Medical Diagnosis or Treatment
In general
• One . . . exception generally permits statements made for the purpose of medical diagnosis or treatment to be admitted into evidence, even when the declarant is available.
VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013)(citing Evid. R. 803(4))
See Miles v. State, 777 N.E.2d 767, 771 (Ind. Ct. App. 2002)(“Evid. R. 803(4) provides that statements made to medical personnel for the purpose of obtaining a diagnosis and treatment are admissible.”)
Exception to the rule against hearsay: Text
• (4) Statement Made for Medical Diagnosis or Treatment. A statement that:
(A) is made by a person seeking medical diagnosis or treatment;
(B) is made for—and is reasonably pertinent to—medical diagnosis or treatment; and
(C) describes medical history; past or present symptoms, pain or sensations; their inception; or their general cause.
Rationale
• Rule 803(4)'s exception is grounded in a belief that the declarant's self-interest in obtaining proper medical treatment makes such a statement reliable enough for admission at trial—more simply put, Rule 803(4) reflects the idea that people are unlikely to lie to their doctors because doing so might jeopardize their opportunity to be made well.
VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013)
Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015)(quoting VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013))(“This exception ‘reflects the idea that people are unlikely to lie to their doctors because doing so might jeopardize their opportunity to be made well.’”)
See State v. Velasquez, 944 N.E.2d 34, 40 (Ind. Ct. App. 2011), trans. granted, order vacated, trans. denied(citing Nash v. State, 754 N.E.2d 1021, 1023 (Ind. Ct. App. 2001), trans. denied)(“Hearsay is admitted under this exception because the reliability of the out-of-court statement is assured based upon the belief that a declarant's self-interest in seeking medical treatment renders it unlikely the declarant will mislead the person that she wants to treat her.”)
See also Palilonis v. State, 970 N.E.2d 713, 726 (Ind. Ct. App. 2012), trans. denied(quoting Miles v. State, 777 N.E.2d 767, 771 (Ind. Ct. App. 2002))(“This exception is ‘based upon the belief that a declarant's self-interest in seeking medical treatment renders it unlikely that the declarant would mislead the medical personnel person she wants to treat her.’”)
See also Mastin v. State, 966 N.E.2d 197, 201 (Ind. Ct. App. 2012), trans. denied(citing Sibbing v. Cave, 922 N.E.2d 594, 598 (Ind. 2010))(“The rationale for this hearsay exception is that a declarant has a personal interest in obtaining a medical diagnosis and treatment, and this interest motivates the patient to provide truthful information.”)
Admissibility: In general
• This belief of reliability, though, necessitates a two-step analysis for admission under Rule 803(4): First, “is the declarant motivated to provide truthful information in order to promote diagnosis and treatment,” and second, “is the content of the statement such that an expert in the field would reasonably rely on it in rendering diagnosis or treatment.”
VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013)(quoting McClain v. State, 675 N.E.2d 329, 331 (Ind. 1996))
See Palilonis v. State, 970 N.E.2d 713, 726 (Ind. Ct. App. 2012), trans. denied(quoting Nash v. State, 754 N.E.2d 1021, 1023-24 (Ind. Ct. App. 2001), trans. denied)(There is a two-step analysis for determining whether a statement is properly admitted under Evidence Rule 803(4): ‘(1) whether the declarant is motivated to provide truthful information in order to promote diagnosis and treatment; and (2) whether the content of the statement is such that an expert in the field would reasonably rely upon it in rendering diagnosis or treatment.’”)
See also Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015)(citing VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013))(“To test whether the declarant's self-interest in obtaining effective medical treatment makes the hearsay report adequately reliable for admission, we determine: (1) whether the declarant was motivated to provide truthful information to promote diagnosis and treatment and (2) whether the content of the statement was such that an expert in the field would reasonably rely on it when rendering diagnosis or treatment.”)
See also Perry v. State, 956 N.E.2d 41, 49 (Ind. Ct. App. 2011), reh’g denied(citing In re Paternity of H.R.M., 864 N.E.2d 442, 446 (Ind. Ct. App. 2007))(“In determining the admissibility of hearsay under Rule 803(4), courts evaluate (1) whether the declarant's motive was to provide truthful information to promote diagnosis and treatment and (2) whether the content of the statement is such that an expert in the field would reasonably rely on it in rendering diagnosis or treatment.”)
• [I]n order for statements to be admissible under Evidence Rule 803(4), they need not be in furtherance of diagnosis and treatment. Rather, the statements must be relied on either to render a diagnosis or provide treatment. Nor is it required that the statement be made to the individual who ultimately will render a diagnosis or provide treatment. It is necessary only that the statement is made to promote diagnosis or treatment.
Clark v. State, 978 N.E.2d 1191, 1197 (Ind. Ct. App. 2012), clarified on reh’g, 985 N.E.2d 1095 (Ind. Ct. App. 2013))(citing State v. Velasquez, 944 N.E.2d 34, 42 (Ind. Ct. App. 2011), trans. granted, order vacated, trans. denied)
Admissibility: Was the declarant motivated to provide truthful information in order to promote diagnosis and treatment?
• In order to satisfy the requirement of the declarant's motivation, the declarant must subjectively believe that he was making the statement for the purpose of receiving medical diagnosis or treatment.
McClain v. State, 675 N.E.2d 329, 331 (Ind. 1996)
VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013)(quoting McClain v. State, 675 N.E.2d 329, 331 (Ind. 1996))(alteration in the original)(“‘[T]he declarant must subjectively believe that he was making the statement for the purpose of receiving medical diagnosis or treatment.’”)
See Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015)(citing VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013))(“The first prong is a subjective inquiry about whether the declarant believed she was making the statement for the purpose of receiving medical diagnosis or treatment.”)
• With most declarants, this is generally a simple matter: “[o]ften, for example where a patient consults with a physician, the declarant's desire to seek and receive treatment may be inferred from the circumstances.”
VanPatten v. State, 986 N.E.2d 255, 260-61 (Ind. 2013)(quoting McClain v. State, 675 N.E.2d 329, 331 (Ind. 1996))(alteration in the original)
See Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015)(quoting VanPatten v. State, 986 N.E.2d 255, 261 (Ind. 2013))(“Answering this question is generally simple because when a patient consults a physician, the ‘desire to seek and receive treatment may be inferred from the circumstances.’”)
• But in cases like the one here, where the declarant is a young child brought to the medical provider by a parent, we have acknowledged that such an inference may be less than obvious.
VanPatten v. State, 986 N.E.2d 255, 261 (Ind. 2013)
• Such young children may not understand the nature of the examination, the function of the examiner, and may not necessarily make the necessary link between truthful responses and accurate medical treatment.
VanPatten v. State, 986 N.E.2d 255, 261 (Ind. 2013)
• In that circumstance, “there must be evidence that the declarant understood the professional's role in order to trigger the motivation to provide truthful information.”
VanPatten v. State, 986 N.E.2d 255, 261 (Ind. 2013)(quoting McClain v. State, 675 N.E.2d 329, 331 (Ind. 1996))
• This evidence does not necessarily require testimony from the child-declarant; it may be received in the form of foundational testimony from the medical professional detailing the interaction between him or her and the declarant, how he or she explained his role to the declarant, and an affirmation that the declarant understood that role.
VanPatten v. State, 986 N.E.2d 255, 261 (Ind. 2013)(citing United States v. Barrett, 8 F.3d 1296, 1300 (8th Cir. 1993))
Admissibility: Was the content of the statement such that an expert in the field would reasonably rely on it in rendering diagnosis or treatment?
• Generally, “statements attributing fault or identity are typically inadmissible under” Evidence Rule 803(4).
State v. Velasquez, 944 N.E.2d 34, 40 (Ind. Ct. App. 2011), trans. granted, order vacated, trans. denied(quoting Nash v. State, 754 N.E.2d 1021, 1025 (Ind. Ct. App. 2001), trans. denied)
• Statements attributing fault or establishing a perpetrator's identity are typically inadmissible under the medical diagnosis exception, as identification of the person responsible for the declarant's condition or injury is often irrelevant to diagnosis and treatment.
Perry v. State, 956 N.E.2d 41, 49 (Ind. Ct. App. 2011), reh’g denied(citing Beverly v. State, 801 N.E.2d 1254, 1259 (Ind. Ct. App. 2004), trans. denied)
See In re Paternity of H.R.M., 864 N.E.2d 442, 447 (Ind. Ct. App. 2007)(“We wish to point out that identity is rarely admissible under the medical diagnosis exception to hearsay, as identity is not normally relevant to a medical diagnosis or treatment.”)
See also Beverly v. State, 801 N.E.2d 1254, 1259 (Ind. Ct. App. 2004), trans. denied(citing Nash v. State, 754 N.E.2d 1021, 1024 (Ind. Ct. App. 2001), trans. denied)(“As for the second step, hearsay statements admissible for the purpose of medical diagnosis or treatment typically do not involve statements of identity because identity of the person responsible for the injury is usually not necessary to provide effective medical care.”)
• [T]here are exceptions to this general rule, such as where injury occurs as the result of domestic violence . . . .
Beverly v. State, 801 N.E.2d 1254, 1259 (Ind. Ct. App. 2004), trans. denied
• Statements made by victims of sexual assault or molestation about the nature of the assault or abuse—even those identifying the perpetrator—generally satisfy the second prong of the analysis because they assist medical providers in recommending potential treatment for sexually transmitted disease, pregnancy testing, psychological counseling, and discharge instructions.
VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013)
See Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015))(quoting VanPatten v. State, 986 N.E.2d 255, 260 (Ind. 2013))(“Statements about ‘the nature of the assault or abuse,’ even if they identify the perpetrator, can satisfy the second prong of the reliability test if the statements ‘assist medical providers in recommending potential treatment for sexually transmitted disease, pregnancy testing, psychological counseling, and discharge instructions.’”)
• [I]n the context of physical or sexual child abuse, “knowledge of the perpetrator is important to the treatment of psychological injuries that may relate to the identity of the perpetrator and to the removal of the child from the abuser's custody or control.”
In re Paternity of H.R.M., 864 N.E.2d 442, 447 (Ind. Ct. App. 2007)(quoting Nash v. State, 754 N.E.2d 1021, 1024 (Ind. Ct. App. 2001), trans. denied)
• Thus, “in cases involving child abuse, sexual assault, and/or domestic violence, courts may exercise their discretion in admitting medical diagnosis statements which relay the identity of the perpetrator.”
Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015)(quoting Perry v. State, 956 N.E.2d 41, 49 (Ind. Ct. App. 2011), reh’g denied)
See Nash v. State, 754 N.E.2d 1021, 1025 (Ind. Ct. App. 2001), trans. denied(“However, in cases such as the present one where injury occurs as the result of domestic violence, which may alter the course of diagnosis and treatment, trial courts may properly exercise their discretion in admitting statements regarding identity of the perpetrator.”)
• [W]e strongly counsel prosecutors and trial courts that statements made to medical personnel are admissible under Indiana Evidence Rule 803(4) only where shown to be medically relevant. Legal relevance is not sufficient; nor is the mere presence of the statement in the medical record.
Dowell v. State, 865 N.E.2d 1059, 1065 n. 4 (Ind. Ct. App. 2007), aff’d in relevant part, 873 N.E.2d 59 (Ind. 2007)
Admissibility: Individuals permitted to be the declarant
• [Evid. R. 803(4)] permits accounts of statements by a person needing medical treatment, but not statements attributed to the treating professional.
Jackson v. State, 925 N.E.2d 369, 375 (Ind. 2010), reh’g denied(citing Sibbing v. Cave, 922 N.E.2d 594, 598 (Ind. 2010))
• In some cases, “statements by others, most often close family members, may be received if the relationship or the circumstances give appropriate assurances” as to the statements' reliability.
Jackson v. State, 925 N.E.2d 369, 375 (Ind. 2010), reh’g denied(quoting 2 McCormick on Evidence § 277, at 286 (Kenneth S. Broun et al. eds., 6th ed. 2006))
Admissibility: Individuals permitted to be the listener
• Although the statement need not be made to a physician, it must be made “to advance a medical diagnosis or treatment” to fall within the purview of Evidence Rule 803(4).
Mastin v. State, 966 N.E.2d 197, 201 (Ind. Ct. App. 2012), trans. denied(quoting In re Paternity of H.R.M., 864 N.E.2d 442, 446 (Ind. Ct. App. 2007))
• [W]e must agree with [the defendant] that [the declarant’s] statement to her grandmother, made after a medical examination had concluded and no health professional was present, was not made to advance her medical diagnosis or treatment.
Mastin v. State, 966 N.E.2d 197, 201 (Ind. Ct. App. 2012), trans. denied
• If the declarant's statements are made to advance a medical diagnosis or treatment, Evidence Rule 803(4) encompasses statements made to non-physicians, including clinical social workers.
State v. Velasquez, 944 N.E.2d 34, 40 (Ind. Ct. App. 2011), trans. granted, order vacated, trans. denied
• [I]n cases where there is a proper showing of reliability, a statement to a family therapist may be admissible pursuant to the medical diagnosis or treatment hearsay exception.
McClain v. State, 675 N.E.2d 329, 331 (Ind. 1996)
Requirement that the statement be reasonably pertinent to medical diagnosis or treatment: Discretion of the trial court
• “The extent to which a statement as to cause is pertinent to diagnosis or treatment rests within the discretion of the trial judge, who may consider the health care provider's testimony in making that determination.”
Perry v. State, 956 N.E.2d 41, 50 (Ind. Ct. App. 2011), reh’g denied(quoting 13 Robert Lowell Miller, Jr., Indiana Practice: Indiana Evidence § 803.104 (3d ed. 2007))
See Steele v. State, 42 N.E.3d 138, 142 (Ind. Ct. App. 2015)(citing Perry v. State, 956 N.E.2d 41, 50 (Ind. Ct. App. 2011), reh’g denied)(“The determination whether a statement about the cause of injuries is pertinent to diagnosis or treatment is left to the discretion of the trial judge, who may consider the health care provider's testimony.”)