Case Title: Williams v. U.S. Dist. Court

Citation: 127 Nev. Adv. Op. No. 45

Docket Number: 56928

State: nevada

Court: Nevada Supreme Court

Date: 2011-07-28T00:00:00Z

Document:
427 Nev, Advance Opinion 45
IN THE SUPREME COURT OF THE STATE OF NEVADA

JAMES M. WILLIAMS AND HEIDI
WILLIAMS, HUSBAND AND WIFE;
AND JOANNE ALLEN AND KENNETH
G, ALLEN, HUSBAND AND WIFE,
Petitioners,
vs.
‘THE EIGHTH JUDICIAL DISTRICT
COURT OF THE STATE OF NEVADA,
IN AND FOR THE COUNTY OF
CLARK; AND THE HONORABLE
KATHLEEN E. DELANEY,
Respondents,

and
BAXTER HEALTHCARE,
CORPORATION; SICOR, INC.; TEVA
PARENTERAL MEDICINES, INC.,
FYK/A SICOR PHARMACEUTICALS,
INC. AND MCKESSON MEDICAL-
SURGICAL, INC.,
Real Parties in Interest.

 

SICOR, INC.; TEVA PARENTERAL

MEDICINES, INC. (F/K/A SICOR
PHARMACEUTICALS, INC.);
MCKESSON MEDICAL-SURGICAL,
INC.; AND BAXTER HEALTHCARE
CORPORATION,
Petitioners,
‘THE EIGHTH JUDICIAL DISTRICT
COURT OF THE STATE OF NEVADA,
IN AND FOR THE COUNTY OF
CLARK; AND THE HONORABLE
‘TIMOTHY C. WILLIAMS, DISTRICT
JUDGE,
Respondents,

and

 

No. 56928

FILED

WL 25 201

No, 57079

 

 
00 Se

    

MARIA V. PAGAN, INDIVIDUALLY;
AND WILLIAM I, BILGER, JR., AND
MARILYN ELAINE BILGER,

HUSBAND AND WIFE,
Real Parties in Interest.

      
   
 
  

Consolidated petitions for writs of mandamus challenging
district court rulings regarding the admission of evidence.

 

Petitions granted in ied in part,

Mainor Bglet and Robert T. Eglet, Las Vegas; Kemp Jones & Coulthard
LLP and Will Kemp, Las Vegas,

for James M, Williams; Heidi Williams; Joanne Allen; Kenneth G. Allen;
Maria V. Pagan; William I. Bilger, Jr.; and Marilyn Elaine Bilger.

Lewis & Roca LLP and Daniel F. Polsenberg, Las Vegas; Olson, Cannon,
Gormley & Desruisseaux and James R. Olson, Michael E. Stoberski, and
Max E. Corrick II, Las Vegas; Alan M. Dershowitz, Cambridge,
Massachusetts,

for Baxter Healthcare Corporation; McKesson Medical-Surgical, Inc.
Sicor, Inc.; and Teva Parenteral Medicines, Inc.

BEFORE THE COURT EN BANC.)
INION

By the Court, HARDESTY, J.:
‘These consolidated writ petitions raise two novel issues

involving the admissibility of expert testimony: (1) whether a nurse can
1The Honorable Kristina Pickering, Justice, and the Honorable Ron

Parraguirre, Justice, voluntarily recused themselves from participation in
the decision of this matter.

 

 
testify as an expert regarding medical causation, and (2) whether defense
expert testimony offering alternative causation theories must meet the
“reasonable degree of medical probability” standard set forth in Morsicato
v, Sav-On Drug Stores, Inc, 121 Nev. 158, 155, 111 P.8d 1112, 1114
(2005). We conclude that a nurse can testify regarding matters within his
or her specialized area of practice, but not as to medical causation unless
he or she has obtained the requisite knowledge, skill, experience, or
training to identify cause. We further take this opportunity to clarify the
standard for defense expert testimony regarding medical causation and
conclude that the standard differs depending on how the defendant
utilizes the expert's testimony. When a defense expert traverses the
causation theory offered by the plaintiff and purports to establish an
independent causation theory, the testimony must be stated to a
reasonable degree of medical probability pursuant to Morsicato. However,
when a defense expert's testimony of alternative causation theories
controverts an clement of the plaintiff's prima facie case where the
plaintiff bears the burden of proof, the testimony need not be stated to a
reasonable degree of medical probability, but it must be relevant and
supported by competent medical research.

Here, in Docket No. 56928, we conclude that the district court
abused its discretion when it allowed an unqualified nurse to offer expert
testimony regarding medical causation; however, it did not abuse its
discretion when it determined that one of the defense's other expert
witnesses could offer testimony regarding alternative causation theories.
In Docket No. 57079, we conclude that the district court abused its

discretion when it precluded the same nurse from offering any expert

testimony because a nurse can testify within his or her area of expertise

 

 
but not as to causation, unless he or she possesses the requisite
knowledge, skill, experience, or training to identify cause.? Therefore, writ
relief is granted in part and denied in part.

FACTS:

These writ petitions arise out of two separate actions resulting
from an outbreak of hepatitis C at the Endoscopy Clinic of Southern
Nevada (ECSN) in Las Vegas. The dofendants in the district court are

companies involved in the pharmaceutical industry that are being sued by

 

 

former patients who were allegedly infected with hepatitis C while having
procedures performed at ECSN and their spouses,

In each case below, the plaintiffs are suing the defendants for
strict products liability, including design defect, failure to warn, and
breach of implied warranty of fitness for a particular purpose. The
plaintiffs? theorize that defective vials of the anesthetic Propofol caused
them to contract hepatitis C. They claim that defendants Baxter
Healthcare Corporation; Sicor, Inc.; Teva Parenteral Medicines, Inc., fk.a.
Sicor Pharmaceuticals, Inc; and McKesson Medical-Surgical, Inc.

*The district court in Docket No. 57079 did not address the
admissibility of Dr. Cohen’s testimony regarding causation.

5In Docket No. 56928, the plaintiffs in the lower court and
petitioners here are James M. and Heidi Williams, and Joanne and
Kenneth G. Allen. Heidi and Kenneth are suing in their capacity as
spouses of James and Joanne, who underwent procedures at ECSN. We
collectively refer to them as the Williams Petitioners. In Docket No.
57079, the plaintiffs in the lower court and the real parties in interest here
are Maria Pagan and William I. and Marilyn Elaine Bilger. Marilyn is
suing in her capacity as William's spouse. We collectively refer to them as
the Pagan Parties.

 

 

 

 

 
 

(collectively, Sicor), are liable for their distribution of 50mL vials of
Propofol to endoscopy clinics because that size vial lends itself to reuse
and contamination. More specifically, the plaintiffs allege that medical
personnel at CSN injected needles contaminated with hepatitis into vials
of Propofol. ‘The medical personnel then allegedly reused those vials and
injected the plaintiffs with the now-contaminated Propofol.

To rebut these claims, Sicor obtained opinions from several

 

experts, including the two who are at issue in this appeal: David
Hambrick, a registered nurse, and Jonathan Cohen, M.D., a professor of
medicine, In both cases, these experts opined that improper cleaning and
disinfection techniques at the clinic may have caused the plaintiffs to
contract hepatitis C, but they could not identify a specific piece of
equipment that transmitted the virus. The Williams Petitioners refer to
this theory as the “dirty scopes” theory. Based on those opinions, the
plaintiffs in each case filed motions in limine to exclude Nurse Hambrick’s
and Dr. Cohen’s testimony. However, the district courts hearing these two
cases came to different conclusions concerning Nurse Hambrick.
Docket. No. 56928

‘The Williams Petitioners filed two motions in limine to
exclude expert testimony. In the first motion, the Williams Petitioners
asked the district court to preclude Sicor from offering testimony that
“dirty scopes” caused their hepatitis C because Dr. Cohen and Nurse
Hambrick “did not have an opinion to a reasonable degree of medical
probability that a ‘dirty scope’ was the cause of hepatitis...” In the
second motion, the Williams Petitioners similarly asked the district court
to preclude the defendants from offering testimony regarding a “dirty
scope” alternative theory of causation, and they also argued that nurses

cannot give testimony regarding causation. At the hearing on the

  

 
motions, the Williams Petitioners again argued that Nurse Hambrick
could not qualify as an expert.

‘The district court denied both motions for two reasons. First,
the court noted that “NRS 632.019 does not preclude a nurse from
providing expert testimony." The district court cited Staccato v. Valley
Hospital, 123 Nev. 526, 631-32 n.13, 170 P.8d 503, 506 n.13 (2007), for the
proposition that assessing a nurse as an expert requires an evaluation of
his or her skill and knowledge and that this court has determined that
nurses can testify against doctors. The district court further found that
Nurse Hambrick was well-qualified and met the standard set forth in
Morsicato, 121 Nev. 153, 111 P.3d 1112, for expert testimony. The district
court next determined that Sicor would “be able to offer competent
evidence and expert testimony regarding [its breach of infection control
practices] theory of medical causation.”

Docket No, 57079

‘The Pagan Parties filed a similar motion in limine to exclude
testimony regarding a “dirty scope” theory. Unlike in the Williams
Petitioners’ case, the district court granted the Pagan Parties’ motion to
exclude Nurse Hambrick from offering his opinion that unsafe cleaning
practices caused the plaintiffs to contract hepatitis C. The district court
found that Nurse Hambrick’s opinion was related to a specific alternative
‘causation theory and, therefore, had to meet the reasonable degree of
medical probability standard announced in Morsicato. Applying this
standard, the district court determined that, based on Nurse Hambrick’s

4NRS 632.019 is the statutory definition of “[rJegistered nurse.”

 

 
deposition testimony, he could not testify to greater than a 10-percent
probability that the cleaning processes used caused the plaintiffs’
and Morsicato requires greater than 50 percent, The district
court also found that, pursuant to Morsicato, an “expert can not

hepatitis

 

simultaneously testify as to 2 different medical causation opinions,” and,
here, Nurse Hambrick could not identify a specific piece of equipment a
the cause of the plaintiffs’ hepatitis C.

After the district courts entered their respective orders
regarding Sicor’s expert: witnesses, the aggrieved parties (the Williams
Petitioners in their case and Sicor in the Pagan Parties’ matter) petitioned
this court for extraordinary writ relief, On October 14 and November 4,
2010, this court granted temporary stay orders in the underlying matters
pending the resolution of the writ petitions. The November 4 order also
consolidated these two original writ proceedings,

DISCUSSION
When a writ of mandamus is appropriate

“A writ of mandamus is available to compel the performance of
an act that the law requires as a duty resulting from an office, trust, or
station or to control an arbitrary or capricious exercise of discretion.”
International Game Tech. v. Dist. Ct., 124 Nev. 193, 197, 179 P.3d 556,
568 (2008) (footnote omitted); NRS 34.160. This court has held that the
decision to admit or exclude expert opinion testimony is discretionary and
is not typically subject to review on a petition for a writ of mandamus.
Walton v. District Court, 94 Nev. 690, 693, 586 P.2d 309, 311 (1978).
Mandamus is also not available when the “petitioner has a plain, speedy,

and adequate remedy in the ordinary course of law,” Mineral County v.
State, Dep't of Conserv., 117 Nev. 285, 243, 20 P.3d 800, 805 (2001), and

 

 
the opportunity to appeal a final judgment typically provides an adequate
legal remedy, see Walton, 94 Nev. at 693, 586 P.2d at 310.

Despite these limitations, we recognize some narrow
exceptions when writ relief is appropriate concerning challenges to
decisions that admit or exclude evidence. We acknowledge that the ability
to appeal a final judgment may not always constitute an adequate and
speedy remedy that precludes writ relief, depending on the “underlying
proceedings’ status, the types of issues raised in the writ petition, and
whether a future appeal will permit this court to meaningfully review the
presented.” D.R. Horton v, Dist, Ct., 123 Nev. 468, 474-75, 168 P.3d
781, 736 (2007). ‘Thus, we may consider writ petitions challenging the

 

admission or exclusion of evidence when “an important issue of law needs
clarification and public policy is served by this court's invocation of its
original jurisdiction,” Sonia Fv, Dist. Ct., 125 Nev. 495, 498, 215 P.3d
705, 707 (2009) (quoting Mineral County, 117 Nev. at 243, 20 P.8d at 805),
or when the issue is “one of first impression and of fundamental public
importance,” County of Clark v. Upchurch, 114 Nev. 749, 753, 961 P.2d
754, 757 (1998). We may also consider whether resolution of the writ
petition will mitigate or resolve related or future litigation, Id,
Ultimately, however, our analysis turns on the promotion of judicial
economy. Smith v, District Court, 113 Nev. 1343, 1345, 950 P.2d 280, 281
(1997) (‘The interests of judicial economy ... will remain the primary
standard by which this court exercises its discretion,”).

We conclude that an exception to our normal rule rejecting
writ petitions challenging evidentiary rulings is necessary in this matter,
and we exercise our discretion to consider these writ petitions. These

petitions involve issues of first impression regarding whether a nurse can

 
os

offer expert testimony about medical causation and the appropriate
standard for defense expert testimony regarding alternative theories of
medical causation, and these issues have the potential of being repeated in
the many endoscopy cases pending before the district court, We also
conclude that, in this narrow instance, waiting for an appeal to resolve
these issues does not provide the parties with an adequate or speedy
remedy because the ongoing litigation of multiple cases in the district
court and conflicts in evidentiary rulings limits our ability to meaningfully
review the issues on appeal. We reemphasize, however, that generally
this court will not consider writ petitions challenging evidentiary rulings,

those rulings are discretionary and there typically is an adequate

 

remedy in the form of an appeal following an adverse final judgment.
However, in the interest of judicial economy, it is necessary to resolve the
issues presented in these writs.
Standard of review

In the context of a writ petition, this court gives deference to
the district court's findings of fact, but reviews questions of law de novo.
Ct, 126 Nev. __, _, 245 P.8d 1164, 1168 (2010). The

Gonski v. Dist
issues raised in these petitions are questions of law.

  

Admissibility of Nurse Hambrick’s and Dr. Cohen's testimony
An “expert witness assessment turns on whether the proposed

witness's special knowledge, skill, experience, training, or education will
assist the jury.” Staccato, 123 Nev. at 531, 170 P.3d at 506; see also NRS
50.275 (witnesses who possess the requisite “knowledge, skill, experience,

 

training or education may testify to matters within the scope of such
knowledge’). Before a witness may testify as an expert under NRS 50.275,
the district court must first determine his or her qualifications, including
whether

 

 
(1) he or she [is] qualified in an area of “scientific,
technical or other specialized knowledge” (the
qualification requirement); (2) his or her
specialized knowledge must “assist the trier of fact,
to understand the evidence or to determine a fact,
in issue” (the assistance requirement); and (3) his,
or her testimony must be limited “to matters
within the scope of [his or her specialized]
Knowledge” (the limited scope requirement).

Hallmark v. Eldridge, 124 Nev. 492, 498, 189 P.3d 646, 650 (2008)
(quoting NRS 50.275). In their petition and accompanying supplement,

 

the Williams Petitioners challenge the qualification requirement and the
assistance requirement as to Nurse Hambrick, and the assistance
requirement as to Dr. Cohen.

Nurse Hambrick is not qualified to testify as to medical causation
‘The Williams Petitioners and the Pagan Parties make two

 

arguments regarding Nurse Hambrick’s qualifications to testify as to
medical causation, First, they argue that nurses can never testify as to
medical causation because NRS 632.019 defines “[rJegistered nurse” as “a
person who is licensed to practice professional nursing,” and NRS 632.018

provides that professional nursing “does not include acts of medical

 

diagnosis.” Thus, they argue, nurses are not qualified to render expert
opinions regarding causation. They ask us to adopt what they
characterize as a “near universal rule that a nurse can not play doctor and
give medical causation testimony.” Second, they challenge whether Nurse
Hambrick possesses the requisite skill, knowledge, experience, training, or

education to testify to the cause of the hepatitis C transmission that

occurred at ECSN. We disagree that nurses are per se precluded from
testifying as to medical causation, but we agree that Nurse Hambrick did

 

 
ne

 

not meet the requirements to testify as an expert regarding medical
causation here.

In Staccato, we recognized that “in accordance with Nevada's
statutory scheme governing expert witness testimony, and in furtherance
of sound public policy, the proper measure for evaluating whether a
witnes

can testify as an expert is whether that witness possesses the

   

skill, knowledge, or experience necessary to [testify].”. 128 Nev. at 527,
170 P.3d at 604; see also Hallmark, 124 Nev. at 499, 189 P.3d at 650

(holding that a witness may testify as an expert if “he or she is qualified in

 

an area of scientific, technical, or other specialized knowledge”). This
court has recognized the following nonexhaustive factors in assessing
whether an expert witness is appropriately qualified: “(1) formal schooling
and academic degrees, (2) licensure, (3) employment experience, and (4)
practical experience and specialized training.” Hallmark, 124 Nev. at 499,
189 P.3d at 650-51 (internal footnotes omitted), However, we have
consistently rejected the notion that any rigid guidelines can govern this
analy:
of NRS 50.275, to fulfill their gatekeeping duties” to evaluate the
admissibility of expert testimony.’ Higgs v. State, 126 Nev. _, __. 222
P.3d 648, 658 (2010); see also Staccato, 123 Nev. at 530, 170 P.3d at 505.

,, and district courts have “wide discretion, within the parameters

 

 

5We recognize that some jurisdictions have adopted bright-line
standards holding that, while nurses are qualified to give opinions related
to standard of care, they are not similarly qualified to make medical
diagnoses or opine as to medical causation. See Phillips v. Alamed Co.,
Inc, 588 So. 2d 463, 465 (Ala. 1991) ("[W]e cannot say that the trial judge
abused his discretion by requiring the testimony of a physician and,
implicitly, holding that a registered nurse was not competent to testify as,
an expert on the issue of proximate cause.”); Vaughn v, Miss, Baptist Med.

‘continued on next page...

uw

 
In some circumstances, a nurse may obtain the requisite skill,
to cause. See Maloney v. Wake
Hospital Svstems, Inc., 262 S.E.2d 680, 684 (N.C. Ct. App. 1980)

(excluding nurse's testimony

knowledge, or experience to testify

 

to cause was in error because “nurses and

 

 

other physicians’ assistants play a much greater role in the actual
diagnosis and treatment of human ailments than previously”); Longuy v,
La Societe Francaise De Bienfaisance Mutuelle, 198 P, 1011, 1014 (Cal,
Ct. App. 1921) ([Tlestimony [regarding cause of death] sought to be

elicited from the prof

 

ional nurses who were familiar with the baby’s
condition became very material and should have been admitted.”). Thus,
the relevant inquiry does not end with a reading of a statute defining the

practice of professional nursing; rather, it depends upon a case-by-case
continued

Center, 20 So. 3d 645, 652 (Miss. 2009) (‘[Nlursing experts cannot opine
as to medical causation and are unable to establish the necessary element
of proximate cause.”); Kent_v. Pioneer Vallev Hoap., 930 P.2d 904, 907
(Utah Ct. App. 1997) CAlthough a nurse may well be trained in the proper
location to administer injections, we are not persuaded that a nurse is
qualified to opine as to nerve damage caused by an allegedly improper
injection."). Other courts that have not allowed nurses to testify have
noted that causation is a legal question separate from the question of the
appropriate standard of care, which can be within a nurse’s area of
expertise. See Elswick v. Nichols, 144 F. Supp. 2d 758, 767 (E.D. Ky.
2001); Colwell v. Holy Family Hosp,, 15 P.3d 210, 213-14 (Wash. Ct. App.
2001). Still other courts have examined statutory restrictions on the
practice of nursing and concluded that those restrictions preclude nurses
from testifying as to medical causation. See Flanagan v. Labe, 666 A.2d
333, 337-38 (Pa. Super. Ct. 1995) (holding that because a Pennsylvania
statute did not permit nurses to make medical diagnoses, they were not
qualified to opine as to medical causation). However, we decline to follow
these authorities,

 

 

 
nee a

 

examination of a nurse's actual skill, knowledge, experience, or training
that is gained through practicing his or her profession.®

Nurse Hambrick has extensive experience in cleaning and
disinfecting the type of equipment used during an endoscopy procedure,
He is a rogistered nurse in Texas, has been certified in gastroenterology
for ten years, and he is currently the manager of the gastroenterology lab

at the Methodist Dallas Medical Center. He has also been published in a

   

peer-reviewed journal regarding biopsy and tissue acquisition equipment,
nd has

 

written and spoken extensively on the topic of infection control,
trained over 75 people on proper disinfection techniques. Additionally, he
served as director of the national board of directors for the Society of
Gastroenterology Nurses and Associates. Nurse Hambrick’s educational
experience includes a two-year nursing degree, and he was due to
complete a bachelor of science in nursing in December 2010. Both the
Williams Petitioners and the Pagan Parties argue that these facts do not
make Nurse Hambrick qualified to testify as an expert because he does
not a have a four-year college degree, and his experience with endoscopy
equipment cleaning and disinfectant techniques is insufficient to qualify
him to give medical causation opinions. The Williams Petitioners also

‘Just as a licensed professional may gain experience beyond the
scope of his or her license, see Staccato v. Valley Hospital, 123 Nev. 526,
580, 170 P.3d 603, 505 (2007), a nurse may similarly acquire skill,
knowledge, experience, or training outside the scope of the statutory
definition of that occupation. ‘Thus, the district court must evaluate an
individual nurse's qualifications when deciding whether to admit or
exclude expert testimony.

 

13.

 
argue that Nurse Hambrick’s lack of knowledge about the hepatitis C
virus demonstrates that he is unqualified as a medical expert.

Despite his experience with endoscopy equipment and
disinfectant techniques, Nurse Hambrick has little, if any, experience in
diagnosing the cause of hepatitis C. Nurse Hambrick never indicated, and
Sicor did not contend, that Nurse Hambrick ever made medical diagnoses
to assess cause. In fact, Nurse Hambrick noted that in his previous
nursing positions, doctors, not nurses, always determined the cause of
illnesses indicated on a patient's chart. Also, by Sicor’s own admission,
Nurse Hambrick is only a leading expert on “endoscopic reprocessing” and
“the standards governing and proper means of disinfecting

gastrointestinal endoscopy equipment.” This does not, by extension,

 

qualify him to testify regarding medical causation. We thus conclude that,
while Nurse Hambrick may be more than qualified to testify as to proper
cleaning and sterilization procedures for endoscopic equipment and can
testify on those subjects, he does not possess the requisite skill,
Knowledge, or experience to testify as an expert witness regarding the
medical cause of hepatitis C transmission at ECSN.7
Dr. Cohen will assist the trier of fact

To assist the trier of fact, medical expert testimony regarding
causation must be “made to a reasonable degree of medical probability.”
‘Morsicato v. Sav-On Drug Stores, Inc., 121 Nev. 158, 157, 111 P.3d 1112,
1115 (2005); see also Hallmark, 124 Nev. at 500, 189 P.3d at 651 (If a

"Because we conclude that Nurse Hambrick is not qualified to offer
testimony regarding medical causation, we do not analyze the assistance
requirement as it pertains to him.

 

 
person is qualified to testify
court must then determine whether his or her expected testimony will

 

an expert under NRS 50.275, the district

 

the trier of fact in understanding the evidence or determining a fact

 

in issue"). Such specificity is required because “if the . ., medical expert

cannot form an opinion with sufficient certainty so as to make a medical

 

judgment, there is nothing on the record with which a jury can make a
decision with sufficient certainty so as to make a legal judgment.”
‘Morsicato, 121 Nev. at 158, 111 P.3d at 1116 (quoting McMahon v. Young,
276 A.2d 534, 635 (Pa, 1971), The Williams Petitioners
Parties, and Sicor disagree on the meaning of “reasonable degree of
medical probability’ when that term is used in the context of defense

 

the Pagan

experts who offer alternative causation theories to controvert the
plaintiff's prima facie case. ‘Therefore, we clarify the standard and
conclude that when defense expert testimony regarding cause is offered as
an alternative to the plaintiff's theory, it will assist the trier of fact if it is
relevant and supported by competent medical research.

Sicor argues that, in light of the plaintiff's burden of proving
causation in a products liability action, Rivera v. Philip Morris, Inc., 125
Nev. 185, 191, 209 P.3d 271, 275 (2009), the reasonable degree of medical
probability standard applies only to the plaintiff's expert’s testimony
regarding cause. However, the standard exists to ensure the competence
and quality of testimony establishing causation, and whether it applies is
not determined by the party who offers it. Stinson v, England, 633 N.E.2d
582, 637 (Ohio 1994) (“Inasmuch as the expression of probability is a
condition precedent to the admissibility of expert opinion regarding
causation, it relates to the competence of such evidence and not its weight.

Accordingly, it is essential to focus on the quality of the evidence adduced

 

 
regardless of the identity of its proponent.”). Rather, the relevant inquiry
in determining whether the reasonable degree of medical probability

standard applies is the purpose of the testimony. Any expert testimony

 

introduced for the purpose of establishing causation must be stated to a
reasonable degree of medical probability. However, defense experts may
offer opinions concerning causation that either contradict the plaintiff's
1s to that offered by the

 

expert or furnish reasonable alternative cau
plaintiff,

Once the plaintiff has demonstrated a prima facie case and
met his or her burden, the defendant can traverse the plaintiff's case in
three ways. See id, The defendant may (1) cross-examine the plaintifi’s
expert, (2) contradict the expert's testimony with his own expert, and/or
(8) propose an independent alternative causation theory. Id, If the
defendant chooses the third approach, his or her expert's testimony is
subject to the reasonable degree of medical probability standard because,
in order to assist the trier of fact, testimony establishing cause must meet
a heightened threshold requirement. Id. at 538; see also Goudreault v.
Kleeman, 965 A.2d 1040, 1058 (NH. 2009) (holding that a lowered
standard only applies when the defense expert is rebutting the plaintiff's
causation theory). In instances where the expert is expressing an opinion
as to causation, it is irrelevant whether the testimony is offered by the
plaintiff or the defendant.

However, if the defense expert's testimony is used for the
purpose of cross-examining the plaintiff's expert or to otherwise contradict,

the plaintiff's causation theory by comparing that theory to other plausible

 

 
oe

 

causes, the defense expert does not need to state each additional cause to a
greater-than-50-percent probability. Stinson, 633 N.E.2d at 538.
Because the defense expert in this instance is controverting a key element

of the plaintiff's prima facie case, as long as his or her alternative

 

causation theory or theories are competent and supported by relevant
evidence or research, they need not be stated as being more likely than
not. This lowered standard is necessarily predicated on whether the

defense expert includes the plaintiffs causation theory in his or her

 

analysis. If the defense expert does not consider the plaintiff's theory of
causation at all, then the defense expert must state any independent
alternative causes to a reasonable degree of medical probability because
he or she then bears the burden of establishing the causative fact for the
trier of fact. Otherwise, the testimony would be “incompetent not only
because it lacks the degree of probability necessary for admissibility but
also because it does nothing to controvert the evidence of appellants.”
Stinson, 633 N.E.2d at 538.

In Wilder v, Eberhart, 977 F.2d 673, 676-77 (Ist Cir. 1992),
the First Circuit Court of Appeals considered a similar issue in a medical
malpractice action. The court held that requiring a defense expert to

'By definition, probability requires more than 50-percent likelihood.
‘Stinson v. England, 633 N.E.2d 632, 536 (Ohio 1994) (“{P]robability means
more than a fifty percent likelihood.”); see also Morsicato, 121 Nev. at 159,
111 P.ad at 1116 (reversing the district court because a defense expert
could not state that an alternative theory of causation was “more likely
than not” the cause of the plaintiff's injuries); Black's Law Dictionary 1201
(6th ed. 1990) (defining probability as "[a] condition or state created when
there is more evidence in favor of the existence of a given proposition than
there is against it”).

 

Ww

 
one

 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 

identify a specific cause to a medical probability standard when rebutting
the plaintiff's prima facie case would improperly shift the burden to the
defendant. Id. Thus, the court concluded, defense experts may offer
several alternative causes to rebut the plaintiff's theory of cause with less
than 50-percent certainty. Id, at 677.

We agree with the Wilder court’s holding, and it logically
comports with our conclusion that when a defense expert's testimony is
used to contradict a plaintiff's causation theory by comparing that theory
to other plausible causes, each additional cause does not need to be stated
to a greater-than-50-percent probability. To hold otherwise would
severely hinder a defendant's ability to undermine the causation element
of the plaintiff's case and could result in an unfair shifting of the burden of
proof to the defendant. As illustrated by the Wilder court

if ninety-nine out of one hundred medical experts

agreed that there were four equally possible

causes of a certain injury, A, B, C and D, and

plaintiff produces the one expert who conclusively

states that A was the certain cause of his injury,

defendant would be precluded from presenting the

testimony of any of the other ninety-nine experts,

unless they would testify conclusively that B, C, or

D was the cause of injury. Even if all’ of

defendant's experts were prepared to testify that

any of the possible causes A, B, C or D, could have

equally caused plaintiffs injury, so long as none

would be prepared to state that one particular

cause, other than that professed by plaintiff more

probably than not caused plaintiffs injury, then

defendant's experts would not be able to testify at

all as to causation. We think that such a

result... would be manifestly unjust and unduly

burdensome on defendants.

977 F.2d at 677. Further, the Morsicato standard is not meant to preclude

a defendant from undermining the plaintiffs prima facie case with

 

18

 
relevant, medically competent expert testimony on alternative causation
theories so long as the defense expert's testimony is being used to
controvert the plaintiff's theory.

Although we recognize a lower standard for rebuttal expert

 

testimony regarding medical causation, any alternative causation theories
proffered by a defense expert to controvert the plaintiff's theory of caus
are still subject to certain threshold requirements, namely that medical
experts testifying as to cause must avoid speculation. See Morsicato, 121
Nev. at 157-68, 111 P.3d at 1115; see also Stinson, 633 N.B.2d at 538
CAln expert for the defense is precluded from engaging in speculation or
conjecture with respect to possible causes"). The defense expert’s
testimony must also be relevant and supported by competent medical
research. Seo Higgs v. State, 126 Nev. __, __, 222 P.8d 648, 659 (2010)
({The qualification, assistance, and_—ilimited —_scope
requirements... ensure reliability and relevance.”). Therefore, if Dr.
Cohen's testimony in Docket No. 56928 is introduced to contradict the
Williams Petitioners’ and the Pagan Parties’ theory as to how they
contracted hepatitis C by providing an alternative causation theory, then
he does not need to testify to a reasonable degree of medical probability as
ong as his opinion about the alternative theory is relevant and supported
by competent medical research. If his testimony meets these standards, it
is admissible and will assist the trier of fact.

Accordingly, for the reasons set forth above, we grant in part
and deny in part the Williams Petitioners’ petition for extraordinary writ

relief and direct the clerk of this court to issue a writ of mandamus in
Docket No. 56928 instructing the district court to set aside that portion of
its order allowing Nurse Hambrick to testify as to medical causation. We

 

 
further grant in part and deny in part Sicor’s petition for extraordinary
writ relief and direct the clerk of this court to issue a writ of mandamus in
Docket No. 57079 instructing the district court to set aside that portion of
its order excluding Nurse Hambrick from testifying as an expert witness
on the subjects of proper cleaning and sterilization procedures for
endoscopic equipment. Nurse Hambrick may testify within his area of
expertise; however, because we conclude he does not possess the requisite
qualifications, he may not testify as to medical causation.®

tM tak

Hardesty

 

We concur:

 

Gibbons

"We vacate the stays
November 4, 2010.

 

issued on October 14 and