Helling v. Carey, decided by the Washington Supreme Court in 1974, is a widely cited and debated medical malpractice case in American law. Two ophthalmologists were held negligent for failing to give a 32-year-old patient a simple glaucoma pressure test, even though the universally accepted custom in the profession at the time was not to test patients under 40. The court ruled that following professional custom does not automatically protect a doctor from liability. Reasonable prudence is the legal standard, and courts, not the medical profession alone, decide what it requires.
The decision provoked a sharp backlash. The Washington legislature passed a statute the following year aimed at restoring the pre-Helling rule, and no other state has formally adopted the Helling approach to medical malpractice. Even so, the case remains a fixture of legal education and continues to shape how lawyers and judges think about missed diagnoses and the failure to use simple, available tests. This article walks through what happened, why the court ruled the way it did, and what Helling v. Carey still means for patients pursuing medical malpractice claims today.
What Happened in Helling v. Carey?
Barbara Helling first consulted Dr. Thomas F. Carey and Dr. Robert C. Laughlin, partner ophthalmologists, in 1959 for nearsightedness. She was fitted with contact lenses and did not return until September 1963, when she reported irritation from the lenses. Over the next several years she came back intermittently with similar complaints.
In August 1968, when Helling was 32, she reported a visual field problem for the first time. Dr. Carey administered a tonometry test, which measures intraocular pressure, in October of that year. The test revealed primary open-angle glaucoma. Because the disease had gone undetected for years, much of her vision was already permanently lost.
The key issue: should the doctors have tested Helling for glaucoma years before her vision was lost?
Helling sued. The case went to a jury, which returned a verdict for the doctors. The Washington Court of Appeals affirmed. At trial, expert witnesses for both sides agreed on the same point: the standard of the ophthalmology profession did not call for routine glaucoma testing in patients under 40, because the incidence of the disease in that age group was extremely low. The defense argued that compliance with that customary standard ended the inquiry.
The Standard of Care vs. Reasonable Prudence
For most of the twentieth century, the legal medical malpractice standard of care was straightforward: the customary standard holds that a doctor who follows accepted professional practice is not negligent. Plaintiffs almost always needed an expert to testify that the defendant had deviated from accepted custom. If the doctor proved compliance, the case ended.
The Washington Supreme Court took a different path. It reached back to general tort principles and to a famous 1932 admiralty decision by Judge Learned Hand, The T.J. Hooper, 60 F.2d 737 (2d Cir. 1932). In that case, an entire industry of tugboat operators was held negligent for failing to equip boats with radios that could have received storm warnings, even though radios were not yet the industry custom. Judge Hand wrote that "a whole calling may have unduly lagged in the adoption of new and available devices" and that "courts must in the end say what is required."
The Washington Supreme Court applied that reasoning to medicine. Customary practice is evidence of reasonable care, the court held, but it is not the final word.
Why Did the Court Rule Against the Eye Doctors?
The Washington Supreme Court reversed the lower courts and held the doctors negligent as a matter of law in failure to diagnose glaucoma. The reasoning was a straight cost-benefit analysis:
- The tonometry test was simple, fast, and inexpensive
- The test was harmless to the patient
- Glaucoma is asymptomatic in its early stages and detectable only through this kind of pressure test
- The harm from missing the diagnosis was severe and irreversible: permanent loss of vision
Given that the burden of administering the test was minimal and the magnitude of the potential harm was catastrophic to the patient, the court concluded that reasonable prudence required the test regardless of the patient's age and regardless of what the rest of the profession was doing. The court held that a doctor can be negligent even when following professional custom if the burden of care was minimal and the potential harm was severe. The decision is one of the most often-cited examples of an American court rejecting professional custom as the legal standard of care in a malpractice case.
How the Profession and the Legislature Responded
The ruling drew immediate and forceful opposition from physicians, who argued that courts were not equipped to set medical standards on a case-by-case basis. The Washington legislature responded the following year by enacting RCW 4.24.290, which the House Judiciary Committee's bill report stated was intended to "re-establish the pre-Helling standards of negligence." A companion statute, RCW 7.70.040, codified the customary standard for medical malpractice claims arising after June 25, 1976.
In Gates v. Jensen, 92 Wn.2d 246 (1979), the Washington Supreme Court partially preserved Helling by reading RCW 4.24.290 narrowly. The court held that because the statute referred to skill and care "possessed" by other practitioners rather than "practiced" by them, it did not fully displace the reasonable prudence rule. Even so, Helling is now treated as an exceptional circumstance in its home state, and the modern Washington statutory scheme leans heavily on professional custom.
Outside Washington, the case has fared no better. Legal commentary has consistently noted that Helling has not become a precedent followed by other states. In most malpractices lawsuits, the standard of care is still set by what a reasonably competent practitioner in the same specialty would have done, established through expert testimony.
How Does Helling v. Carey Affect Malpractice Cases Today?
Helling is not binding law outside Washington, but its influence on how courts, juries, and lawyers think about proving negligence in a medical malpractice case is real. Three points carry forward.
- First, the cost-benefit framing has stuck. When a missed diagnosis turns on whether a doctor should have ordered a test, modern juries are often invited to weigh the burden of the test against the consequences of skipping it. That framing comes from Helling and from The T.J. Hooper before it.
2. Second, the case is a reminder that custom is not an automatic defense. Courts in most states still treat professional custom as the standard, but plaintiffs can argue, with the right facts and expert support, that an entire field has lagged behind available technology or diagnostic tools. These arguments are difficult to win, but they exist precisely because Helling opened the door.
3. Third, the case continues to shape disputes over delayed-diagnosis cancer, missed strokes, and other conditions where a simple, inexpensive test could have caught a serious disease at an earlier stage. Insurance company guidelines and hospital cost-containment policies sometimes discourage testing that would have been routine a generation ago. When those policies result in a missed diagnosis, the Helling framework, even though it is not the controlling rule, gives plaintiffs' lawyers a useful way to argue that following protocol is not the same as exercising reasonable care.
Frequently Asked Questions
Is Helling v. Carey still good law today?
Inside Washington state, partially. The Washington Supreme Court in Gates v. Jensen (1979) and Harris v. Groth (1983) held that the legislature's 1975 statute, RCW 4.24.290, did not fully overrule Helling. The reasonable prudence rule survives in narrow circumstances. Outside Washington, no state supreme court has adopted the Helling rule, and the customary standard remains the controlling test for medical malpractice claims.
Does Helling v. Carey apply outside Washington state?
No state appellate court has adopted Helling as the rule for setting the medical standard of care. Patients in New Jersey, New York, Pennsylvania, Connecticut, Massachusetts, and elsewhere must still prove that the defendant deviated from the standard of care accepted within the profession, and they must usually do so through qualified expert testimony. Helling is studied, cited persuasively, and quoted in legal commentary, but it is not binding outside Washington.
Can I sue a doctor for not ordering a test that was not part of standard screening?
Sometimes, but it is harder than it sounds. In most states, you would need a qualified medical expert to testify that, under the specific circumstances of your case, a reasonably competent practitioner in the same specialty would have ordered the test. If the only argument is that the test is cheap and the disease is serious, that alone is usually not enough outside Washington. Whether a claim has merit turns on what your symptoms were, what the medical records show, and what the standard of care required. This is general information only and does not constitute legal advice. Whether you have a viable claim depends on the specific facts of your case.
What is the difference between the customary standard and the reasonable physician standard?
Under the customary standard, the question is whether the doctor did what other doctors in the field would have done. Under the reasonable physician standard, the question is whether the doctor acted reasonably under the circumstances, which a jury can decide even if the doctor followed custom. Most states still use the customary standard for medical malpractice. A growing minority use a reasonable-physician-style approach or some hybrid. Helling is the most extreme example of the reasonable-prudence side of that divide.
Call Brandon J. Broderick For Legal Help
Medical malpractice cases turn on the details: what the doctor knew, what the records show, what testing was available, and what a reasonably competent practitioner would have done. The standard of care in your state may be more forgiving of medical custom than the Helling rule, but that does not mean a custom defense is automatic. If a simple, available test or diagnostic step was skipped and you suffered serious harm, you may have a medical malpractice claim worth pursuing.
Our attorneys work with respected medical experts to evaluate whether the care you received fell below the legal standard and what the full financial impact of that failure has been. Contact us for a free consultation to discuss your case.