Case Title: Joshi v. Providence Health System

Citation: 

Docket Number: S52590

State: oregon

Court: Oregon Supreme Court

Date: 2006-12-21T00:00:00Z

Document:
FILED: December 21, 2006
IN THE SUPREME COURT OF THE STATE OF OREGON
NISHA JOSHI,
Personal Representative of the Estate of Satyapriy Joshi,
Petitioner on Review,
v.
PROVIDENCE HEALTH SYSTEM OF OREGON CORP.,
dba St. Vincent Hospital & Medical Center,
an Oregon business;
JAMES L. HEDTKE, M.D.;
EZRA ASHAR, M.D.,
Individually;
and ALOHA FAMILY PRACTICE CLINIC,
an Oregon business,
Respondents on Review.
(CC 9911-12261; CA A117813; SC S52590)
On review from the Court of Appeals*
Argued and submitted March 6, 2006.
Kathryn H. Clarke, Portland, argued the cause and filed the
brief for petitioner on review.  With her on the brief was John
E. Uffelman, Beaverton.
Lindsey H. Hughes, Keating Jones Bildstein & Hughes, PC,
Portland, argued the cause and filed the briefs for respondent on
review James L. Hedtke, M.D.  Janet M. Schroer, Hoffman Hart &
Wagner LLP, Portland, argued the cause and filed the brief for
respondent on review Ezra Ashar, M.D., and Aloha Family Practice
Clinic.  Michael T. Stone, Brisbee & Stockton, LLC, Hillsboro,
argued the cause and filed the brief for respondent on review
Providence Health System of Oregon Corp., dba St. Vincent
Hospital & Medical Center.
Robert K. Udziela, Beaverton, filed the briefs for amicus
curiae Oregon Trial Lawyers Association.
Before De Muniz, Chief Justice, and Carson, Gillette,
Durham, Riggs, Balmer, and Kistler, Justices.**
DURHAM, J.
The decision of the Court of Appeals is affirmed.  The
judgment of the circuit court is affirmed.
*Appeal from Multnomah County Circuit Court, Stephen L. Gallagher, Judge. 198 Or App 535, 108 P3d 1195 (2005)
**Riggs, J., retired September 30, 2006, and did not
participate in the decision of this case.  Walters, J., did not
participate in the consideration or decision of this case.
DURHAM, J.
Oregon's wrongful death statute, ORS 30.020, provides,
in part:  
"(1) When the death of a person is caused by the
wrongful act or omission of another, the personal
representative of the decedent, * * * may maintain an
action against the wrongdoer, if the decedent might
have maintained an action, had the decedent lived,
against the wrongdoer for an injury done by the same
act or omission."
Plaintiff sued under that statute, alleging that her husband
(decedent) died as a result of the failure of defendants
Providence Health Systems of Oregon, James Hedtke, M.D., Ezra
Azhar, M.D., and Aloha Family Practice Clinic to diagnose and
treat decedent's stroke.  On review, we must interpret the phrase
"when the death of a person is caused by * * * another" in ORS
30.020, and determine what plaintiff must prove to establish
liability in this wrongful death action based on alleged medical
malpractice.   
On or about November 27, 1996, decedent arrived by
ambulance at St. Vincent Hospital, operated by defendant
Providence Health Systems, complaining of severe headache,
blurred vision, and dizziness.  Defendant Hedtke, an emergency
room physician at St. Vincent, ordered a CT scan and a lumbar
puncture.  He eventually discharged decedent with a prescription
for pain medication.
On November 30, 1996, decedent continued to experience
vision problems, as well as disorientation.  Plaintiff contacted
defendant Azhar by telephone; Azhar attributed decedent's
symptoms to the pain medication, and recommended that decedent
replace it with an over-the-counter medication.
The next day, an ambulance again transported decedent
to the hospital.  The hospital personnel determined that decedent
had suffered a stroke.  Treatment was unsuccessful, and decedent
died two days later, on December 3, 1996.
Thereafter, plaintiff brought this wrongful death
action against both physicians and the hospital and clinic where
each physician practiced.  The parties tried the case to a jury. 
Plaintiff offered the testimony of Edward Jauch, M.D., who, among
other things, testified regarding the treatment options available
at the time of decedent's stroke.  Those options included three
medications: (1) tissue-plasminogen activator (t-PA); (2)
heparin; and (3) aspirin.  T-PA is a thrombolytic agent that
helps to break apart blood clots.  Heparin is an anti-thrombotic
medication, which helps prevent further clots from developing. 
Aspirin also helps prevent clots by preventing blood platelets
from aggregating.
In an offer of proof outside the presence of the jury,
Jauch testified that, had hospital personnel diagnosed a stroke
within three hours of its onset, decedent likely would have
benefitted from t-PA.  As to heparin, Jauch testified that he
"believed that heparin would have given [decedent] the increased
chance of not having that progression of his stroke."  Jauch also
testified that "aspirin would have been beneficial to prevent
recurrence and prevention of stroke."
On cross-examination, however, Jauch testified that he
could not state, to a reasonable degree of medical probability,
that administration of t-PA, heparin, or aspirin would have
changed the outcome and saved decedent's life.  Specifically,
Jauch testified that timely administration of t-PA would have
afforded, at most, a 30 percent chance of improvement in outcome. 
As to heparin, Jauch could not testify to a specific percentage
of the chance of improvement had heparin been administered.  As
to the efficacy of aspirin, Jauch testified that, at most,
decedent would have had a 28 percent chance of improved outcome. 
Therefore, according to plaintiff's expert, had defendants
properly diagnosed and treated decedent with one of the three
treatments, decedent's chance of survival would have improved by,
at most, 30 percent.  The trial court directed a verdict for
defendants because Jauch could not testify that decedent probably
would have survived if defendants had correctly diagnosed and
treated him. 
The Court of Appeals affirmed the trial court's
directed verdict.  Joshi v. Providence Health System, 198 Or App
535, 108 P3d 1195 (2005).  The Court of Appeals determined that
"cause," as used in ORS 30.020, meant "cause-in-fact."  Id. at
538.  "Cause-in-fact," according to the Court of Appeals,
requires "evidence of a reasonable probability that, but for the
defendant's negligence, the plaintiff would not have been
harmed."  Id. at 538-39 (emphasis added) (citing Horn v. National
Hospital Association, 169 Or 654, 679, 131 P2d 455 (1942)). 
Plaintiff argued that Oregon courts had abandoned the "but-for"
standard of causation, and instead applied a "substantial factor"
test to determine causation.  Id. at 539.  The Court of Appeals
rejected plaintiffs' argument and explained that the two tests
were the same, except in two types of cases.  Id. at 539-40. 
According to the Court of Appeals, those two types of cases are:
(1) where the acts of multiple tortfeasors cause one injury; and
(2) where two causes concur to bring about a harmful result, and
either cause alone probably would have brought about the harm. 
Id. at 540  The Court of Appeals concluded that neither situation
applied to this case.  Id. at 540-41.  Finally, the Court of
Appeals agreed with the trial court that plaintiff had not
presented evidence sufficient to permit a jury to conclude that
defendants' negligence caused decedent's death.  Id. at 545.  
Plaintiff sought review, which we allowed to address
two related causation questions:  (1) whether the "but for"
standard or the "substantial factor" standard applies to this
wrongful death action; and (2) whether expert testimony that
defendants' conduct probably increased the chance of decedent's
death creates a jury question as to causation. 
In answering those questions, we start with the text
and context of the wrongful death statute.  As previously noted,
we must interpret the phrase "when the death of a person is caused by the
wrongful act or omission of another."  ORS 30.020.  Essentially,
we must interpret the requirement under ORS 30.020 that
defendants' act or omission caused decedent's death.
"In interpreting the text of a provision, we * * *
consider 'rules of construction that bear directly on
the interpretation of the statutory provision in
context.'  One such well-established rule is that words
in a statute that have a well-defined legal meaning are
to be given that meaning in construing the statute."
Gaston v. Parsons, 318 Or 247, 253, 864 P2d 1319 (1994) (internal
citations omitted).  This court has given legal meaning to the
word "cause" in several cases.  We assume that, in using the term
"caused," the legislature intended to incorporate the legal
meaning of that term that this court has developed in its cases. 
As the following discussion illustrates, this court has employed
somewhat different legal standards of causation in different
factual settings.   
In Sandford v. Chev. Div. Gen. Motors, 292 Or 590, 606,
642 P2d 624 (1982), this court explained:
"Causation in Oregon law refers to causation in fact,
that is to say, whether someone examining the event
without regard to legal consequences would conclude
that the allegedly faulty conduct or condition in fact
played a role in its occurrence."
See also Fergison v. Belmont Conv. Hospital, 217 Or 453, 480, 343
P2d 243 (1959) (applying "cause in fact" to action brought under
wrongful death statute). 
What constitutes "cause in fact" in this court's
jurisprudence has varied.  In Horn, this court addressed
causation in the medical malpractice context.  The plaintiff
there alleged that the defendant was negligent in failing to
discover her gall bladder disease.  Id. at 656.  This court
described the causation standard as follows:
"Where the alleged negligence of the defendant
consisted of physical non-feasance, that is, where the
defendant did no physical act which affected
plaintiff's condition, and the negligence, if any, was
the failure to diagnose and advise, it is not
sufficient for a plaintiff to show subsequent ailments
and rest his case upon the specious doctrine of post
hoc ergo propter hoc.  One must go further and show
that competent action would have been substituted for
negligent inaction, and that there was a reasonable
probability that the subsequent ailments would have
been less if the substitution had been made."
Id. at 679 (emphasis added).  The court further held that "where
the causal connection between the negligent failure of a
defendant and subsequent ailments of a plaintiff is left to mere
speculation, a nonsuit is required."  Id.  
This court reiterated the "reasonable probability"
standard of causation in Sims v. Dixon, 224 Or 45, 48, 355 P2d
478 (1960):
"It is well established that the causal connection
between defendant's acts or omissions and the
plaintiff's injuries must not be left to surmise or
conjecture.  The proof of the material issue must have
the quality of reasonable probability, and a mere
possibility that the alleged negligence of the
defendant was the proximate cause of plaintiff's
injuries is not sufficient."
(Emphasis added.)  Specifically, the court held that, because the
plaintiff's medical expert could only testify to a possibility,
and not a probability, that the defendant had caused the
plaintiff's injury, the trial court should have directed a
verdict for the defendant.  Id. at 49; see also Cleland v.
Wilcox, 273 Or 883, 887-88, 543 P2d 1032 (1975) (quoting Sims,
224 Or at 48). 
Applying the "reasonable probability" causation
standard to the word "caused," as used in the wrongful death
statute, a plaintiff in a wrongful death case must demonstrate
that the defendant's negligent act or omission more likely than
not brought about the death of the decedent.  Any showing of
causation less than a reasonable probability would be merely a
possibility and, therefore, insufficient under Sims and Horn.    
Plaintiff contends, however, that the "reasonable
probability" causation standard has been superseded by the
"substantial factor" standard.  As plaintiff notes, this court
has applied the "substantial factor" causation standard in a
number of cases.  See, e.g, Dewey v. A. F. Klaveness & Co., 233
Or 515, 541, 379 P2d 560 (1963) (phrasing the causation standard
as whether the defendant's conduct was a "substantial factor" in
physically producing the injury); see also Babler Bros. v. Pac.
Intermountain, 244 Or 459, 463, 415 P2d 735 (1966) (noting that,
in most negligence cases, "the factual inquiry whether the
actor's conduct was a substantial factor in producing the harm is
relatively uncomplicated"); Stewart v. Jefferson Plywood Co., 255
Or 603, 606, 469 P2d 783 (1970) (noting "substantial factor"
standard).
In McEwen v. Ortho Pharmaceutical, 270 Or 375, 407-21,
528 P2d 522 (1974), this court applied the "substantial factor"
standard to evaluate the liability of two pharmaceutical
companies who manufactured oral contraceptives used by the
plaintiff.  The plaintiff alleged that each defendant failed to
adequately warn the medical profession concerning the potential
danger that the drugs could cause damage to the user's vision. 
Id. at 381.  The plaintiff also alleged that her combined use of
the oral contraceptives resulted in her injuries.  Id.  This
court held that "[t]he respective liability of multiple
defendants depends on whether the negligence of each was a
substantial factor in producing the complained of harm."  Id. at
418 (emphasis added).  This court also explained that the
plaintiff need not show that each defendant's negligence was
 "sufficient to bring about plaintiff's harm by itself;
it is enough that [each defendant] substantially
contributed to the injuries eventually suffered by
[the plaintiff.]"
Id.
In Simpson v. Sisters of Charity of Providence, 284 Or
547, 588 P2d 4 (1978), this court applied the "substantial
factor" causation standard in a medical malpractice case.  The
plaintiff alleged that the defendant hospital failed to take
adequate x-rays when the plaintiff injured his neck and
shoulders.  Id. at 549-50.  The x-ray had failed to detect a
cervical fracture and the plaintiff became paralyzed from the
shoulders down as a result of that fracture when he was
positioned a certain way at the hospital.  Id. at 551.  The
defendant argued that the plaintiff could not demonstrate
causation.  Id. at 555.  In other words, the defendant claimed
that the plaintiff could not show that the failure to take
adequate x-rays caused the plaintiff's injury.  Id. at 556.  This
court stated, "[t]he issue raised is really whether the negligent
conduct of the defendant, as alleged by the plaintiff, was a
substantial factor in producing plaintiff's injury."  Id. at 555
(emphasis added).  On appeal, the defendant contended that the
trial court should have instructed the jury on "but-for"
causation.  Id. at 560-61.  In response, the court explained
that, in its view, the substantial factor test and the but-for
test produced the same result in most cases.  Id. at 561.  The
court further elaborated that the substantial factor standard
required the jury to find that the injury would not have occurred
without the alleged negligence.  Id.
A leading treatise explains the difference between the
"but-for" rule of causation and the "substantial factor" rule of
causation.  See W. Page Keeton, Prosser and Keeton on The Law of
Torts 265-68, § 41 (5th ed 1984) (Prosser & Keeton). (1)  As to
the "but-for" rule, Prosser & Keeton states:
"[The 'but-for' rule] may be stated as follows: The
defendant's conduct is a cause of the event if the
event would not have occurred but for that conduct;
conversely, the defendant's conduct is not a cause of
the event, if the event would have occurred without
it."
Id. at 266.  Prosser & Keeton note, however, that there is one
situation where the "but-for" test fails:  where "two causes
concur to bring about an event, and either one of them, operating
alone, would have been sufficient to cause the identical
result[.]"  Id.  In that situation, "defendant's conduct is a
cause of the event if it was a material element and a substantial
factor in bringing it about."  Id. at 267.  Prosser & Keeton go
on to explain:
"[The substantial factor formula] is an improvement
over the 'but for' rule for this special class of
cases.  It aids in the disposition of these cases and
likewise of two other types of situations which have
proved troublesome.  One is that where a similar, but
not identical result would have followed without the
defendant's act; the other where one defendant has
made a clearly proved but quite insignificant
contribution to the result, as where he throws a
lighted match into a forest fire.  But in the great
majority of cases, it produces the same legal
conclusion as the but-for test.  Except in the classes
of cases indicated, no case has been found where the
defendant's act could be called a substantial factor
when the event would have occurred without it; nor
will cases very often arise where it would not be such
a factor when it was so indispensable a cause that
without it the result would not have followed."
Id. at 267-68 (footnotes omitted).  
Contrary to plaintiff's argument, our cases and Prosser
& Keeton's treatise indicate that the "substantial factor"
standard has not supplanted the "but-for" or "reasonable
probability" standard of causation.  Instead, the two standards
apply to different types of negligence cases.  The "but-for" test
for causation, in which a plaintiff must demonstrate that the
defendant's negligence more likely than not caused the
plaintiff's harm, applies to the majority of cases. 
Additionally, as this court noted in Simpson, the two standards
produce the same result in most cases.  Moreover, the situations
in which the standards may produce a different result are unlike
the present case.  For example, unlike the plaintiff in McEwen,
plaintiff here has not demonstrated that two tortfeasors acted
concurrently to bring about decedent's death.  Neither has
plaintiff demonstrated that decedent's death would not have
occurred without defendants' alleged negligence.  Further,
plaintiff has not shown facts suggesting that this case is like
either of the two other types of cases described by Prosser &
Keeton.  We therefore agree with the Court of Appeals' conclusion
that plaintiff here has not shown that the "substantial factor"
standard should be applied in this case.  
Plaintiff also asks this court to adopt the lost chance
of survival theory, which would allow her to demonstrate
causation by offering evidence that defendants' negligence
deprived decedent of a chance of surviving the stroke he
suffered.  One court has described the lost chance theory as
follows:
"In the typical loss of a chance case, a plaintiff
already has a condition or is subject to risk from a
hazard, unlike a healthy plaintiff in most personal
injury cases.  A plaintiff claims the negligence has
increased the risk of harm by hastening or aggravating
the effect of the pre-existing condition or risk. 
Additionally, the typical case often involves a
situation in which the duty breached by a tortfeasor
is imposed to prevent the harm which ultimately
becomes the basis for the damages sought.  Often times
these cases are problematic as the tort may prevent a
determination of whether the exercise of due care
under the circumstances could have produced a better
result."
McKellips v. Saint Francis Hosp., 741 P2d 467, 471-72 (Okla
1987).  
The lost chance theory applied by certain jurisdictions
incorporates a "substantial factor" standard of causation: 
"Once the plaintiff shows that the defendant's
negligence increased the risk that the plaintiff's
injury would occur, sec. 323(a) [of the Restatement
(Second) of Torts] allows the trier of fact to
determine whether the negligence was a substantial
factor in causing the injury."
Ehlinger v. Sipes, 155 Wis2d 1, 11-12, 454 NW2d 754 (1990)
(emphasis added). (2)  Other courts reduce the causation
standard to that of a "substantial possibility," as announced in
Hicks v. United States, 368 F2d 626, 632 (4th Cir 1966):
"When a defendant's negligent action or inaction has
effectively terminated a person's chance of survival,
it does not lie in the defendant's mouth to raise
conjectures as to the measure of the chances that he
has put beyond the possibility of realization.  If
there was any substantial possibility of survival and
the defendant has destroyed it, he is answerable. 
Rarely is it possible to demonstrate to absolute
certainty what would have happened in circumstances
that the wrongdoer did not allow to come to pass.  The
law does not in the existing circumstances require the
plaintiff to show to a certainty that the patient would
have lived had she been hospitalized and operated on
promptly."
(Emphasis added.)  
We cannot accept plaintiff's invitation to adopt that
theory in actions brought under ORS 30.020.  That statute
requires that a plaintiff prove that a defendant's negligent act
or omission caused the decedent's death.  Whether the plaintiff
does so by showing a reasonable probability that a defendant's
act led to decedent's death or by showing that defendant's act
was a substantial factor in decedent's death, the plaintiff must
demonstrate that defendant's negligent acts or omission was
sufficient to bring about decedent's death.  Plaintiff cannot
avoid this requirement by showing that defendants' negligent act
or omission merely increased the risk of death.  Moreover, our
prior cases make clear that plaintiff cannot discharge her
obligation by showing only a "substantial possibility" that
defendants' actions caused decedent's death.  See Sims, 224 Or at
48-49 (holding that, where proof amounts to a possibility, the
plaintiff has not satisfied her burden);Cleland, 273 Or at 887-88 (same).  Additionally, this court has also held, in the
wrongful death context, that "if the evidence discloses with
equal cogency two or more possible causes for only one of which
the defendant is responsible, the plaintiff has failed to
discharge the burden of proof."  Copenhaver, Admtr'x v. Tripp,
187 Or 662, 682, 213 P2d 450 (1950).
We have so far concluded that "caused," as used in ORS
30.020, encompasses both the reasonable probability standard of
causation as well as the substantial factor standard; the
standard to be applied in a given case depends on the
circumstances of that case.  We have also concluded that the
circumstances of this case require plaintiff to demonstrate, to a
reasonable degree of probability, that defendants' alleged
negligent acts or omissions caused decedent's death.  To prove
causation, plaintiff offered the testimony of her medical expert,
Jauch.  Jauch, however, could not testify that, to a reasonable
probability, defendants' failure to diagnose and treat decedent's
stroke caused decedent's death.  Instead, Jauch testified that,
at most, defendants' failure deprived decedent of a 30 percent
chance of surviving a stroke.  Although deprivation of a 30
percent chance of survival may constitute an injury, the injury
that is compensable under ORS 30.020 is death.  Therefore,
plaintiff has failed to prove the elements of the wrongful death
action as set forth in the statute.  The trial court therefore
correctly directed a verdict for defendants.
The decision of the Court of Appeals is affirmed.  The
judgment of the circuit court is affirmed.
1. This court has repeatedly looked to Prosser and Keeton
for explication of tort law.  See, e.g., Oregon Steel Mills, Inc
v. Coopers & Lybrand, LLP, 336 Or 329, 339, 83 P3d 322 (2004);
Simpson, 284 Or at 561.
2. The Restatement (Second) of Torts section 323, referred
to above, provides: 
"Negligent Performance of Undertaking to Render
Services.  One who undertakes, gratuitously or for
consideration, to render services to another which he
should recognize as necessary for the protection of the
other's person or things, is subject to liability to
the other for physical harm resulting from his failure
to exercise reasonable care to perform his undertaking
if (a) his failure to exercise such care increases the
risk of such harm, or (b) the harm is suffered because
of the others reliance upon the undertaking."
Restatement (Second) of Torts, § 323 (1965).