D espit e t he co ncl usi o n o f the t ri al c o urt a nd the majo ri t y t hat D r. H ays ’ op i ni o ns were speculat i ve, t he reco rd 1 i ndi cat es ot her wi s e. Speci f i cal l y , D r
. H ay s was as ked at one po i nt i f he coul d s t at e “ t o a r eas onabl e deg r ee of medi cal (c o n tinu e d ...) -1- 

### IN THE S UP REME COURT OF TENNESS EE

AT NAS HVILLE O ct obe r 7, 200 4 S es sio n SHE RRY HUNTER, A DMI NISTRATRIX O F THE 

### E STATE OF 

### L AWRENCE 

### H UNTER 

### , D ECEASED 

### v. J AY MICHAEL URA, M.D ., ET AL.

App e al b y P e r m iss ion fro mth e Co ur t o f Appe als Circuit Court

for Davidson County No. 96C-3784 M ariet ta M. Shipl ey, Judge

No. M2002- 02573-SC-R11- CV - F iled March 29, 2005

W I L L I AM M. B ARKE R , J., wi th w ho m F R A NK F. D R OW OT A , I I I , C.J ., joins, concur ring in pa rt, and dis se nti ng in p art

. I disag ree with the majority ’s holding that the trial court c orre ctly excluded the deposition testimonyof Dr. Mic hael Hay s because he did not state his opinion as to causation of plaintiff’s inj ury to a “ re a so na blede g re e of

me dic a l c e rt a inty .” I

a m of the op ini on that hi s te sti mon y sh ou ld ha ve be e n he ard by the jury a nd that it wa s re ve rs ibl e e rr or fo r the tria l cou rt to e xclu de it. Whil e I fully ag ree with the m ajority ’s resolution of all of t he other issues, I would nevertheless g rant a new trial to the defe ndants bec ause I am of the opinion that the jury should have be en allowe d to hear Dr. Hay s’ opinion. By its decision today , the majority has held that in de fending a medical malpr acticeaction a defe ndant may only offe r expert medical pr oof of c ausation if the opinions expressed on beha lf of the def ense are those held t o a reasonable deg ree of m edica l certainty

. I n my view, such a conc lusion is errone ous beca

use it serve s to shift the burden of pr oof and doe s not comport with the objectives of Tenne ssee Rules of Evide nce 702 and 703.
I n th is c a se , the de fe nd a nts so ug ht to i ntr od uc e thede po sit ionte sti mon y of Dr . H a y s b e c aus e he wa s diag nosed during trial with canc er and, acc ording to de fense counsel, wa s unable to testify in person. The trial court, afte r revie wing the deposition te stimony , conclude d that the opinions Dr. Hay s offe red w ere“spec ulative” and there fore not admissible. 1(

. . . con t i n u ed) 1

ce r t ai n t y t h at t h at i s wh at h appe n ed?” D r
. H ay s r es pon ded, “ I t h i n k I c an s ay t h at

. ” H e we n t on t o s t at e t h at “ [ a] l l of [t hese fact o rs ] com b i ned , I feel wi t h m ed i cal cert ai nt y t hat t hat i s what i s res p o nsi b l e fo r t hi s o ut co m e. ” Later , near t he end of hi s depo s i t i on, t he fol l owi ng ex cha ng e t oo k pl ace : Q ue st i o n ( b y de fen se c o un sel): Is yo ur o p i nio n a b o ut cau sati o n, ab o ut t he co m b i na t i o n o f t he se fac to rs tha t co m b ine to c a u se this p ro b le m w ith M r. H u n te r, d o yo u h o ld tha t o p inio n to a re a so n a b le d e g re e o f m e d ic a l ce rta inty? An s w e r ( by Dr

. Hay s ) : Ye s
. I me a n , t h a t i s wh a t I ge t ou t of al l t h i s i n for ma t i on i s t h a t t h a t i s , i n my opi n i on a r ea s on abl e ex pl an at i on of wh at ma y h av e ca u s ed t h i s e v en t

. I k n ow t h er e ar e a l ot of po s s i bi l i t i es an d m ay bes i n t her e. I don’ t t hi nk an y bo dy ha s a g oo d under s t andi ng or can wr i t e down what t hey t hi nk exact l y hap p ened i n t hi s ca se
. H e had reas o ns t o have d i m i ni shed f l o w i n vari o us ar t er i es t o t he brai n. T hat , t o m e, provi des a r eas onabl e e xpl ana t i on of t hi s out com e.
D r. H ays ad d ed t hat t he co m b i nat i o n of f act o rs was “ t he exp l anat i o n t hat m akes t he m o st s en se ” to h im

. F ina l l y , t he q ue st i o n w as p o sed , “[I]s i t you r o p i nio n t ha t the se [three fac t o rs] m o re l i ke l y than n o t c o m b i ne d d uring the c ase t o ca use this o u tc o m e ? ” D r. H a ys’ an sw e re d , “Y e s.”

I do agr ee, howev er , t hat on s eve r al occas i ons dur i ng hi s t es t i mo ny D r
. H ay s di d s t at e t hat hi s opi ni on provi ded a “ po s s i bl e” al t er nat i ve cau s e f or t he pl ai nt i f

f ’ s i nj ur y ot her t han t he defendan t ’ s ne gl i gen ce.
P urs uant t o T enness ee C o d e A nno t at ed s ect i o n 29

- 2 6

- 1 1 5 (a) (20 0 0 ), t he “ M ed i cal M al p ract i ce A ct , ” t he 2 p l ai nt i f f i n a m ed i cal m al p ract i ce case has t he b urden o f pro vi ng t he fo l l o wi ng: (1 ) T h e re c o g n iz e d sta n d a rd o f ac c e p ta b le p ro fes sio n a l p ra c tice in the p ro fes sio n a n d the sp e c ia lty t her eof , i f

an y , t hat t he defendan t pra ct i ces i n t he com muni t y i n w hi ch he prac t i ces or i n a s i mi l ar c o m m u n ity a t t h e ti m e the a lleg e d inj u ry o r w ro n g ful a c tio n o c c u rr e d ; (2 ) T h a t t h e d e fen d a n t ac te d w ith le ss th a n o r fa iled to a c t with o rd ina ry a n d re a so n a b le c a re in
ac cor dan ce w i t h s u ch s t an dar d; a n d ( 3) As a pr oxi mat e r es ul t of t he defendan t ’ s ne gl i gen t ac t or om i s s i on, t he pl ai nt i f f s uf fer ed i nj ur i es w h ic h w o u ld no t o the rw ise ha v e o c c u rr e d

.
T enn. C o d e A nn. § 2 9

- 2 6

- 1 1 5 (a); s ee al so C ardw el l v. B echt o l , 72 4 S.W

. 2 d 73 9 , 75 3 (T enn. 19 8 7 ).

-2- I n a medical malprac tice ca se, th e p l aint iff, not the def endant, be ars the bur den of pr oof. 2 I n most c ases, expert medical testimony is require d to establish both the rec og nized standard of c are and a de viation from that ac cepta ble standar d of ca

re, pr ox imately causing the pl aintiff’s injury . See Seaver s v. Methodist Med. Ctr. of Oak Ridg e, 9 S.W.3d 86, 95 (Tenn. 1999). The defe ndant, by contra st, is require d to prove nothing. The defendant’s task is to rebut the plaintiff’s evide nce so that a jury may properly evaluate and we igh the plaintiff’s theory and supporting evidenc e.
I n this case the plaintiff theorized that the decedent died as a result of cer ebra l hypox ia, i.e., ins uf fi c ie nt o xy g e n to thebr a in, du ri ng su rg e ry . T he plaintif f the orize d th a t th e oxy g e n s up ply to the dec edent’ s brain wa s diminis hed due to the fact that the surg ery was pe rformed with the dec edent in a “semi-recumbe nt” or inclined position. Dr. Wil liam Wi tt testified for the plaintiff and was of theop ini on that th e de c e de nt’ s in c lin e d p os iti on du ri ng su rg e ry ma de him “ ve ry su sc e pti ble to thisA ltho u g h the re w a s n o e v id e n c e tha t t h e d e c e d e n t’s he a d w a s t u r n e d to the sid e d u rin g su rg e ry, D r. H a ys 3
t es t i f i ed t h at h e bas ed h i s opi n i on i n t h i s r eg ar d on h i s ow n pe r s on al e x per i en ce
. D r
. H ay s s t at ed:

I wo ul d s ay f

r om exper i enc e i n wat chi ng t hes e cas es t hat t he hea d i s at s om e po i nt dur i ng t he ca se t u r n ed t o t h e n on
- oper at i v e s i de, a way f r om t h e s h ou l der , e i t h er f r om pu l l i n g on t h e s h ou l der or s t ar t i ng wi t h t he hea d, t he nec k bas i cal l y , s t r ai gh t but t he hea d t ur ned s l i gh t l y t o t he l ef t j us t as I s t at ed bef or e t o g et mor e ex pos u r e t o the shou l der on t h e oper at i v e s i de. I w ou l d e x pec t t h at i t w ou l d be tur n e d sligh tly to the left. I d o n ’t thin k I c a n q u a n tif y d e g re e s o f an g le o r a n ythin g li k e tha t. -3- ty pe of in ju ry ” and th at it w a s c ri tic a l to pr op e rl y mon ito r the patie nt t o e ns ur e that a n a de qu a te supply of oxy g en wa s rea ching the brain. Dr. Wit t testified that Dr. Ur a improperly monitored the dece dent’s ce rebr al perfusion pressure during surg ery and that Dr . Ura ’s ac tions in t his reg ard, a long with his failure to take corr ective me asure s, fell below the applicable s tandar d of care and resulted in t h e d ec ed en t ’s death. Dr. Witttestified that he he ld these opinions to a rea sonable de g reeof m e d i c a l c e rt a i n t y. To rebut the plaintiff’s theory of causation and the testimony of Dr. Witt , t he def

endant soug ht to introduce the deposition te stimony of Dr. Hay s, a board- certified and p ra cti cing a n e s t h e s i o l o g i s t

. D r
. H a ys h e l da n o p i n i o n d i f f e r e n tf r o mt h a to f

D r
. W i t t

. A l t h o u g h D r
. H a ys ag ree d that the dec edent’ s death wa s cause d by reduc ed blood flow to t he brain, it was his opinion that this reduce d blood flow was the result of “a combination of factors” c ombining and c oncurring a t on e po int

in time . Dr . Ha y s id e nti fi e d th e se thr e e fa c tor s a s: ( 1) thede c e de nt’ s a bn orma lly elong ated sty loid bone , (2) the eff ects of the intersc alene block administered to the de cede nt during theop e ratio n, a nd(3 ) the turnin g or po sit ion ing of

thede c e de nt’ s h e a d d uring theop e ratio n. I n h is 3 opinion, each of

these thre e fa ctors possibly impeded blood flow to the dece dent’s brain and that they “all in combination provide an explanation” for the death. Dr. Hay s’ disag ree d with the plaintiff’s theory that t h e d ec ed en t’s reduc ed blood flow re sulted solely from being place d in an inclined position during surg ery
. I nstead, Dr . Hay s’ opinion was that, base d upon his medical experienc e, “som et hing e lse had to ac count for this outcome.” Dr. Hay s further added that “I

don’t think a n yb o d y i s g o i n g t o b e ab l e t o k n o w e x a c t l y w h a th ap p e n e dt o M r
. H u n t e r
. ” H o w e v e r , D r
. H a ys state d th a t hi s th e ory

pr ov ide d a

re a so na blee xpla natio n f

or thede c e de nt’ s in

jury a nd de a th. I n my vie w, thi s te sti mon y

sh ou ld h a ve be e n a dmi tte d andthejur y , a s th e so le tr ier of

fa c t, allo we d to we ig h andc on sid e r i t inre a c hin g its ve rd ic t. Other jurisdictions that have addre ssed this issue have a lso held tha t ex p ert witnesse s testify ing f

or the de fense can pr esent a l t er n at ive theorie s of causation couche d in terms of possibili ties rather

than p robabili ties. The fa cts of Sakler v. Anesthesiolog y

Assocs., P.S.C., 50 S.W .3d 210 (Ky . Ct. App. 2001), areparticula rly rele vant here

. I n Sakler an expert witness for the defe ndants in a medica l malprac tice ca se testified a s to severa l p o s s i b le causes of the plaintiff’s inj ury , andthat, i n h is op ini on , on e c ou ld “ on ly ta lk abo ut po ssi bil iti e s” rathe r than p ro ba bil iti e s w ith respe ct to causation. 50 S.W .3d at 212-13. The witness further stated that, because the plaintiff ha d se ve ral a g g ravatin g fa c tor s that c ou ld po te nti a lly le a d to the inj ury , it w ou ld b e “ pr e su mptuo us ” to narr ow causation to one fac tor. I d. at 212. The c ourt held the testimony admissible in light of theA s f urt her s up p o rt t hat t hi s p o si t i o n i s gai ni ng a ccep t ance, I no t e t hat A m eri can Juri sprud ence p rovides t he 4 fol l owi ng i n r ef

er enc e t o provi ng ne gl i gen ce:
P ract i ce G ui d e: T o co nvi nce t he t ri er of f act t hat t he al l eged negl i gence i s no t t he l egal cause of t he i nj ur y , t he defendan t may produce ot her poss i bl e c aus es of t he pl ai nt i f

f ’ s i nj ur y ; t hes e poss i bl e c aus es n e e d no t b e p ro v e d w ith c e rta inty o r m o re p ro b a b ly t h a n no t.
5 7 A A m
. Jur. 2d , N egl i gence § 44 1 (20 0 4 ) ( ci t at i o n om i t t ed ). -4- fac t that it was offere d in support of the def endant, who bor e no burde n of proof , rathe r than the plaintif f. I d. a t 21 3- 14 . T he c ou rt pr ov ide d th e fo llo wi ng a na ly sis : These othe r possible causes nee d not be prove d with certainty or more proba

bly than n o t

. T o fa s h i o n s u c h a r u l e w o u l du n d u l y t i e ad ef en d an t ’s h an d s i n re b u t t i n g a plaintif f’s case , wher e a s h e re , p la intif f’ s e xpe rt te sti fi e s th a t no oth e r c aus e c ou ld have c aused plaintiff’s injury

. . . . Were weto acc ept plaintiff’s a rg ument that once a plaintiff puts on a prima fac ie ca se, a de fendant cannot re but it withoutproving another cause , the re sulting inequities would abound. F or example if ninety -nine out of one hundr ed medical experts ag ree d that there wer e four equally possible cause s of a c ertain injury , A, B , C and D, and plaintiff produce s the one e x pert who conclusively

states that A wa s t he ce rtain cause of his injury , defe ndant would be pr e c lud e d f

ro m pr e se nti ng thete sti mon y of a ny of th e ot her nin e ty -n inee xpe rt s, unless they

would testify

conclusively

that B, C, or D wa s the cause of injury . Even if all of defe ndant’s experts w ere prepa red to te stify that any of the possible cause s A, B , C or D, could have equally cause d plaintiff’s injury , so long a s none would be prepa red to state that one particular c ause, othe r than that professed by plaintiff more probably than not cause d plaintiff’s injury , then def endant’ s experts would n o t be able to testify

at all as to causation. Sakler, 50 S.W.3d at 214 (quoting Wil der v. Eberha rt, 977 F.2d 673, 676-77 (1 Cir. 1992)). Several st other c ourts have a ddresse d t h i s i s s u e and r easone d simil arly . See Wilder, 977 F.2d at 676-77; Haa s v. Z acc aria , 659 So. 2d 1130, 1133 (F la. Dist. Ct. App. 1995); Mitchell v. Ensor, N o. W2001- 01683-COA-R3-CV, 2002 WL 31730908 (Tenn. Ct. App. Nov. 18, 2002)

. 4
Th e ma jority su rm ise s th a t a llowi ng def e nd a nts to i ntr od uc e e vid e nc e of oth e r p os sib le the o r ie s o r c au s e s w o u ld u n d e r mi n e th e s a f e g u ar d s in T e n n e s s e e Ru le s o f E v id e n c e 7 0 2 and 703. I disag ree . The saf

eg uards pr ovided by

Rules 702 and 703 serve simply to scree n out expert opinions ba se d o n u ntr

us tw orthy or sc ie nti fi c a lly inv a lid fa c ts anddata or that w ou ld n ot s ub stanti a lly a ssi st the trier of fac t in de termining an issue. See Mc Daniel v. CSX Transp., I nc., 955 S.W.2d 257, 266 (T e nn . 1 99 7) (h old ing e vid e nc e wa s pr op e rl y a dmi tte d up on a sh ow ing that it w ou ld s ub stanti a lly assist the jury

to understand the e vidence and the sc ientific principles underlying it we re trustworthy and re liable). Alternative theories of ca usation, when pre sented by a qualifie d expert and supported by the cur rent state of medical or scientific knowledg e in the rele vant field, serve to educate the jury as to other potential c auses of the plaintiff’s injury . Presenting such evide nce allows the defe ndant-5-

to “test” the plaintiff’s ca se and a ssists t he jury in under s t an d i n g the full import of the plaintiff’s pr oo f b e fo rea ssi g nin g we ig ht t o th e e vid e nc e a ndultimate ly de te rm ini ng fa c tual is su e s.
P u rs u an tt o R u l e 7 0 2 , a w i t n es s wh o i s q u al i fi ed b y “k n o wl ed ge, s k i l l , ex p er i en ce , tra i n i n g, or educ ation” may

testify if such testimony

will “substantially

assist the trier of fac t to understand the evidenc e or to de termi n e a fact in issue.” Te nn. R. Evid. 702. The expert’s opinions or infere nces a

re a dmissibl e if ba sed on fac ts or data “of a type re asonably relied upon by

experts in the pa rtic ula r fi e ld. ” Te nn
. R. Ev id. 70 3. I n thepr e se nt c a se , th e rewa s n o d isp utethat D r. Hay s, a s a board- certified prac ticing anesthesiolog ist, was qualif ie d to o f f e r ano p in io n in this case. Throug hout his deposition, Dr. Hay s emphasized that he ba sed his opinions on curre nt medical literature a long with his own medical experienc e and e x pertise. Fo r ex ample, Dr . Hay s testified that he ha d participated in theses ty

pes of surg ical proc edure s on n u m er o u s occa sions, although ne ver in a sim ila r o ne ha vin g thi s o utc ome . H e ha d a lso re vie we d se ve ral me dic a l tr e a tis e s r e latin g sp e c if ic a lly to b loo d p re ssu re , a ne sth e sia a ndre late d is su e s r e le vant t o th is c a se . Fu rthe rm or e , D r. Hay s h a d a lso re vie we d th e de c e de nt’ s me dic a l hi sto ry a ndthede po sit ion s o f the plaintif f’s med ic a l e xpe rt s, a ll prior to forming an opinion as to the possible causes of de ath.
Ba sed upon these sour ces, D r. Hay s o p i nion was that the de cede nt’s death wa s cause d by reduc ed blood flow to t he brain, and that this reduce d blood flow was the r esult of “a combination of fa c tor s th a t all h app e ne d at on e po int in time .” I n h is o pin ion , e a c h o f the se thr e e fa c tor s c ou ld have possibly

impeded blood flow to the de cede nt’s brain an d t hat they “all in combination provide[d] an explanation” for the death.
Dr . H a y s’ state d th a t e a c h o f the thr e e po ssi blec aus e s o f d e a th w e resu pp orte d b y sc ie nti fi c or me dic a l li te ratur e or

me dic a l evi de nc e in thi s ca se
. He te sti fi e d that heha d r e vie we d th e auto ps y re po rt re ve a lin g thede c e de nt’ s e lon g a te d s ty loi d b on e a ndth at med ical li te ratur e “ se e me d to support” that this could i mpinge on the carotid arte ry
. The doc tor stated that fr om his own medical k n o wl ed ge a n i n t er s ca l en e b l o ck , as ad m i n i s t er ed t o t h e d ec ed en t , co u l d i m p ed e bl o o dfl o w t h ro u gh t h e ca rotid arte ry
. Also, the treatises D r. Hay s rese arc hed supported his the ory that t u rn i n g a patient’s hea d to one side would l essen blood flow to the brain. Dr. H ay s also testified conc erning thelim itatio ns of

me dic a l sc ie nc e in this are a and wa s of theop ini on that no me dic a l e xpe rt c ou ld say with certainty

what ca used the de ath.
I n my view, the jury should ha ve been allowed to he ar Dr. Hay s’ testimony that these thre e fa c tor s p os sib ly

c omb ine d to c aus e thede c e de nt’ s d e a th, that th e se fac tor s p ro vid e d a re a so na ble alternative causefor his death, and that no one could be certain as to the cause of death. I n my view, for a trial court to exclude such e vidence does an injustice to the de fe n d an t an d is an abuse of dis c re tio n. Se e State v. Shi rl e y , 6 S.W. 3d24 3, 24 7 ( Te nn . 1 99 9) . I a m not, a s the ma

jority su g g e sts , su bs tituti ng my op ini on fo r that of thetria l c ou rt . I

c on c lud e that th e tria l c ou rt ind e e d a bu se d it s dis c re tio n b e c aus e it “ app lie d a n inc or re c t le g a l stand ard , o r r e a c he d a de c isi on wh ic h [w a s] a g a ins t logic or re asoning that cause d an inj ustice t o the party complaining .” I d. (citing State v. Schuck, 953 S.W .2d 662, 669 (Tenn. 1997) . Acc ording ly , in the prese nt case I would hold, a s did the Court of-6-

Appea ls, that the trial court c ommitt ed re versible e rror in excluding the deposition testimony of Dr. Hay s a ndthat th e de fe nd a nts aree nti tle d to a ne w t ri a l.
I am authorized to state that Chief Justi ce D rowota joins with me i n t h i s co ncurring and dissenting opinion.

______________________________ WILL I AM M. B AR KE R, JUS TI CE