Rx & The Law

Do Pharmacists Have A Duty To Warn In Texas? - A Definite Maybe!

By Kenneth R. Baker, B.S.Pharm., J.D.
Vice President, General Counsel
Pharmacists Mutual Insurance Company

In August 2000, an appellate court in the State of Texas handed down a pharmacy law decision in the case of Morgan v. Wal-Mart.[1]  Until this case, Texas courts had not ruled on a duty to warn case, so this was a case of first impression in Texas.  Most recent decisions in other states had consistently expanded the concept of pharmacist duty as including something more than the obligation to correctly fill a prescription as written by the physician.  Examples of courts recognizing expanded professional duties for pharmacists are: the Tennessee Appellate Court[2] (duty of drug review and duty to warn) in 1990; the Indiana Supreme Court[3] (duty to monitor and duty to warn); the Arizona Court of Appeals[4] (duty to monitor and duty to warn) in 1994, and the Missouri Court of Appeals[5] (duty of drug review and duty to warn)  in 1999.   With this recent history, the Texas Court’s decision came as a surprise.  Recent decisions have been clear and definitive, but not the Texas decision.

Do pharmacists have a duty to warn in the State of Texas?  The Texas Court of Appeals managed to spend several pages analyzing the issue and yet failed to completely answer the question.  The Court’s answer can best be described as “definitely maybe”.  The Court should not be completely castigated, however, since it did reach the correct answer under the facts of the case.  

Cameron Pettus was a 13-year-old child who tragically died in 1993 after taking desipramine for two years.    The prescriptions were first filled at Walgreen’s, but in August of 1992, the prescription was transferred to Wal-Mart.  Cameron began suffering pain, numbness and other symptoms later identified by medical witnesses as a result of hypereosinophilic syndrome, a multi-system disease that affected several organs. The physician who performed the autopsy on Cameron testified the condition was a result of taking desipramine.  Physicians testifying for Wal-Mart reached a different conclusion.  

The mother and father of the deceased child sued several physicians, the manufacturer, Walgreen’s and Wal-Mart.  All defendants, except Wal-Mart, settled prior to trial, leaving only Wal-Mart who was charged with “failing to properly warn intended users of the hazards and harms associat[ed] with the use of the product.[6]  Trial began in March 1999.   When it concluded the jury returned a finding that Wal-Mart was responsible for 15% of the verdict and the mother and father responsible for 9% and 2%, respectively.  Wal-Mart was ordered to pay slightly over one million dollars.  Wal-Mart appealed, as did the parents.  

The Court of Appeals quickly determined that the first question to be answered was “whether Wal-Mart owed a legal duty to [Cameron and his parents] to warn them of the risks associated with Cameron’s use of desipramine.[7]”  The Court correctly noted, “If no duty exists, there can be no negligence liability.[8] The Court then began a lengthy, although not exhaustive, review of pharmacists’ “duty to accurately fill” cases and “duty to warn” cases from around the country.  In its analysis, the Court seemed not to have noticed the time line of these cases or any significance that time may have played in these decisions.  The Court did not seem to be aware of the extent of, or significance of, recent changes in the profession of pharmacy.  Also missed was the importance of the changes in state court holdings over a short period of time, most notably the one hundred eighty degree shift in the Missouri position from the decision in Kampe to the decision in Horner.  In 1999 the Horner Court rejected the earlier decision, stating, “We reject the suggestion in Kampe that the only functions which a pharmacist must perform to fulfill his duty is to dispense drugs according to a physician's prescription.[9]

The Texas Court said, “[T]he prescriptions filled by Wal-Mart [did not contain] clear errors or obvious inadequacies triggering a duty to warn.[10]”   However, the Court added, “We do not imply that pharmacists may not warn patients of potential adverse reactions or dangerous side effects; we merely hold that pharmacists are not legally obligated to do so.[11]”   

At this point in the decision, the Court seemed to stumble upon the truly logical justification for its decision.  The OBRA 90 regulations, as enacted in Texas, provide, as they do in most states, that the pharmacist should provide information when counseling “which in the exercise of the pharmacist’s professional judgment the pharmacist deems significant[12], including “common severe side effects or adverse effects or interactions[13].  No rules, the Court noted, “address a pharmacist’s role with respect to uncommon adverse reactions[14] such as the one in this case.  Indeed, in this case several physicians failed to relate Cameron’s symptoms with desipramine.    

The Court ruled, “Therefore, we hold that any liability of Wal-Mart’s for negligently filling Cameron’s prescription for desipramine must be based on neglect in the face of information on which a reasonably prudent pharmacist would have acted.[15]  The Court could have stopped here noting that, as a matter of law, no reasonable practicing pharmacist would be likely to consider counseling a patient on such an obscure potential reaction as that suffered by Cameron.  Instead the Court seemed compelled to go on.  The Court noted that the pharmacist’s role has changed “from a mere dispenser of medication to a trusted professional who plays a vital role in patient treatment[16]”, and concluding with “We do not imply that pharmacists may not warn patients of potential adverse reactions or dangerous side effects; we merely hold that pharmacists are not legally obligated to do so.[17]  But the Court also said that if a prescription “contained clear errors or obvious inadequacies[18], this could trigger a duty to warn.

So what is the rule in Texas?  The Court’s holding is a pharmacist‘s duty is judged by what a reasonably prudent pharmacist would have done in the same or similar circumstances.  That leads to the conclusion that whether the pharmacist has a duty to warn is a question of fact:  “What would the reasonably prudent pharmacist have done?”  Since a question of fact is for a jury to determine, a Texas jury could determine that a pharmacist may have a duty to warn of common, severe side effects.  The jury would make that determination based upon testimony from experts – practicing pharmacists.  On the other hand, following its holding, the Court reached a conclusion that “pharmacists have no generalized duty to warn . . . absent special circumstances.[19](emphasis added).  

So, the final answer to whether pharmacists have a duty to warn in Texas is:  “Definitely maybe”. 

[1] Morgan v. Wal-mart, ___ S.W.2d  _____, (Tex App.-Austin 2000) [W.L].  Official cite and page numbering is not yet available.
[2] Dooley v. Everett, 805 S.W.2d 380 (Tenn.App. 1990).
[3] Hooks SuperX, Inc. v. McLaughlin, 642 N.E.2d 514 (1994).
[4] Lasley v. Shrake’s Country Club Pharmacy, Inc., 880 P2d 1129 (Ariz. Ct. App. 1994).
[5] Horner v. Spalitto, 1 S.W.3d 519 (Mo. Ct App. 1999)
[6] Morgan v. Wal-Mart, supra, at W.L. 4.
[7] Morgan, subra at W.L. 5.
[8] ID
[9] Horner v. Spalitto, 1 S.W.3d 519, 524 (Mo. App. 1999).
[10] Morgan, supra at W.L. 11.
[11] Morgan, supra at W.L. 14
[12] Morgan, supra at W.L. 11; Tex. Admin. Code § 291.33 et seq.
[13] Morgan, supra at W.L. 11; Tex. Admin. Code § 291.33 et seq.
[14] Morgan, supra at W.L. 11
[15] Morgan, supra at W.L. 12
[16] Morgan, supra at W.L. 14
[17] Morgan, supra at W.L. 14
[18] Morgan, supra at W.L. 14
[19] Morgan, supra at W.L. 14

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with the policies and procedures of their employers and insurance companies, and act accordingly.