the injury was followed well into the Twentieth Century.
The individual hardship visited on those plaintiffs who failed to discover
the injury before the end of the statute-of-limitations period was largely
considered to be the price paid to achieve the greater societal goals of the
statute of limitations. See W. Page Keeton, et al., Prosser and Keeton on
the Law of Torts § 30, at 165 (5th ed. 1984). Yet, the Iowa legislature was
not totally unsympathetic to litigants who were unaware of their rights
until after the statute of limitations had run. In 1860, the legislature
enacted a separate statute of limitations for actions based on fraud that
delayed the accrual of the action until the fraud was discovered. Iowa
11
Code § 2741 (1860). The statute was consistent with the established
English statute of limitations
that where the party against whom a cause of action existed
in favor of another, by fraud or actual fraudulent
concealment prevented such other from obtaining knowledge
thereof, the statute would only commence to run from the
time the right of action was discovered, or might, by the use
of diligence, have been discovered.
Dist. Twp. of Boomer v. French, 40 Iowa 601, 607 (1875). The Iowa
statute was later amended to add actions for trespass to property to the
exception, see 1868 Iowa Acts ch. 167, § 9, and still later, in 1873, to
add actions grounded on mistake, see Iowa Code § 2530 (1873). See
Beerman v. Beerman, 225 Iowa 48, 51–52, 279 N.W. 449, 450–51 (1938)
(tracing the evolution of what was then Iowa Code section 11010
(1935)).4
During the time we maintained allegiance to the bright-line rule
that the statute of limitations for personal injury actions commenced at
the time the injury occurred, we began to develop a body of law
surrounding the common-law discovery rule. In applying the discovery
rule to the specific legislative exceptions, we held that actual knowledge
of the fraud and other wrongs was not required before the statute of
limitations began to run. Instead, we declared:
The “discovery” of the fraud or wrong which will set the
statute in motion does not necessarily mean actual and
direct personal knowledge by the complaining party. It is
sufficient if such party has such knowledge or notice as
would lead a man of reasonable prudence to make inquiries
which would disclose the fraud.
Van Wechel v. Van Wechel, 178 Iowa 491, 496, 159 N.W. 1039, 1041
(1916) (citing E.B. Piekenbrock & Sons v. Knoer, 136 Iowa 534, 538, 114
4Statutoryexceptions for actions based on fraud, mistake, and trespass to land
remain today and are codified in section 614.4.
12
N.W. 200, 201 (1907)). Thus, we introduced into our discovery rule
jurisprudence the concept that the knowledge needed to start the statute
of limitations only meant that the plaintiff needed that amount of
information to allow a reasonably prudent person to discover the fraud or
wrong by making inquiries. This concept later became known as “inquiry
notice.” See Franzen v. Deere & Co., 377 N.W.2d 660, 662 (Iowa 1985).
While the discovery rule began to take root in Iowa, its impact on
the general statute of limitations remained limited. Other jurisdictions,
however, began to apply the “discovery rule” to the general statute of
limitations for personal injury tort claims. This broader application of
the discovery rule was in response to the harshness of the prevailing rule
to unsuspecting plaintiffs who were blamelessly ignorant of their legal
rights. In the same year we rejected the discovery rule in Ogg, Maryland
became the first, or arguably the first, state in the nation to apply the
discovery rule to a medical malpractice case. See Note, The Statute of
Limitations in Actions for Undiscovered Malpractice, 12 Wyo. L.J. 30, 34
(1957) (suggesting Maryland was the first court to adopt a discovery rule
in malpractice claims). In Hahn v. Claybrook, 100 A. 83 (Md. 1917), a
plaintiff brought a malpractice action against her doctor, claiming the
doctor negligently prescribed argentum oxide for a six-year period
between 1904 and 1910. Hahn, 100 A. at 84. The plaintiff claimed the
excessive quantities of the drug caused silver poisoning, a chronic
discoloration of the skin. Id. The Maryland court determined the
discoloration of her skin was apparent by 1908, and
was a sufficient indication of an injury, to have put her upon
notice and inquiry, and it is clear from the evidence that if
she had exercised ordinary care and diligence to have
ascertained her rights, she could have discovered the cause
of her alleged injury.
13
Id. at 86. Consequently, the court held the statute of limitations began
to run at the time the plaintiff first noticed her skin discoloration in
1908, not when the doctor began prescribing the drug. Id.
The application of the discovery rule to the general statute of
limitations grew in popularity throughout the Twentieth Century,
although not all jurisdictions utilized the same event to trigger the
statute of limitations under the discovery rule. See Roberts, 837 P.2d at
449 (recognizing a shift in the weight of authority towards the discovery
rule); A. Sonerstein, A Discovery Rule in Medical Malpractice:
Massachusetts Joins the Fold, 3 W. New Eng. L. Rev. 433, 433–34 & n.1
(1981) (listing forty-one jurisdictions that adopted the discovery rule in
some form); W. Page Keeton, et al., Prosser & Keeton on the Law of Torts
§ 30 (5th ed. 1984 & Supp. 1988) (recognizing a wave of decisions and
legislative enactments adopting the discovery rule). The decision that
gave the movement its greatest thrust was Urie v. Thompson, 337 U.S.
163, 69 S. Ct. 1018, 93 L. Ed. 1282 (1949), an action under the Federal
Employers Liability Act in which the plaintiff contracted silicosis from his
work environment over a ten-year period, but his condition was not
diagnosed until two weeks after he became too ill to work. Urie, 337 U.S.
at 165–66, 59 S. Ct. at 1022–23, 93 L. Ed. at 1290. The Court rejected
the claim that the injury occurred years prior to a diagnosis and held the
claim did not accrue until the disease manifested itself. Id. at 169–70,
69 S. Ct. at 1024, 93 L. Ed. at 1292–93.
In 1967, Iowa joined the parade of states to apply the discovery
rule to the general statute of limitations. In Chrischilles, we recognized
the national trend toward adopting the discovery rule as the better
approach for claims based on negligence. 260 Iowa at 461, 150 N.W.2d
at 100. We also observed with approval that the discovery rule as
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defined in other jurisdictions meant the statute of limitations did not
begin to run until the date “the wrongful act” was discovered or should
have been discovered. Id. Yet, we ultimately held that actions for
negligence do not accrue until the plaintiff discovers or should have
discovered “the injury to his interest.” Id. The distinction between “the
wrongful act” and “the injury” as the triggering event went unnoticed.
Seven years later, we applied the discovery rule to the general
statute of limitations in a medical malpractice action. In Baines v.
Blenderman, 223 N.W.2d 199 (Iowa 1974), superseded by statute, 1975
Iowa Acts ch. 239, § 26, as recognized in Langner, 533 N.W.2d 511, the
plaintiff, Baines, awoke from surgery on a herniated disk and was unable
to see out of his right eye. Baines, 223 N.W.2d at 202. The surgery took
place on March 30, 1970. Id. at 200. A treating physician told Baines
the condition was temporary. Id. Baines, however, was eventually
examined by another doctor on July 15, 1970. Id. at 201. This doctor
informed Baines his vision loss could have been caused by the
deprivation of blood to his eye during the surgery and his condition was
permanent. Id. Baines filed an action against the surgeon more than
two years after the surgery but less than two years after he was informed
of the probable cause of his condition and that his condition was
permanent. Id. at 200–01.
The doctor moved for summary judgment based on the statute of
limitations, and Baines invoked the discovery rule. Id. at 201. Baines
claimed he was unaware of his cause of action under the discovery rule
adopted in Chrischilles until he was informed on July 15, 1970, that his
injury was permanent and he learned how it likely occurred. Id. The
doctor claimed the statute of limitations began to run when Baines
awoke from surgery because this was the date he knew of his injury
15
(blindness) and knew it resulted from surgery. Id. Thus, the question
was whether discovery of the cause of action, to commence the running
of the statute of limitations, should include the element of the negligence
of the physician.
We resolved the dispute over the application of the discovery rule
by holding that a claim did not accrue under the discovery rule to trigger
the statute of limitations until the plaintiff knew or should have known of
the existence of the cause of action. Id. at 202. More specifically, we
held a plaintiff must not only discover the injury and its cause, but must
also discover the physician was negligent. Id. Yet, we reached this
conclusion without acknowledging the rule followed in other jurisdictions
that discovery of the injury and its factual cause triggers the statute of
limitations. See Kubrick, 444 U.S. at 122, 100 S. Ct. at 359, 62 L. Ed. 2d
at 269 (setting forth the rule that discovery of the injury and its factual
cause triggers the statute of limitations); Maestas v. Zager, 152 P.3d 141,
147 (N.M. 2007) (clarifying that their cases since the adoption of the
discovery rule to the medical malpractice statute of limitations were
consistent with the holding in Kubrick). As in Chrischilles, we simply
assumed the discovery rule meant the statute of limitations was triggered
upon discovery of the cause of action, which included the negligence of
the physician, and gave no consideration to a discovery rule that would
trigger commencement of the limitations period upon actual or imputed
knowledge of the injury and its cause.
Importantly, at the time Baines was decided, two movements had
surfaced in courts around the nation as a result of the discovery-rule
trend sweeping the country. First, two main distinct legal theories
emerged from our nation’s state and federal courts to govern the
triggering event for the discovery rule. Conceptually, the national
16
movement responsible for introducing the discovery rule into the statute
of limitations merely transformed the commencement of the limitation
period from the date the elements of the cause of action occurred to the
date the elements were discovered. The difficult subissue, however, was
how the discovery rule should be applied to the elements of the claim,
i.e., whether or not it should be applied to all of the elements. Most state
courts, as we did in Baines, triggered the discovery rule upon knowledge
of the cause of action, including at least some knowledge that the
conduct of the physician was negligent or wrongful. See Baines, 223
N.W.2d at 202; see also Bussineau v. President & Dirs. of Georgetown
Coll., 518 A.2d 423, 428 (D.C. 1986) (noting that all states that have
considered the question of when a statute of limitations is triggered
under the discovery rule require either knowledge of some evidence of
wrongdoing or knowledge of all elements of a cause of action); Mastro v.
Brodie, 682 P.2d 1162, 1168 (Colo. 1984) (observing “[t]he overwhelming
majority” of state courts have interpreted “the injury” that triggers a
medical malpractice action to mean discovery of “legal injury”); Lillicrap v.
Martin, 591 A.2d 41, 46 (Vt. 1989) (explaining that the “clear trend
among the courts of the nation” is to commence medical malpractice
statutes of limitation upon discovery of “legal injury,” so that the plaintiff
must discover the injury and the fact that it was caused by the
defendant’s negligence). Other courts interpreted the discovery rule more
narrowly to require only knowledge of the injury and its factual cause,
without requiring discovery of any negligence or possible wrongdoing.
See Kubrick, 444 U.S. at 122, 100 S. Ct. at 359, 62 L. Ed. 2d at 269;
Maestas, 152 P.3d at 147; see also Lindsay v. Romano, 696 N.E.2d 520,
522 (Mass. 1998) (holding it is not necessary for plaintiff to have notice
defendant was actually responsible for the injury, only that plaintiff have
17
notice the medical care may have caused the injury). In fact, many
courts made the choice between the two theories without recognizing
there was even a choice to be made, and others vacillated back and forth
with little recognition they were doing so. See Roberts, 837 P.2d at 448
(recognizing the existence of conflicting cases).
More importantly, many courts failed to precisely describe the full
meaning of their rule governing the breadth of knowledge required to
trigger the statute of limitations, which has made it difficult at times to
discern which rule was actually followed. Instead, courts in the
discovery rule era would refer to their accrual rule in shorthand, just as
we did in describing when a cause of action accrued prior to the adoption
of the discovery rule. For instance, courts would simply declare the
statute of limitations commenced upon discovery of the “injury,” when a
full articulation of the rule would have revealed whether they required
discovery of all the elements of the cause of action, or merely discovery of
the injury and its cause. This phenomenon was aptly described by the
New Hampshire Supreme Court:
One might read several discovery cases and conclude
that the courts are applying two substantively distinct rules.
In most cases the courts frame the rule in terms of the
plaintiff’s discovery of the causal relationship between his
injury and the defendant’s conduct. In some cases, . . . a
court will state simply that, under the discovery rule, a
cause of action accrues when the plaintiff discovers or
should have discovered his injury. Still other courts use
both statements of the rule within the same case. The
reason for these apparent differences is that in most cases in
which the court states the rule in terms of the discovery of
the injury, the injury is the kind that puts the plaintiff on
notice that his rights have been violated. Thus, there is no
reason for the court to express the rule in terms of the
discovery of the causal connection between the harm and the
defendant’s conduct. In a case, such as the one before us, in
which the injury and the discovery of the causal relationship
do not occur simultaneously, it is important to articulate
exactly what the discovery rule means. We believe that the
18
proper formulation of the rule and the one that will cause
the least confusion is the one adopted by the majority of the
courts: A cause of action will not accrue under the discovery
rule until the plaintiff discovers or in the exercise of
reasonable diligence should have discovered not only that he
has been injured but also that his injury may have been
caused by the defendant’s conduct.
Raymond v. Eli Lilly & Co., 371 A.2d 170, 174 (N.H. 1977).
The national trend of using the term “injury” to describe the
triggering event under the discovery rule not only meant the term
continued in its former capacity as a designation of the time of accrual,
but it continued to reflect a larger meaning than the concept of physical
harm. Yet, on occasion, this background was not fully captured, which
gave rise to the suggestion from time to time that the discovery rule only
looked to the injury to commence the running of the period of limitation,
without any requirement of knowledge of its cause or the physician’s
wrongdoing. See Lillicrap, 591 A.2d at 45 (citing Allen v. Newport, 427
F. Supp. 42, 44 (M.D. Tenn. 1976); Layton v. Allen, 246 A.2d 794, 798
(Del. 1968); Condon v. A.H. Robins Co., 349 N.W.2d 622, 627 (Neb.
1984)); see also Mastro, 682 P.2d at 1167 (recognizing a statute of
limitations that uses discovery of the “injury” to trigger the limitation
period can be interpreted to mean the date the injury manifests itself in a
physical, objective manner). However, this interpretation was
consistently rejected, when properly scrutinized, as inconsistent with the
purpose of the discovery rule. See Lillicrap, 591 A.2d at 45–46; Borello v.
United States Oil Co., 388 N.W.2d 140, 145 (Wis. 1986) (“[M]ere
knowledge of the fact of an injury and nothing more will not trigger the
commencement of the period of limitations.”). The cases cited from time
to time for the proposition that the statute of limitations commences
upon discovery of the injury did not include a supporting rationale.
Instead, the cases expressed the concept in the context of circumstances
19
where factual causation was known by the plaintiff or where the court
intended to include causation in fact as an element of the discovery of
the injury without specifically mentioning it. See Allen, 427 F. Supp. at
44–45 (holding statute of limitations commenced upon discovery of
“physical injury, rather than an act of negligence”; yet the element of
factual causation was never at issue in the case because the nature of
the injury was such that the discovery of the factual cause would have
occurred at the same time as the discovery of the injury); Bussineau, 518
A.2d at 426 (“Although the language of our [prior] holding . . . refers only
to the time when a plaintiff has or should have ‘knowledge of injury,’ the
facts of the case and the analysis engaged in by the court make it clear
that we required a finding of more than mere knowledge of injury . . . .”);
Booth v. Wiley, 839 N.E.2d 1168, 1172 (Ind. 2005) (citing example of one
of its prior medical malpractice statute-of-limitations cases that
“summarily referred to a plaintiff’s discovery of injury without any
specific reference to the discovery of the malpractice itself,” but without
intending to retreat from its rule that requires knowledge of the
malpractice and resulting injury to trigger the statute of limitations). No
court at the time expressed a principled notion that the cause of action
accrued under the discovery rule based on mere knowledge of the injury.
The second circumstance of importance at the time Baines was
decided was the concomitant drumbeat of tort reform sweeping the
country, predicated on claims of a mounting medical malpractice crisis.
See generally Anderson v. Wagner, 402 N.E.2d 560, 563–64 (Ill. 1979)
(discussing “medical malpractice crisis” and discovery rule). One
common reform centered on the need to tighten the statute of limitations
to reduce a physician’s exposure to future liability for malpractice
lawsuits. In particular, as the popularity of the discovery rule (that often
20
delayed the running of the statute of limitations that otherwise would
have commenced under the former bright-line occurrence-of-injury rule)
picked up steam in the 1960s, the medical malpractice insurance
industry began to increase premiums to protect against the resulting
“long tail” of potential liability. Id.; Austin v. Litvak, 682 P.2d 41, 44–45
(Colo. 1984) (citing Howard A. Learner, Restrictive Medical Malpractice
Compensation Schemes: A Constitutional “Quid Pro Quo” Analysis to
Safeguard Individual Liberties, 18 Harv. J. on Legis. 143 (1981)). In
response to this problem, “various state and national commissions
recommended placing an outside limit on the discovery rule in medical
malpractice cases.” Anderson, 402 N.E.2d at 565–66 (citing American
Bar Association, Report of the Commission on Medical Professional
Liability 140–43 (1977); Medical Injury Insurance Reparations
Commission, Report and Recommendation to Governor Dan Walker and
Members of the 79th General Assembly (Ill. 1976); Medical Malpractice:
The Duke L.J. Symposium 253–54 (1977)). Iowa joined in with its own
legislative study. See Koppes v. Pearson, 384 N.W.2d 381, 384 (Iowa
1986) (noting the Iowa legislature undertook a comprehensive study,
resulting in a malpractice injury study committee). As a result, statutes
of repose, which bar medical malpractice claims after a specific period of
time regardless of the date of discovery, were proposed “to reduce
malpractice premiums by eliminating the insurance companies’ inability
to predict future claims and losses.” Austin, 682 P.2d at 46. Clearly, the
medical malpractice crisis was not a fight over the adoption and
definition of the discovery rule, but a reform movement to achieve
restrictions on the discovery rule to accommodate the problems it
presented to the insurance industry and medical field due to the open-
ended liability. See Koppes, 384 N.W.2d at 384 (noting the existence of a
21
“critical situation . . . because of the high cost and impending
unavailability of medical malpractice insurance”).
The reform became particularly relevant to Iowa after Baines made
the discovery rule specifically applicable to medical malpractice cases.
Thus, the Baines case set the stage for Iowa’s adoption of the national
tort reform proposal of a statute to place an outside limit on the
applicability of the discovery rule in medical malpractice actions.
In 1975, one year following Baines, the Iowa legislature enacted
Iowa Code section 614.1(9)(a) as a specific exception to the general
statute of limitations for malpractice actions against a specific group of
medical personnel and medical facilities. See 1975 Iowa Acts ch. 239,
§ 26. The statute maintained the two-year limitation period, adopted the
discovery rule, and placed a six-year period of repose on the applicability
of the discovery rule as proposed by the reform movement. The statute
of repose provided an outside limitation for all lawsuits, even though the
injury had not been discovered.
Since the enactment of the statute, the dispute in Iowa has not
involved the adoption of the discovery rule or the six-year period of
repose. Instead, the dispute has mostly centered on the extent to which
the legislature intended to restrict the triggering event for the two-year
limitation. While the Iowa legislature adopted the discovery rule concept,
it defined the rule to begin the two-year statute of limitations when the
patient “knew, or through the use of reasonable diligence should have
known [of], . . . the injury or death for which damages are sought in the
action.” Iowa Code § 614.1(9). In contrast, the definition of the discovery
rule in Baines provided for the cause of action to accrue not only upon
the discovery of the injury and its cause, but also the discovery of the
negligent conduct.
22
In our first cases to address section 614.1(9) following its
enactment, we observed the legislative purpose behind the statute was
“to restrict the Baines discovery rule.” Schultze v. Landmark Hotel Corp.,
463 N.W.2d 47, 50 (Iowa 1990); see also Koppes, 384 N.W.2d at 387
(citing Farnum v. G.D. Searle & Co., 339 N.W.2d 392, 395 (Iowa 1983));
Kohrt v. Yetter, 344 N.W.2d 245, 247 (Iowa 1984). Yet, we did not begin
to analyze the specific statutory restriction placed on the discovery rule
until Schultze.
In Schultze, a patient was admitted to a hospital for treatment of a
hip fracture and died seventeen days later. 463 N.W.2d at 48. Her
personal representative eventually sued the hospital and treating
physicians for malpractice by filing a claim more than two years after the
death, but less than two years after the plaintiff discovered the alleged
negligence of the physicians. Id. We concluded the lawsuit was untimely
under the statute because the discovery rule did not delay the running of
the statute until the plaintiff discovered the wrongful act. Id. at 49–50.
We focused on the triggering event used by the legislature under the
statute—injury or death—and found neither the plain language of the
statute nor the history of the statute permitted us to inject any modifying
language that the injury or death be wrongful. Id. In reviewing the
legislative history, however, we did not acknowledge or discuss the two
different triggering events recognized around the country or how the
concept of an injury in the context of a statute of limitations traditionally
embraced other elements of the claim. Instead, we observed the
discovery rule was generally inapplicable to wrongful-death claims
because death from medical care is the type of event that should give rise
to the duty to investigate a cause of action. Id. at 50.
 23
Our first occasion to substantively address section 614.1(9)(a) in
the context of a medical malpractice injury claim was Langner v.
Simpson, 533 N.W.2d 511 (Iowa 1995). There, we said:
Subsection 9 means the statute of limitations now begins to
run when the patient knew, or through the use of reasonable
diligence should have known, of the injury for which
damages are sought. The statute begins to run even though
the patient does not know the physician had negligently
caused the injury.
Id. at 517. We also formally read inquiry notice into the application of
the statute and indicated the duty to investigate begins “once a person is
aware that a problem exists.” Id. at 518. The “injury” claimed to have
been suffered in Langner was posttraumatic stress disorder allegedly
caused, in part, by the rude bedside statements of a treating
psychiatrist. The plaintiff’s “problem” surfaced so as to give rise to a
duty to investigate at the time the conduct of the psychiatrist hurt her
feelings, even though she did not understand the medical reasons why
the conduct adversely affected her. Id.
We next made a passing reference to the statute of limitations for
medical malpractice claims in McClendon v. Beck, 569 N.W.2d 382, 386
(Iowa 1997). There, we referred to the plaintiff’s injury as “constant pain”
following her surgery and found the “district court correctly concluded
that the constant pain experienced by McClendon following the
operations was sufficient to put her on notice of the injury” for which she
claimed damages. Id.
We next faced the statute in Schlote v. Dawson, 676 N.W.2d 187
(Iowa 2004). In that case, the patient brought a malpractice action
against a physician based on a claim that the physician negligently
treated a throat condition by unnecessarily removing his voice box. Id. at
189. However, the patient did not discover the surgery may have been
24
unnecessary until more than two years later and, consequently, filed the
lawsuit more than two years after the voice box was removed. Id.
Relying primarily on Schultze, we determined the legislature intended the
word “injury,” to refer to its common dictionary meaning of physical
harm, as opposed to its legal meaning involving the violation of a right or
protected interest. Id. at 192–93. Additionally, we concluded the
legislature must have intended for the statute, as a direct response to
Baines, to exclude any consideration of wrongful conduct in applying the
discovery rule. Id. at 194. Consequently, we found the statute of
limitations began to run when the plaintiff knew the fact of his injury,
even though the plaintiff did not know of the physician’s wrongful
conduct. Id.
We last considered the statute of limitations in Ratcliff v. Graether,
697 N.W.2d 119 (Iowa 2005). In that case, the plaintiff experienced
blurry vision following LASIK eye surgery. Id. at 121. Relying on our
view in Schlote that “injury” for purposes of the discovery rule merely
meant physical harm, apart from any notion that the harm was wrongful,
we found Ratcliff was put on inquiry notice of his injury the day after his
surgery and later gained actual knowledge as a result of his investigative
finding that his doctor may have been legally responsible for the harm.
Id. at 124. Because these events occurred more than two years prior to
the time he filed his lawsuit, his claim was barred. Id.
As a whole, our cases interpreting section 614.1(9) have given rise
to the rule that the statute of limitations begins to run when the plaintiff
knows or, through the use of reasonable diligence, should have known of
the physical harm. Langner, 533 N.W.2d at 517. Moreover, we have
narrowly defined the injury as physical harm and have applied inquiry
notice to commence the statute of limitations once symptoms of the
25
physical harm are experienced by a patient during or after medical
treatment, even though there is no indication of a cause or negligent
conduct by the doctor. Consequently, we have severely restricted the
discovery rule, essentially using it to require only inquiry notice of
physical harm. See Schlote, 676 N.W.2d at 194 (recognizing our
interpretation of section 614.1(9) effectively eliminates the discovery rule
from medical malpractice actions). In narrowly construing the statute as
not requiring discovery of the negligent conduct of the physician, we have
not considered the role of any form of causation as a part of the analysis.
In applying this case law to the undisputed facts of the summary
judgment proceedings in this case, it is clear the Rathjes were placed on
inquiry notice when Georgia was suffering from physical harm prior to
April 26, 1999, more than two years prior to filing the petition. She was
experiencing increasing signs of physical harm to her body, which an
investigation revealed within two years from the time of the onset of the
symptoms was caused by the administration of Antabuse. Under the
rule applied in Schlote, the Rathjes failed to timely file their petition, even
though they had no idea of the cause of the harm prior to the
commencement of the statute of limitations. Thus, we are again faced
with the prospect of applying the statute of limitations to deny an
unsuspecting plaintiff of the right to pursue a claim for medical
malpractice.
Understanding the consequences of this state of the law, the
Rathjes attempt to sidestep this result by arguing the relevant injury for
the purpose of the statute of limitations is not the symptoms Georgia
experienced prior to April 26, 1999, but the later damage to her liver.
They claim the liver damage is the injury that is the basis for the lawsuit,
26
and this injury was not discovered, or could not have been reasonably
discovered, until after April 26, 1999.
The approach advocated by the Rathjes gives rise to concerns
about allowing plaintiffs to separate injuries and only leads to additional
problems in an already troubled area of the law. See LeBeau v. Dimig,
446 N.W.2d 800, 802–03 (Iowa 1989). Our law does not allow the
splitting of a cause of action, and any effort to do so to avoid the
commencement of the statute of limitations would be inconsistent with
the purpose of cutting off stale claims. Id.
While we agree with our prior observation that the enactment of
section 614.1(9) was a “direct response to our decision . . . in Baines,”
the circumstances at the time of the enactment reveal the response was
not primarily directed at the reasoning we used in Baines to support our
adoption of the discovery rule. Instead, the legislature was largely
reacting to the national movement for a statute of repose as a response
to the prevailing trend toward the adoption of the discovery rule in
medical malpractice cases. Baines, of course, made the movement
particularly relevant in Iowa by 1975. Yet, there was no similar
organized legislative movement that would indicate our legislature
intended for the physical injury, alone, to serve as the triggering event
under the discovery rule.
Nevertheless, the Baines decision did present a clear choice
between two distinct triggering events. As mentioned, the doctor in
Baines argued that the cause of action should accrue under the
discovery rule when the patient knows or should know of the injury and
that it was caused by medical care. Baines, 223 N.W.2d at 201. Instead,
we adopted the rule that the cause of action accrued when the patient
knew or should have known of the injury and that it was caused by the
27
negligence of the medical provider. Id. at 202. Thus, the legislature
could very well have intended to make its own choice by enacting the
statutory language that tied the discovery rule to actual or implied
knowledge of “the injury.” Yet, we cannot identify any outside
circumstance to support an intention for our legislature to enact section
614.1(9), in response to Baines, to strip the triggering event under the
discovery rule down to the bare bones of the common definition of an
“injury.” In fact, in an article written and published shortly after the
enactment of section 614.1(9), the legislative counsel for the Iowa
Medical Society explained the two-part effect of the new medical
malpractice statute of limitations was to change the triggering event for
the two-year statute-of-limitations period from “the time the injured
person knew he had a cause of action, i.e., that the physician was
negligent” to the “date of discovery of the injury . . . but not more than
six years from the occurrence.” James B. West, Iowa Medical Liability
Legislation—A Summary of House File 803, 65 Iowa Med. Soc’y J. 493,
496 (1975). Clearly, the legislature intended to reject discovery of the
physician’s negligence as a triggering event for the discovery rule, but
there was no indication the legislature intended to also reject causation
as a component of the discovery of the injury.
The actual debate over the triggering event reflected in the national
case law at the time the legislature adopted section 614.1(9) in 1975 was
not over discovery of the cause of action versus discovery of the existence
of physical harm, but rather whether the discovery of the cause of action
required actual or imputed knowledge that the physician breached a
duty of care. There was no indication our legislature sought to narrow
the triggering event to something other than the two prevailing schools of
thought or something other than the two choices presented in Baines.
28
This dispute over the triggering event was aptly illustrated in Kubrick,
444 U.S. 111, 100 S. Ct. 352, 62 L. Ed. 2d 259.
In Kubrick, a patient brought a medical malpractice action under
the Federal Tort Claims Act to recover for a loss of hearing that allegedly
resulted from prior treatment he received for an infection to his leg. Id.
at 113–15, 100 S. Ct. at 355, 62 L. Ed. 2d at 264. The patient knew of
his hearing loss more than two years before filing his petition and knew
it was most likely caused by the drug used to irrigate the leg infection.
Id. However, the patient did not discover the treating physician should
have known that using the drug to treat the infection would cause
hearing loss until less than two years before filing the petition. Id. at
115, 100 S. Ct. at 356, 62 L. Ed. 2d at 265.
The district court and the United States Third Circuit Court of
Appeals held the claim did not accrue under the two-year statute of
limitations until the plaintiff discovered the possibility that the treatment
provided by the physician was negligent (i.e., a breach of a legal duty),
even though the patient knew of the injury and knew the physician was
responsible for the injury. Id. at 115–16, 100 S. Ct. at 356, 62 L. Ed. 2d
at 265–66. Thus, the only thing the patient did not know was that the
responsible conduct constituted negligence.
The United States Supreme Court rejected the concept that the
discovery rule required knowledge of the actual legal cause before the
statute of limitations began to run. It explained the rationale for only
using discovery of the injury and its factual cause to trigger the discovery
rule for purposes of the statute of limitations instead of also requiring
knowledge of negligent treatment, as follows:
That [the plaintiff] has been injured in fact may be unknown
or unknowable until the injury manifests itself; and the facts
about causation may be in the control of the putative
29
defendant, unavailable to the plaintiff or at least very
difficult to obtain. The prospect is not so bleak for a plaintiff
in possession of the critical facts that he has been hurt and
who has inflicted the injury. He is no longer at the mercy of
the latter. There are others who can tell him if he has been
wronged, and he need only ask. If he does ask and if the
defendant has failed to live up to minimum standards of
medical proficiency, the odds are that a competent doctor
will so inform the plaintiff.
Id. at 122, 100 S. Ct. at 359, 62 L. Ed. 2d at 269. For these reasons, the
plaintiff’s lack of awareness that the “injury was negligently inflicted”
does not postpone the commencement of the limitations period under
this approach. Id. at 123, 100 S. Ct. at 360, 62 L. Ed. 2d at 270.
Importantly, the Kubrick case illustrates that the ongoing dispute
over the application of the discovery rule to the statute of limitations was
limited to the question of whether knowledge that the conduct of the
doctor was negligent was needed to trigger the statute of limitations.
There was no suggestion that knowledge of an injury, without more,
triggered the statute of limitations.
Considering the pervasive national adoption of the discovery rule
at the time Iowa enacted its statute, we think our legislature had to be
aware of the debate over the triggering event and whether the discovery
rule should include discovery that the defendant’s conduct was
negligent. See Roberts, 837 P.2d at 446 (considering the wide-ranging
movement for medical malpractice legislation at the time and observing
that the legislature must have canvassed the current trends). Moreover,
this was the precise debate waged in Baines, the case that prompted our
legislature to enact the statute of limitations for medical malpractice
actions. Thus, it would have been reasonable for our legislature to
intend to adopt what would become the rule in Kubrick, rejecting the rule
in Baines. Additionally, it would have been reasonable for our legislature
to adopt a Kubrick-type rule by using the term “injury” in the statute,
30
since that term had been used for more than a century in the context of
a statute of limitations to mean more than physical harm. The
contemporary circumstances do not reasonably suggest our legislature
actually sought to narrow the triggering event for the statute of
limitations to discovery of a mere “physical injury.” Thus, our past cases
have correctly observed that “the statute begins to run even though the
patient does not know the physician had negligently caused the injury.”
Langner, 533 N.W.2d at 517. Our past cases have also correctly
identified that our legislature did not intend the word “injury” in the
statute to mean legal injury, but only physical injury. Schlote, 676
N.W.2d at 193 (determining the legislature had physical harm in mind
when using the word “injury”). Legal injury encompasses the violation of
the rights for which an action to recover damages may be brought. See
id. at 192. This was the view we adopted in Baines and the view rejected
by our legislature in enacting section 614.1(9).
While we have correctly discerned that the legislature clearly
narrowed the discovery rule under the statute to exclude any
requirement that a plaintiff discover that the injury was caused by
negligence or wrongdoing of the physician, our prior cases have failed to
identify the role of factual causation as an element of the statutory
discovery rule. As experienced in other jurisdictions from time to time,
we have applied the discovery rule literally in terms of “the injury” and
have neglected to affirmatively acknowledge the role and necessity of any
type of causation in the analysis. Yet, this result is understandable
because each time we have considered the statute since its enactment
the factual cause of the injury was not at issue. Instead, the factual
cause was known or discovered at the time the injury was discovered. In
particular, when we stated in Langner that the statute began to run upon
31
discovery of the injury, the plaintiff knew at the time the injury was
discovered that it was caused by care provided by the physician. 533
N.W.2d at 515. Similarly, even the injury identified in Schlote was
known by the patient to be factually caused by the physician at the time
the injury was discovered. 676 N.W.2d at 189. Accordingly, we have
never had to address the continued necessity of knowledge of some form
of causation until this case, in which the injury and its cause in fact
were not known simultaneously. Thus, when we said in Langner that a
patient only needs to be “aware that a problem exists” to commence the
statute of limitations, the “problem” necessarily embraced the cause in
fact of the injury. As identified in Kubrick, this type of causation is
necessary so there are enough facts to alert a reasonable person that the
injury and its cause should be investigated. Of course, it is not
important in this case, for the purposes of the statute of limitations, to
discover if the conduct was negligent, only that the conduct of the
physician was factually responsible for the injury.
This view is also supported by our application of inquiry notice to
the discovery rule. Inquiry notice plays a role in the medical malpractice
statute due to the implied knowledge (“should have known”) component
of the statute. This component charges a plaintiff with knowledge of
those facts that a reasonable investigation would have disclosed. See
Franzen, 377 N.W.2d at 662. Under the statute, once a plaintiff gains
information sufficient to alert a reasonable person of the need to
investigate “the injury,” the limitation period begins to run. Id. The
acquisition of this information is notice that imposes a duty to make a
factual inquiry into the existence of the injury. The statute of limitations
is triggered upon the acquisition of this information because, once a
plaintiff is “armed with the facts about the harm done to him, [the
32
plaintiff] can protect himself [from the statute of limitations] by seeking
advice in the medical and legal community.” See Kubrick, 444 U.S. at
123, 100 S. Ct. at 360, 62 L. Ed. 2d at 270.
If the limitation period to file a lawsuit under the statute is
interpreted to commence once plaintiffs gain sufficient information of the
injury or physical harm without regard to its cause, some plaintiffs may
not know enough to understand the need to seek expert advice about the
possibility of a lawsuit to protect themselves from the statute. In some
instances, the cause of medical malpractice injuries may be evident from
facts of the injury alone, but in other cases it may not. Yet, in all cases,
a plaintiff must at least know the cause of the injury resulted or may
have resulted from medical care in order to be protected from the
consequences of the statute of limitations by seeking expert advice from
the medical and legal communities. The fundamental objective of
applying the discovery rule to the statute of limitations is to put
malpractice plaintiffs on comparable footing as “other tort claimants” to
be able to “determine within the period of limitations whether to sue or
not.” Id. at 124, 100 S. Ct. at 360, 62 L. Ed. 2d at 270. Thus, the
discovery of relevant facts about the injury to commence the statute of
limitations must include its cause in order to justify the commencement
of the limitation period. The Iowa legislature could not have intended to
commence the running of the statute of limitations through inquiry
notice before inquiry is warranted.
We think it is clear our legislature intended the medical
malpractice statute of limitations to commence upon actual or imputed
knowledge of both the injury and its cause in fact. Moreover, it is equally
clear this twin-faceted triggering event must at least be identified by
33
sufficient facts to put a reasonably diligent plaintiff on notice to
investigate.
This approach rejects the claim made by the Rathjes that “the
injury” that will trigger the statute can be separated into different
degrees of harm or different categories of harm that separately give rise
to different triggering dates. The statute does not work in that manner.
We adhere to the rule that a plaintiff does not need to know the full
extent of the injury before the statute of limitations begins to run. See
LeBeau, 446 N.W.2d at 803 (holding statute of limitations begins to run
even though the plaintiff is unaware of the full extent of his injury); see
also Murphy v. Aero-Med, Ltd., 345 F. Supp. 2d 40, 44 (D. Mass. 2004)
(declaring plaintiff does not need to know the full extent of injury or need
to identify the particular cause of the symptoms).
The statute begins to run only when the injured party’s actual or
imputed knowledge of the injury and its cause reasonably suggest an
investigation is warranted. See Ralph V. Seep, Annotation, Accrual of
Cause of Action for Purpose of Statute of Limitations in Medical Malpractice
Actions Under Federal Tort Claims Act—Post-Kubrick Cases, 101 A.L.R.
Fed. 27, 33 (1991) (“When the plaintiff has the knowledge of the “critical
facts” concerning his or her injury and its cause, he or she is charged
with the duty to investigate promptly and present any claim for relief.”).
The symptoms experienced by a patient can be sufficient to alert a
reasonable person to the existence of the injury, but those symptoms
may not always alert the plaintiff to the cause of the injury. These
elements must be considered together to allow the statute of limitations
to operate in its intended manner to protect unsuspecting plaintiffs.
The general approach we adopt today is consistent with the
framework followed in other jurisdictions that apply the discovery rule to
34
statutes of limitation in medical malpractice cases. As previously
indicated, nearly all jurisdictions in this country apply some form of the
discovery rule to statutes of limitation in medical malpractice cases.
David W. Feeder II, When Your Doctor Says, “You Have Nothing to Worry
About,” Don’t Be Sure: The Effect of Fabio v. Bellomo on Medical
Malpractice Actions in Minnesota, 78 Minn. L. Rev. 943, 953 (1994).
While these jurisdictions reach different conclusions on the question
whether discovery of causation involves the relationship between the
injury and the factual cause or the relationship between the injury and
negligence (or some evidence of wrongdoing), they all recognize causation
to be an essential component of the analysis. See Bussineau, 518 A.2d
at 430–35 (citing and reviewing cases from at least fifteen states that
require either some evidence of wrongdoing to trigger the medical
malpractice statute of limitations or require discovery of all elements of
the cause of action); Mastro, 682 P.2d at 1167–68 (citing cases that have
adopted the “legal injury” meaning of the word “injury” used in the
statute of limitations governing medical malpractice actions); Catz v.
Rubenstein, 513 A.2d 98, 102–03 (Conn. 1986) (same); see also Booth,
839 N.E.2d at 1172 (medical malpractice statute of limitations triggered
when patient knows or should know of the malpractice and resulting
injury); Lagassey v. State, 846 A.2d 831, 844 (Conn. 2004) (plaintiff
must discover, from a factual standpoint, the nature and extent of the
injury and that the injury was caused by the wrongful conduct of
another); Long v. Mem. Hosp., 969 So. 2d 35, 43 (Miss. 2007) (medical
malpractice statute of limitations begins to run with knowledge of injury,
cause of injury, and causal relationship between injury and conduct of
physician); Stanbury v. Bacardi, 953 S.W.2d 671, 677 (Tenn. 1997)
(medical malpractice statute of limitations begins to run when plaintiff
35
discovers facts sufficient to give notice of an injury as a result of wrongful
conduct). Although some courts appear to state a rule, from time to
time, that the statute of limitations begins to run upon discovery of the
injury alone, as we have done in the past, the validity of those holdings is
suspect. Our review of all the authority from the other jurisdictions
supports the approach we take today.
We emphasize the knowledge standard under the statute is
predicated on actual or imputed knowledge of the facts to support the
injury and of the facts to support a cause. See Kubrick, 444 U.S. at 124,
100 S. Ct. at 360, 62 L. Ed. 2d at 270 (holding statute of limitations
begins to run from plaintiff’s discovery of the relevant facts about the
injury); Maestas, 152 P.3d at 147–48 (same). Importantly, we continue
to adhere to the rule that the plaintiff does not need to discover that the
doctor was negligent.
In applying the medical malpractice statute of limitations, as we
now interpret it, to the undisputed facts in this case, it is clear the
Rathjes knew Georgia was suffering from physical harm. However, a
reasonable jury could find they did not know the cause of the harm until,
at the earliest, April 27, 1999, the date the gastroenterologist made a
diagnosis of “drug-induced hepatitis secondary to Antabuse.” Moreover,
the jury could find that, until that time, no facts were available that
would have alerted a reasonably diligent person that the cause of the
injury may have originated in Georgia’s medical treatment so as to put
the plaintiffs on notice of the need to investigate. Consequently, a
reasonable jury could conclude the Rathjes filed their petition within the
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two-year limitation of section 614.1(9). The district court erred in
granting summary judgment for the defendants.5
The approach taken today departs from the direction we have
taken in our prior cases since the time the statute was enacted. Yet, it is
not necessarily inconsistent with the outcomes of our prior cases.
Moreover, it better reflects the objective of the discovery rule to prevent
the limitations period from commencing when blameless plaintiffs are
unsuspecting of a possible claim.6 We choose this approach because it is
consistent with the language of the statute when placed in proper
historical context, consistent with the purposes and goals of the
statutory discovery rule, fair to patients, doctors and the medical
malpractice insurance industry, respectful of the trust and confidence
essential to a doctor-patient relationship, and best meets the overall
goals of a justice system.
Finally, if our interpretation of the medical malpractice statute of
limitations is out of line with the original intent of the legislature, that
body can respond to correct it. We have tried to define the triggering
date for the discovery rule with more clarity, and this will allow our
legislature to intervene if we have missed the mark. Yet, we firmly
believe this interpretation resolves the basic systemic problem that has
plagued our prior interpretation of the statute and should allow the
statute to work to better achieve its purposes and goals.
5The only issue presented to the district court was whether the defendants were
entitled to summary judgment. The plaintiffs did not file a cross-motion for summary
judgment. Thus, we are not presented with the question whether the Rathjes filed their
petition within the two-year statute of limitations period as a matter of law.
6In all of our prior medical malpractice statute-of-limitations cases under section
614.1(9), the factual cause of the injury was known or should have been known at the
time the injury was discovered. Thus, the absence of the factual-causation component
adopted today from our prior analysis has not been responsible for any unfairness to a
blameless, unsuspecting plaintiff. Any claims of past unfairness in the application of
the discovery rule to the statute of limitations in medical malpractice cases must be
analyzed under the injury component of the rule, a question not at issue in this case.
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IV. Conclusion.
We reverse the decision of the district court and remand the case
to the district court for further proceedings.
REVERSED AND REMANDED.
All justices concur except Wiggins, J., who concurs specially, and
Streit, J., who takes no part.