IN THE COURT OF APPEALS OF IOWA

No. 22-2048

Filed May 8, 2024

FATIMA E. BELHAK and ABDELLATIF ELFILA,

Plaintiffs-Appellees,

vs.

DENICE SMITH, M.D., and WOMEN’S CARE SPECIALISTS, P.C.,

Defendants-Appellants.

________________________________________________________________

Appeal from the Iowa District Court for Scott County, Jeffrey D. Bert, Judge.

A doctor and her employer appeal a jury verdict finding them liable for 

medical malpractice. REVERSED AND REMANDED.

Troy L. Booher and Beth E. Kennedy of Zimmerman Booher, Salt Lake City, 

Utah, and Nancy J. Penner of Shuttleworth & Ingersoll, P.C., Cedar Rapids, for 

appellants.

Anthony J. Bribriesco and William J. Bribriesco of Bribriesco Law Firm, 

PLLC, Bettendorf, for appellees.

Heard by Bower, C.J., and Badding and Langholz, JJ.
2

LANGHOLZ, Judge.

Fatima Belhak and her husband sued her doctor, Denice Smith, and the 

doctor’s employer for medical malpractice over the care that she received following 

an episiotomy performed during the birth of her first child.

1

 The court instructed 

the jury on three alternative specifications of negligence. And the jury returned a 

general verdict that Smith was negligent and her negligence caused damages to 

Belhak—awarding $3.25 million in damages.

Smith seeks a new trial, arguing that the court should not have submitted 

one of the specifications of negligence—that Smith used the wrong size of 

sutures—to the jury because Belhak had failed to present any expert evidence

supporting causation for that theory. She also argues that a new trial is warranted 

because Belhak’s counsel made improper statements in closing argument and 

asked more than fifty improper leading questions throughout the trial.

Because Belhak’s expert did not testify that the use of smaller sutures was

more likely than not a cause of Belhak’s harm, that specification should not have 

been submitted to the jury. And Smith properly preserved error on this issue by 

moving for a directed verdict and raising it again in her posttrial motion for a new 

trial. It matters not that she agreed to the jury instruction. So she is entitled to a 

new trial on this basis alone, and we need not address whether the conduct of 

Belhak’s counsel would also warrant a new trial. We thus reverse and remand to 

the district court for a new trial.

1 Because the arguments on appeal do not vary between the coplaintiffs and 

codefendants, we will generally refer only to Belhak and Smith for simplicity. But 

both defendants appealed the verdict against them and both plaintiffs were 

awarded damages and have participated in the appeal as the appellees. 
3

I.

Belhak and her husband, Abdellatif Elfila, welcomed their first child in 

January 2014. Belhak’s regular obstetrician with Women’s Care Specialists was 

unavailable when she went into labor, so Smith covered the delivery. As the baby’s 

head began crowning, Smith decided she needed to perform an episiotomy

because Belhak’s skin around her vagina was “very tight around the baby’s head,” 

impeding the baby’s outward progress. To perform an episiotomy, a doctor makes

a small incision with a special pair of scissors from the vagina into the mother’s 

perineum—the area between the vagina and the anus. After performing the 

episiotomy, the baby was successfully delivered without issue. And there appears 

to be little dispute about the need for the episiotomy or the way it was performed. 

The parties’ dispute starts with what happened next.

After the birth, Smith conducted a vaginal examination, which included 

checking out the episiotomy incision to see how far it went and how deep it went 

towards the anus and rectum. Smith diagnosed a second-degree laceration with 

an extension up into the vaginal area. And Smith repaired the laceration with 4-0 

vicryl sutures—the suture she “typically” used for vaginal laceration repairs—rather 

than larger 3-0 or 2-0 sutures. Smith did not perform a rectal exam. And she did 

not diagnose that Belhak had a fourth-degree laceration—an extension of the 

laceration into the lining of the rectum.

While still in the hospital, Belhak felt pain in her rectum and noticed small 

pieces of stool and blood on her postpartum pad after birth. She reported this to 

her medical providers. After a nurse conducted a visual examination and saw

nothing out of the ordinary, the nurse gave her an ice pack to ease the pain.
4

Belhak went home. And a few days later, she self-inspected her vaginal 

area. She was still in pain and saw stool coming from her vagina. After calling 

Smith and her regular medical provider, she went to the emergency room, which 

sent her to the University of Iowa Hospitals and Clinics. The University doctors 

diagnosed Belhak with a fourth-degree laceration. They also diagnosed a 

rectovaginal fistula—essentially a hole between the rectum and the vagina that 

allowed stool and gas to pass from the rectum to the vagina and then come out of 

Belhak’s body either or both ways. Because the area became infected—as 

typically happens if not repaired within twenty-four hours of the injury—Belhak had 

to wait about five months to repair the injuries with reconstructive surgery. 

From February until the reconstructive surgery in June, Belhak had to bathe 

for thirty minutes in a sitz bath after every bowel movement to disinfect the wound. 

Even after her reconstructive surgery, she suffers pain. She has trouble walking, 

carrying heavy objects, and sitting or sleeping in certain positions. Sometimes this 

pain radiates from her pelvis down her legs. She does physical therapy and athome exercises to alleviate the pain as much as possible. She cannot be around 

other people too long for fear of uncontrollable bowel movements and gas, and 

she has to restrict her diet to avoid accidents. Her relationship with her husband

has struggled because of her injury. And he has taken on more responsibilities in 

raising their children, caring for Belhak, taking her to appointments, and helping 

her with therapy.
5

In 2016, Belhak and her husband sued Smith and Smith’s employer over

her care following the episiotomy.

2

 Belhak claimed that Smith’s care was medical 

malpractice that caused her physical and mental injury and pain and suffering. And 

her husband claimed loss of consortium.

The case was eventually tried to a jury in March 2022—after the first attempt

a couple of years earlier ended with a mistrial during jury selection. Over seven 

days, the jury heard from Belhak and her husband, Belhak’s original obstetrician

who could not make the birth, and Smith. The jury also heard from two competing 

expert witnesses—one testifying for Belhak and the other for Smith. Belhak’s 

expert was Dr. Gregory Chen, an experienced obstetrician and gynecologist who 

also served on the clinical faculty of Northwestern University.

After the close of Belhak’s case, Smith moved for a direct verdict on the 

specification of negligence that Smith used the wrong size of sutures, arguing that 

“there has not been any testimony that the use of 4-0 vicryl sutures caused any of 

the injuries to the plaintiffs.”3 The court denied the motion, reasoning that Smith 

“has put forth sufficient evidence on both of those issues to make this a jury 

question.”

The court then submitted the case to the jury with a marshaling instruction 

that included three specifications of negligence, instructing that “[t]he plaintiffs 

must prove” that Smith was “negligent in one or more of the following ways:” 

2 Belhak originally filed two suits—one against Smith and a second against Smith’s 

employer, Women’s Care Specialists. The cases were consolidated together with 

all filings after consolidation made in the case originally brought only against 

Women’s Care Specialists. 

3 Smith also made a second motion for directed verdict applicable to all the 

specifications of negligence that is not at issue on appeal. 
6

(1) “by failing to perform a rectal examination after an episiotomy; or” (2) “by failing 

to recognize a fourth-degree laceration; or” (3) “by using 4-0 Vicryl sutures to repair 

the episiotomy.” Smith agreed that the second and third specifications “should be 

submitted.” But she argued that the first specification—and others the court 

decided not to submit—were “duplicative” and “unduly emphasized plaintiffs’ 

case.”

The jury found that Smith was negligent and her negligence caused 

damages to Belhak.

4

 And the jury awarded $3.25 million in damages. The verdict 

form did not require the jury to specify which of the three specifications of 

negligence were proved.

Smith moved for a new trial for a host of reasons. Among other arguments 

not relevant to this appeal, she again argued that the suture specification of 

negligence should not have been submitted to the jury because there was 

insufficient evidence of causation. Smith also argued that Belhak’s counsel made

at least six arguments during closing argument that constituted misconduct and 

prejudiced Smith. And she argued that Belhak’s counsel’s repeated use of leading 

questions during the trial—over fifty in total that Smith successfully objected to—

was also prejudicial misconduct because “the jury was left with the impression that 

defense counsel was attempting to withhold relevant evidence from its 

consideration by having to make repeated objections.”

The court denied Smith’s motion. The court held that Smith had failed “to

preserve error” on her argument that the suture specification should not have been 

4 While the verdict form mentioned only Smith, the parties agreed that her employer 

was also liable for any verdict.
7

submitted to the jury, reasoning that “[w]hile another objection to preserve error is 

unnecessary, a party cannot agree to specification, only to later argue it was given 

in error.” Alternatively, the court concluded that “a review of the record shows 

sufficient evidence regarding harm to Fatima Belhak to allow the jury to decide 

causation without speculation,” pointing mostly to evidence of the many harms 

Belhak has suffered since the episiotomy.

On Smith’s claims of misconduct during closing argument, the court agreed 

that Belhak’s counsel engaged in three instances of misconduct. But the court 

concluded that these improper arguments—standing alone or collectively—did not 

warrant a new trial. The court reasoned that it had given curative instructions to 

the jury, Belhak’s “evidence could be characterized as strong,” and “[n]one of the 

alleged misconduct surrounded [the] central factual dispute.” The court also 

rejected Smith’s argument based on Belhak’s counsel’s leading questions during 

trial, explaining that it was “not convinced the questioning by [Belhak’s] counsel 

was part of a concerted plan to require defense counsel to object” and that “not all 

of defense counsel’s objections were sustained.” Smith now appeals.5 

5 The parties’ appellate filings suggest some confusion about whether Smith has 

been dismissed from this appeal by the supreme court. So to be clear, both Smith 

and her employer—Women’s Care Specialists, P.C.—properly appealed the 

verdict against them and remain as appellants. Because the appellants at first

attempted to appeal from both the consolidated district court proceeding—in which 

the verdict was entered—and the dormant case that had been originally filed 

against Smith alone, our supreme court dismissed the appeal from the dormant

case for lack of jurisdiction. And the supreme court also dismissed a second 

independent appeal that Smith then filed—again from the dormant case—for lack 

of jurisdiction. See Belhak v. Smith, No. 23-0246 (April 14, 2023). But the court 

never dismissed Smith from the appeal. Indeed, it noted as much in the second 

dismissal, stating that Smith “is pursuing an appeal in appeal number 22-2048, 

which was taken from Scott County case number LACE127225, within which all 

the proceedings below had been consolidated.”
8

II.

As with any claim, to submit a particular theory of negligence—often called 

a specification of negligence—to the jury, there must be substantial evidence in 

the record supporting the specification. See Alcala v. Marriott Int’l, Inc., 880 

N.W.2d 699, 708 (Iowa 2016). For a medical malpractice specification, that means 

evidence that establishes “the applicable standard of care, a violation of that 

standard, and a causal relationship between the violation and the injury.” Susie v. 

Fam. Health Care of Siouxland, P.L.C., 942 N.W.2d 333, 337 (Iowa 2020). And 

when multiple specifications are submitted to the jury and “[t]he jury return[s] a 

general verdict without specifying which” specifications the plaintiff proved, “[a]

new trial is required . . . if the evidence was insufficient to submit one of” them. 

Alcala, 880 N.W.2d at 710. We review the decision to submit a specification to the 

jury for correction of errors at law. Id. at 707–08.

Smith argues that a new trial is required because Belhak failed to present 

sufficient evidence of causation for one of her three specifications of negligence—

that Smith used sutures that were too small for the repair of Belhak’s episiotomy. 

But before we can reach the merits of that argument, we must decide whether 

Smith has preserved error for our consideration of this issue on appeal. Belhak 

contends that Smith did not because Smith agreed to the jury instruction containing 

the suture specification and did not adequately argue the issue in her posttrial 

motion for a new trial. We disagree. 

“It is a fundamental doctrine of appellate review that issues must ordinarily 

be both raised and decided by the district court before we will decide them on 

appeal.” Meier v. Senecaut, 641 N.W.2d 532, 537 (Iowa 2002). Moving for a 
9

directed verdict on a specification of negligence is a proper way to raise the issue 

that a plaintiff has introduced insufficient evidence supporting the specification. 

See James ex rel. James v. Burlington N., Inc., 587 N.W.2d 462, 464 (Iowa 1998). 

And when the district court denies a directed verdict, the party need not object

again to the jury instruction submitting the specification to the jury. See id. Indeed, 

this has been the rule in Iowa for nearly a century. See Heavilin v. Wendell, 241

N.W. 654, 658 (Iowa 1932) (“[T]o the end that there may be no misunderstanding 

about this matter, we now fix the ruling to be that, where a party makes a motion 

for a directed verdict and the court overrules the same, the person against whom 

such ruling is made does not waive the error, if there is one, in the court’s ruling 

on a motion to direct a verdict by asking instructions which correctly state the law 

of the case as fixed by the court’s ruling on the motion to direct a verdict.”). 

Smith urged the district court that Belhak had failed to submit sufficient 

evidence of causation on her suture specification in her directed verdict and again 

in her posttrial motion for a new trial. Yet when the court considered the jury 

instructions—mere moments after considering her argument and denying the 

directed verdict—Smith did not again contest including the suture specification in 

the marshalling instruction. Rather, she agreed it “should be submitted,” and 

instead challenged other specifications as “duplicative” and “unduly emphasiz[ing] 

plaintiffs’ case.” Consistent with our century of precedent, Smith preserved error 

and was not required to again remind the district court that she still disagreed with 

its decision that there was enough evidence to submit the specification to the jury.

Belhak tries to distinguish that precedent because Smith agreed to the jury 

instruction rather than merely failing to object to it. But that is a distinction without 
10

a difference. We see little daylight between the lack of an objection—which is 

functionally agreement—and Smith’s statement of agreement. And the precedent 

establishes no such distinction—making clear that there is no waiver from 

“agreeing to jury instructions,” Holdsworth v. Nissly, 520 N.W.2d 332, 335 (Iowa 

Ct. App. 1994), or even “asking [for] instructions,” Heavilin, 241 N.W. at 657, just 

the same as failing to “object to the instructions,” James, 587 N.W.2d at 464. 

What’s more, we see nothing in Smith’s challenge to other specifications on other 

grounds that could “be taken as an abandonment of [her] clear position that, as a 

matter of law, the [specification] should not have been submitted to the jury at all.” 

Id.

Belhak also contends that Smith did not properly raise the issue again in 

her posttrial motion for a new trial. But Smith had a three-page section of her newtrial brief devoted to arguing that the district court “erred denying Defendants’ 

directed verdict motion relating to the use of sutures to repair [Belhak’s] laceration” 

and in “submitting a specification of negligence instruction regarding the size of 

suture used because that specification required the jury to speculate as to 

causation.” While Belhak makes much of the reference to submission of the 

specification instruction, this is just another way to say the same thing Smith

argued in the directed verdict motion and now on appeal—that Belhak introduced 

insufficient evidence on causation to support a jury verdict on the suture 

specification. And the court ruled on Smith’s argument, rejecting it both on the 

merits and because the court found it had been waived by failing to object to the 

instruction too. Because the issue was raised in and decided by the district court, 

it was preserved. So we go to the merits.
11

Causation is a necessary element of a medical malpractice claim. See 

Susie, 942 N.W.2d at 337. This will typically require expert testimony to create a 

jury question because “a plaintiff needs expert testimony to prove causation unless 

the causation is so obvious that it is within the common knowledge and experience 

of a layperson.” Doe v. Cent. Iowa Health Sys., 766 N.W.2d 787, 794 (Iowa 2009). 

Compare Stickleman v. Synhorst, 52 N.W.2d 504, 507 (Iowa 1952) (holding that 

no expert testimony was required on causation where evidence showed that 

patient began bleeding profusely from the neck after doctor inserted needle into 

the throat, apparently missing the intended mark and hitting a blood vessel), with 

Bradshaw v. Iowa Methodist Hosp., 101 N.W.2d 167, 171 (Iowa 1960) (holding 

that plaintiff failed to prove causation without expert testimony that his back injury 

was caused by fall in the hospital rather than a previous workplace injury).

While the evidence “need not be conclusive,” it “must show the plaintiff’s 

theory of causation is reasonably probable—not merely possible, and more 

probable than any other hypothesis based on such evidence.” Doe, 766 N.W.2d 

at 793 (cleaned up). If the evidence before the jury does not meet this standard, 

then there is not substantial evidence supporting submitting the claim to the jury. 

See id. at 792–95; see also Susie, 942 N.W.2d at 337–340. “The jury cannot be 

left to speculate about the but-for causal link.” Susie, 942 N.W.2d at 338–39.

Smith challenges the causation evidence of only one of Belhak’s 

specifications of negligence—that Smith was negligent “by using 4-0 Vicryl sutures 

to repair the episiotomy” rather than larger 3-0 sutures. And to be clear, Smith 

only challenges the causation link for this specification. She does not challenge 

that Belhak presented expert testimony that using smaller 4-0 sutures violates the 
12

standard of care for repairing an episiotomy.6 Nor does she challenge that Belhak 

presented evidence that Belhak and her husband suffered physical and emotional 

injuries after the episiotomy. The narrow question is the causal link between the 

two—whether the use of smaller 4-0 suture was the cause of any of Belhak’s

claimed harm. 

Because the answer is not “so obvious that it is within the common 

knowledge and experience of a layperson,” Belhak needed to provide expert 

testimony that the smaller suture was a reasonably probable cause of the harm.

Doe, 766 N.W.2d at 794. And Belhak does not argue otherwise. We thus focus 

on the testimony of Belhak’s expert witness, Dr. Chen, to see whether it provides 

the jury a basis to find the required causal link without speculation. See Susie, 

942 N.W.2d at 338–39.7

Belhak first points us to a general conclusion that Dr. Chen offered at the 

opening of his testimony. He was asked, “And we are going to get into more details 

later, but as a result of Dr. Smith’s breaches of the standard of care, were they a 

cause of permanent harm to Fatima Belhak?” And Dr. Chen answered, “Yes.” But

6 Of course, this does not mean that Smith agrees that using 4-0 sutures violates 

the standard of care—her own expert witness provided a contrary opinion.

7 Again, the issue before us is whether Dr. Chen’s testimony provides “substantial 

evidence support[ing] the submission of the causal relationship between” Smith’s 

use of the smaller sutures and Belhak’s injury. Doe, 766 N.W.2d at 792. It is not—

as Belhak frames it in her brief—whether “Dr. Chen’s expert opinions are 

supported by the record.” So Belhak is wrong to try to shift the burden for 

developing the causation record onto Smith based on cases challenging the 

admissibility of an expert’s opinion. See Mercy Hosp. v. Hansen, Lind & Meyer, 

P.C., 456 N.W.2d 666, 671 (Iowa 1990). The burden of presenting substantial 

evidence on all required elements of a plaintiff’s claim—so that it may be submitted 

to the jury—remains at all times on the plaintiff. See Doe, 766 N.W.2d at 792–93; 

see also Iowa R. Civ. P. 1.945 (authorizing motion for directed verdict “[a]fter a 

party has rested,” and “no right to relief has been shown, under the law or facts.”). 
13

this alone—without any explanation about what standards of care Dr. Chen was 

referring to or how any particular breach caused harm—does not move a jury out 

of speculative territory. And it is apparent from this introductory comment that 

Belhak’s counsel as well understood that “more details” were needed and 

expected to come to give a basis for the conclusion.

Dr. Chen then provided those added details for the causation of Belhak’s 

other theories of negligence aside from the suture size. He opined that Smith’s 

failure to conduct a rectal examination or to recognize a fourth-degree laceration 

caused a multi-month delay in properly repairing the episiotomy. And he explained

that this delay resulted in harms—both while waiting for treatment and 

permanently. But when it came time to testify about the 4-0 sutures, Dr. Chen was 

asked little about the causal link between the 4-0 sutures and Belhak’s harm. And 

what he did say does not provide the required support to find that link.

True, in explaining his opinion that using 4-0 sutures violates the standard 

of care, Dr. Chen said that he thought using those smaller sutures “would increase 

the risk of the wound breaking down or not have enough strength to hold it 

together.” But he did not testify that Belhak’s sutures did not actually hold together 

or that her wound broke down because of the sutures. 

Much of Dr. Chen’s testimony focused on interpreting medical records from 

the University of Iowa Hospitals and Clinics when Belhak was treated there by 

specialists who diagnosed her with the fourth-degree laceration and observed the 

status of Smith’s original repair with the 4-0 sutures. Belhak did not call those 

specialists to testify directly, so the medical records and Dr. Chen’s interpretation 

of them were the only evidence of their conclusions. One note in those records 
14

said that the “vaginal repair site appears broken down.” When asked what this 

note means, Dr. Chen answered, “It’s hard to say, exactly. From what my guess 

is, they are seeing an opening either in the perineum or in the vagina or both.” 

Belhak’s counsel then pressed Dr. Chen further. And because this exchange is 

key to understanding our resolution of the case, we quote it in full:

Q. When you are looking at this record, what does it mean to 

you? A. So broken down means they may see some intact stitches, 

but you will see tissue that is not sutured, but appears to be 

separated.

Q. And so, you said, “appears to be separated,” so—

A. Correct, whether it’s a millimeter separated or fa[r]ther, just not 

touching each other like they should be; that there is still a defect, I 

guess, for lack of a better term.

Q. Within a reasonable degree of medical certainty, that being 

more likely true than not, was Dr. Smith’s breach of the 4-0 sutures 

that she used a cause of the vaginal repair site breaking down? 

A. My interpretation, also, they may think it was broken down, 

meaning they assume, for example, a fourth degree was repaired, 

and they see a defect in the perineum and don’t see sutures there, 

so they are assuming some of the sutures were dissolved versus it 

not being repaired at all.

Q. Sure. So you can’t tell whether—which circumstance, but 

you know that whatever sutures that this medical provider is looking 

at has been broken down? A. Some of the suture, yes.

After starting to ask another follow-up, Belhak’s counsel then instead moved on to 

covering other topics.

It is tough to know what Dr. Chen was trying to say during this exchange. 

His answer as to whether the use of 4-0 sutures was “a cause of the vaginal repair 

site breaking down” was particularly “cryptic” and “confusing.” Susie, 942 N.W.2d 

at 338. And he never agreed that the 4-0 sutures were likely the cause of 

anything—the breakdown of the repair site or otherwise. Indeed, from the 

exchange it is not clear that he even agreed it is more likely than not that the 

observed breakdown was of the 4-0 sutures rather than just the fourth-degree 
15

laceration that he believed Smith had missed diagnosing—which, again, was one 

of the alternative specifications of negligence not challenged here. This testimony 

thus improperly left the jury to speculate about the but-for causal link. See id. at 

338–39.

But there is another problem. Even if Dr. Chen had answered the question

and agreed that the 4-0 sutures caused a breakdown at the repair site, that 

testimony still would not have completed the causal link between the sutures and 

Belhak’s harm. Dr. Chen was never asked—and thus never explained—whether 

any breakdown in the repair site caused by the sutures in turn caused Belhak harm. 

Unlike his testimony on the other alleged acts of negligence, he never opined that 

the use of the sutures caused the multi-month delay in properly repairing the 

episiotomy or the related concrete harms from that delay. For example, he never 

opined that the sutures likely caused the fourth-degree laceration or that they likely 

made any harm Belhak suffered worse. So any attempt to complete that last

causal link would require improper speculation by the jury too. See id. at 338–39.

Without any evidence from which a jury could conclude that Smith’s use of 

smaller sutures was a cause of Belhak’s injury, it was error for the district court to 

submit the suture specification of negligence to the jury. And because the general 

verdict does not tell us which of the specifications the jury found to be proven, 

Smith is entitled to a new trial. We thus reverse the district court judgment and 

remand this case for a new trial consistent with this opinion.

III.

Because a new trial is required due to the improper submission of the suture 

specification, we need not decide whether the conduct of Belhak’s attorney during 
16

closing arguments also warrants a new trial. But since the new trial will again 

require the parties’ counsel to engage in proper closing arguments, we find it 

appropriate to offer some guidance to prevent these issues from arising again.

The district court concluded that Belhak’s counsel engaged in three 

instances of misconduct during closing arguments. Belhak’s counsel improperly 

attacked defense counsel by accusing him of “character assassination” of Belhak 

during defense counsel’s questioning of Dr. Chen. He improperly attacked the 

defense’s expert witness by suggesting—without any basis in evidence—that the 

expert had violated his Hippocratic oath when performing episiotomies in 

Honduras. And he improperly mischaracterized Belhak’s medical records from the 

University of Iowa Hospitals and Clinics by saying, “The University of Iowa said 

that the fourth-degree laceration was there at the time of delivery,” when that 

conclusion is nowhere in the records or any other trial evidence.

“Attorneys have a duty to refrain from crossing the admittedly hazy line 

between zealous advocacy and misconduct.” Kinseth v. Weil-McLain, 913 N.W.2d 

55, 73 (Iowa 2018). And our decision not to decide whether this conduct would 

independently warrant a new trial should not be interpreted as any disagreement 

with the district court’s well-reasoned conclusions that this conduct by Belhak’s 

counsel crossed that line. 

“When attorneys approach the jury box to present their closing arguments, 

they carry with them an immense responsibility.” Id. While “[w]e presume juries 

follow [their] instruction and do not consider closing statements to be evidence,” 

we recognize that they “will inevitably take [their] cues from attorneys during their 

respective closing arguments.” Id. And so, “we observe a heightened sensitivity 
17

to inflammatory rhetoric and improper statements, which may impress upon the 

jury that it can look beyond the facts and law to resolve the case.” Id. Engaging 

in unwarranted personal attacks against opposing counsel and the opposing 

party’s expert witness and misstating key evidence are violations of this

responsibility we entrust to Iowa attorneys as officers of the court.

Of course, “attorneys may occasionally make one or more isolated missteps 

during closing arguments,” particularly in the heat of zealous advocacy. Id. But 

we caution that “repeated” and “deliberate” misconduct is another matter entirely—

more likely to require a new trial. Id. And so, Belhak’s counsel would be wise to 

take care that his misconduct does not repeat.

REVERSED AND REMANDED.