Helling v. Carey: Medical Malpractice and the Standard of Care

Helling v. Carey is a 1974 Washington Supreme Court decision holding two ophthalmologists negligent for failing to give a young patient a simple glaucoma pressure test, even though no ophthalmologist at the time routinely tested patients under 40. The ruling is famous because it did what courts almost never do: it declared an entire profession’s accepted practice legally inadequate.¹

What Happened to Barbara Helling

Barbara Helling first saw Drs. Thomas Carey and Robert Laughlin in 1959 for nearsightedness. She returned in September 1963 with irritation from her contact lenses and kept coming back through 1967 and 1968, reporting eye discomfort and visual difficulties. Each time, the doctors traced her complaints to her contact lenses.¹

In October 1968, Dr. Carey tested her intraocular pressure and visual field for the first time. She had glaucoma. By then it had already caused severe, permanent damage to her vision. She was still under 40.¹

The Lower Courts Sided with the Doctors

Helling sued for professional negligence. The doctors’ defense was simple. The accepted standard in ophthalmology did not call for routine pressure testing on patients under 40, and expert witnesses confirmed the defendants had followed that standard. The trial court ruled for the doctors. The court of appeals affirmed. Under conventional malpractice analysis, that should have ended the case: a doctor who follows the profession’s own standard has, by definition, met the standard of care.¹

The Washington Supreme Court’s Reversal

The Washington Supreme Court reversed and found the doctors negligent as a matter of law. That phrasing matters. The court didn’t send the case back for a jury to reconsider. It ruled, as a legal conclusion, that failing to give Helling a pressure test was negligent, regardless of what the profession’s custom said.¹

The Court’s Reasoning: Custom Is Not the Ceiling

The decision rested on a 1932 federal case called The T.J. Hooper, in which Judge Learned Hand wrote that while reasonable care usually matches common industry practice, common practice “is never its measure.” An entire profession, Hand reasoned, could lag behind in adopting available safety measures, and when that happens, courts have to say what the law requires.¹

The Washington court quoted Hand and applied his logic. The glaucoma pressure test, tonometry, was simple, inexpensive, and harmless. Undetected glaucoma, on the other hand, could cause irreversible blindness. The court acknowledged that glaucoma occurs in only about one in 25,000 people under 40. But the one person who does develop it deserves the same protection as a patient over 40, where routine testing was already standard.¹

The framework is a cost-benefit test, sometimes called the Hand Formula. If the burden of a precaution is low and the potential harm from skipping it is catastrophic, then skipping it is negligent. The profession’s custom of not testing patients under 40 failed that test. The precaution cost almost nothing. The harm cost a patient her sight.

Why the Ruling Alarmed the Medical Profession

Medical malpractice law had long treated professional custom as a near-absolute shield. If a doctor could show that other competent physicians in the field would have done the same thing, the case was essentially over. Helling opened that framework by letting a court second-guess the profession’s own judgment about what counted as adequate care.

Doctors worried that no level of compliance would protect them from liability if judges and juries could substitute their own view of reasonable care for the collective expertise of the field. The concern wasn’t only about tonometry. If a court could declare the entire ophthalmology profession negligent for a testing practice it universally followed, other long-standing customs could be next.

Washington’s Legislative Override: RCW 4.24.290

The backlash was fast. In 1975, the Washington State Legislature passed RCW 4.24.290, aimed directly at reversing Helling. The statute provides that in a malpractice suit against a licensed hospital, its staff, or a health care provider, the plaintiff must prove the defendant failed to exercise the degree of skill, care, and learning that other professionals in the same field would have shown at the time.²

In practical terms, the statute restored professional custom as the benchmark. If a defendant can show that other qualified professionals in the same specialty would have acted the same way, that is the standard the plaintiff must overcome. The statute reaches a broad range of licensed providers, including physicians, osteopathic physicians, chiropractors, dentists, podiatric physicians, nurses, and acupuncturists.²

One carve-out matters. The statute explicitly does not apply to claims based on failure to obtain informed consent. A patient who was never told about available diagnostic options may still bring that kind of claim outside the professional-custom framework, even in Washington.²

Where the Standard of Care Stands Today

Across nearly every jurisdiction, proving medical malpractice still requires showing that the defendant fell below the standard of care a reasonably competent practitioner in the same specialty would have provided under similar circumstances. Expert testimony from a physician in the same field is almost always required to establish that standard. No other state has adopted the Helling approach of letting courts override professional custom as a matter of law.

RCW 4.24.290 remains on the books with no major amendments since 2019.² Clinical practice guidelines have also expanded dramatically since the 1970s, and routine glaucoma screening for adults is now standard in ophthalmology. The specific gap in Helling closed through professional evolution rather than court mandate.

Why the Case Is Still Taught

Helling v. Carey is still one of the most widely taught cases in American law schools even though the legislature erased its holding within a year. Its durability comes from the question it refused to let the profession sidestep: what happens when a specialty’s accepted practices fail to prevent a preventable harm? Compliance with current professional norms remains a strong defense in malpractice cases. Helling is the reminder that it isn’t an invitation to stop asking whether those norms are enough.

1
Justia. Helling v. Carey
2
Washington State Legislature. RCW 4.24.290 – Action for Damages Based on Professional Negligence of Hospitals or Members of Healing Arts