Opinion ID: 2429561
Heading Depth: 1
Heading Rank: 2

Heading: admissibility and sufficiency of the evidence of causation

Text: SLU's next argument is incongruous because the point of error is stated in terms of sufficiency of evidence, but most of the authority cited by SLU relates to requirements for admissibility, primarily those set forth in Frye v. United States, 293 F. 1013 (D.C.Cir.1923). Frye held that for an expert witness' testimony to be admissible, the testimony must be based on scientific principles that are generally accepted in the relevant scientific community. Id. at 1014. This Court adopted the Frye rule for civil suits in Alsbach v. Bader, 700 S.W.2d 823 (Mo. banc 1985). Plaintiffs, however, contend that Missouri should no longer follow the Frye test. SLU contends that the testimony of plaintiff's experts, Dr. Burmeister and Dr. Malone, should have been excluded or given little or no weight because their testimony failed to meet the requirements set forth in Frye . Both parties argue that the United States Supreme Court case of Daubert v. Merrell Dow Pharmaceuticals, Inc., ___ U.S. ___, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993), is substantially similar to the case before us here. However, the parties failed to recognize that the issue in Daubert was fundamentally different than any issue that is preserved in the present case. Daubert was an appeal from a pretrial summary judgment motion which assumed that, if tried, the appropriate objections would be made to the expert's testimony. The present case is an appeal from a jury verdict at trial in which there was no objection to the testimony of either of plaintiff's experts with respect to their opinions as to the diagnosis and cause of Danny's condition. The Frye rule clearly deals with admissibility rather than submissibility. Admissibility only becomes an issue if there is a timely and specific objection. Mo. Evidence Restated, § 103 (Mo. Bar 2d ed. 1993). In State v. Davis, 814 S.W.2d 593 (Mo. banc 1991), we referred to the Frye doctrine as a standard for admissibility. State v. Stout, 478 S.W.2d 368 (Mo.1972), one of the leading criminal cases in Missouri applying the Frye doctrine, vividly demonstrates that the issue is properly raised as a question of admissibility. The opinion in Stout contains substantial excerpts from the Frye hearing, held outside the presence of the jury, to determine the admissibility of the results of neutron activation analysis of blood stains. In Stout we said, The determining question on this appeal is whether this testimony elicited from [the expert] and presented to the jury was legally admissible.  Id. at 369 (emphasis added). Defendant SLU has cited no case, and we have found no case that permits a party to blissfully ignore the requirement to object to evidence based on the Frye doctrine and then back-door the Frye issues into the lawsuit under the guise of a sufficiency of evidence argument. Since there was no objection to the testimony of plaintiff's experts, there is no issue of admissibility presented and none is preserved for appeal. Therefore, it would be inappropriate for us to decide in this case whether section 490.065, RSMo Supp.1992, supersedes the Frye doctrine in the same manner that Daubert held that Federal Rule 702 changes the requirements for the admissibility of expert testimony in federal court.

Plaintiff contends that because this injury resulted from multiple tortfeasors and more than one cause, the substantial factor causation test should be applied rather than the but for test. Therefore, we need to consider whether Missouri law still includes a but for causation test, and if so, when? Finally, we will consider whether causation was submissible under the evidence in this case. The but for causation test provides that the defendant's conduct is a cause of the event if the event would not have occurred but for that conduct. Prosser and Keeton on Torts, § 41 at 266 (5th ed. 1984). Put simply, but for causation tests for causation in fact. Mere logic requires causation in fact. There has been some confusion in the Missouri cases as to when the but for causation test applies. This confusion arose as a result of the recent trend among courts to describe causation as requiring that the defendant's conduct be a substantial factor in bringing about the plaintiff's harm. The substantial factor test has become popular because in the complex litigation of today, courts are often forced to deal with claims that the conduct of more than one tortfeasor caused the harm. When considering multiple causes it is misleading to talk about the cause, and changing the terminology to a cause is too insignificant an alteration to communicate to the jury the idea of contributing causes. The upshot is that lawyers and judges feel more comfortable using substantial factor language with multiple causes because it is consistent with and better communicates the idea of more than one cause. As this Court has moved to the use of substantial factor language, the cases have suggested that the substantial factor test does not include a but for test. See Jackson v. Ray Kruse Const. Co., 708 S.W.2d 664 (Mo. banc 1986). One reason for the confusion as to when a but for test is required is because the Restatement (Second) of Torts uses substantial factor in a different way than Prosser. Section 430 of the Restatement (Second) requires legal cause for liability. Section 431 provides that legal cause is present if the defendant's conduct is a substantial factor in bringing about the harm. Section 432 provides that the conduct is not a substantial factor unless it meets the but for test, which is always required except for the very narrow exception where there are two independent torts, either of which by itself would have caused the injury. The law school example of the latter type of case is where two independent tortfeasors set fires on opposite sides of the mountain, the fires burn toward the cabin at the top, and either is sufficient to destroy the cabin. Under these circumstances, the but for test fails to accurately test for causation in fact because the absence of either fire will not save the cabin. Applying the but for causation test to fire number one results in the conclusion that the cabin would have burned even if fire number one had not occurred because fire number two would have burned the cabin. For the same reason, applying the but for causation test to fire number two leads to the conclusion that the cabin would have burned even if fire number two had not occurred because fire number one would have burned the cabin. Nevertheless, it is obvious that both fires are causes in fact. This limited circumstance, hereinafter called a two fires case, is the only situation where the Restatement (Second) would not require a but for test. The confusion arises because the Restatement (Second) labels all cases where legal cause is present as substantial factor cases. Thus, under the Restatement's approach the vast majority of cases, although called substantial factor cases, are required to meet a but for causation test. Prosser's approach to causation uses different terminology. He calls the overall requirement proximate cause. Under proximate cause he would require that a but for test be met in all cases except in a two fires case, where he would replace the but for test with a substantial factor test. Thus, when Prosser refers to a substantial factor case, he refers to the narrow category of the two fires cases. In contrast, when the Restatement (Second) refers to a substantial factor case it is referring to all cases where legal causation is present, including the two fires cases. The danger of frittering away a meaningful causation test lies in confusing the substantial factor category under the Restatement, which basically includes all causation, with Prosser's narrow substantial factor case (two fires cases only). Such confusion would eliminate the use of the but for causation test to the point where, as a practical matter, causation in fact would no longer be required. Some lawyers and judges have come to look upon the but for test as a particularly onerous and difficult test for causation. Nothing could be further from the truth. But for is an absolute minimum for causation because it is merely causation in fact. Any attempt to find liability absent actual causation is an attempt to connect the defendant with an injury or event that the defendant had nothing to do with. Mere logic and common sense dictates that there be some causal relationship between the defendant's conduct and the injury or event for which damages are sought. Two causes that combine can be tested easily by a but for causation test. How would such a test for causation be applied to the negligent conduct of SLU in the present case? Assume that each of the following but for issues is supported by the evidence. If Dr. Venglarcik was informed by Nurse Schwarz of Danny's presence and condition at the hospital but failed to see Danny, or even if Dr. Venglarcik saw Danny but failed to incise and drain the abscess, then the jury could conclude that but for the doctor's negligent conduct, Danny would not have contracted paralytic polio. In this instance, Dr. Venglarcik's negligent conduct would meet the but for causation test and would be a contributing cause to Danny's paralytic polio. Likewise, if Dr. Venglarcik learned of Danny's condition at the hospital by reading the medical records, but he failed to see Danny, or even if he saw Danny but failed to incise and drain the abscess, then the jury could conclude that but for the doctor's negligent conduct, Danny would not have contracted paralytic polio. In this instance, Dr. Venglarcik's conduct would again meet the but for causation test and would be an independent sufficient cause of Danny's paralytic polio. If Cardinal Glennon was still a party to this case, how would the but for causation test be applied to Nurse Schwarz's negligent conduct? If Nurse Schwarz failed to inform Dr. Venglarcik of Danny's presence and condition at the hospital, and the doctor had no other source of this information, then a jury could have concluded that but for the nurse's failure to inform the doctor, Danny would not have developed paralytic polio. As such, her conduct meets the but for test and, in that respect, it is causal. This is the classic example of applying the but for causation test to two contributing causes. On the other hand, if the doctor had another source of information as to Danny's presence and condition at the hospital, such as the medical records, then the doctor's negligence would have been independently sufficient to cause the injury to Danny. In this circumstance, Nurse Schwarz's conduct would not have met the but for causation test because, if the doctor already knew of Danny's condition, then Nurse Schwarz's failure to tell the doctor something that he already knew would not be causal absent a convincing policy argument that this situation should be treated as a two fires case. This is essentially the same analysis this Court has applied in failure to warn product liability cases where the injured party already had full knowledge of the information contained in the warning. Arnold v. Ingersoll-Rand Company, 834 S.W.2d 192 (Mo. banc 1992). In summary, there is nothing inconsistent or different about applying a but for causation test to a circumstance involving multiple causes. The but for causation test operates only to eliminate liability of a defendant who cannot meet this test because such defendant's conduct was not causal. The fact that the conduct of a particular defendant either does or does not meet but for causation has no impact on the remaining defendants. The remaining defendants rise or fall on their own but for causation test. Our adoption of the substantial factor test of causation in Jackson v. Ray Kruse has been read by some to dispense with the requirement of but for causation. We attempted to clarify in Wollen v. DePaul Health Center, 828 S.W.2d 681 (Mo. banc 1992), that the but for test continues to apply to the vast majority of cases in Missouri. We now reiterate that the but for test for causation is applicable in all cases except those involving two independent torts, either of which is sufficient in and of itself to cause the injury, i.e., the two fires cases. [1] To the extent that Jackson v. Ray Kruse and the cases discussed therein are contrary, they are overruled. All of this discussion concerning the semantics of causation is less important in Missouri than in most jurisdictions because under MAI we do not use the terms 1) proximate cause, 2) but for causation, or 3) substantial factor when instructing the jury. We merely instruct the jury that the defendant's conduct must directly cause or directly contribute to cause plaintiff's injury. See MAI 19.01 [1986 Revision] Verdict Directing ModificationMultiple Causes of Damage. The debate as to whether and when Missouri requires but for causation has arisen almost exclusively in the sufficiency of evidence cases such as this one. This issue can also arise, however, in the context of what is proper closing argument on a causation issue. MAI contemplates that the lawyers may explain the precise meaning of the instructions in closing arguments. See MAI, Why and How to Instruct a Jury, p. LXVII at XCIV.
We have already concluded that the expert testimony of Dr. Burmeister and Dr. Malone concerning the causal connection between SLU's negligence and Danny's injury was properly admitted. Inadmissible evidence received without objection may properly be considered in determining the sufficiency of the evidence. Appelhans v. Goldman, 349 S.W.2d 204, 207 (Mo.1961). SLU is, therefore, reduced to arguing that the testimony of plaintiff's experts is so deficient in weight and credibility that it has little or no value on the issue of causation. In Appelhans, 349 S.W.2d 204, plaintiffs brought an action for injuries suffered as the result of a car accident. At trial, plaintiffs admitted a stopping distance chart along with the testimony of their expert witness thereon. On appeal, defendant asserted the admission of the exhibit and the testimony by plaintiffs' expert witness was prejudicial error because it was hearsay. Defendant, however, failed to make a proper and timely objection to the admission of such evidence. Defendant merely objected on the general grounds that the exhibit and testimony were irrelevant and that the chart was not properly identified. After several questions and explanatory answers regarding the chart and the witness' answer that he was stating what the chart presented and not his personal knowledge, counsel finally did make an untimely hearsay objection. This Court, however, held that since defendant failed to properly object to the admission of the evidence, plaintiffs' exhibit and the expert's testimony thereon could be considered in determining the sufficiency of the evidence even if it was hearsay. This Court also noted in Appelhans that, in determining the sufficiency of the evidence, plaintiff is entitled to the benefit of all favorable probative evidence and all favorable inferences to be drawn therefrom, and defendant's evidence is to be disregarded unless it aids plaintiff's case.... Id. at 208 (citing Price v. Nicholson, 340 S.W.2d 1 (Mo. banc 1960). We will, therefore, review the testimony of Dr. Malone and Dr. Burmeister in the light most favorable to the plaintiff. Both experts for Danny were able to assert a reliable scientific basis for their theory that the improper treatment of the bacterial infection led to Danny developing poliomyelitis. SLU asserts, however, that Dr. Burmeister and Dr. Malone did not base their testimony on any epidemiological studies indicating that the polio vaccine will develop into the polio virus if a child's immune system becomes suppressed. The doctors did not base their testimony on epidemiological studies because, in the forty year history of the use of the polio vaccine, the occurrence of vaccine-induced poliomyelitis has been extremely rare and there are no definitive studies indicating that a bacterial infection will or will not cause a person's immune system to be suppressed. It is not uncommon for areas of medicine involving rare diseases or causes to receive limited funding for research and studies. Although the absence of epidemiological studies weakens the probative value of Dr. Burmeister and Dr. Malone's conclusions, it is not dispositive of the issue. Both doctors were able to extrapolate from what occurs in other areas of the medical field when a human being's immune system is suppressed to what is likely to occur when a person's immune system is suppressed and comes in contact with the attenuated polio virus in the vaccine. Furthermore, each logical step leading to the opinions of Dr. Burmeister and Dr. Malone was based on reliable scientific knowledge. It is also worth noting that both of plaintiff's experts had a history of testifying primarily for defendants. Dr. Burmeister is board certified in internal medicine and is board eligible in infectious disease. He was an assistant professor of microbiology at SLU. While he was in the military he did research in the field of biological warfare. He was president of the medical staff at SLU and has been the chairman of various committees dealing with control of infectious disease and antibiotic performance at various hospitals. Although he is not a pediatrician, he does treat children in the course of his practice. In forming his opinions, Dr. Burmeister relied on his own experience concerning the interaction between viral infections and bacterial infections. He relied on published studies in other areas of medicine indicating that endotoxins in human beings can cause a person's immune system to be suppressed and cause a person to be more susceptible to disease. Furthermore, he relied on the package inserts and Physician's Desk Reference information that accompanies the polio vaccine, which caution against the use of the vaccine in a patient who is suffering from an acute illness; in a patient with genetic immune deficiencies; and in a patient whose immune system was suppressed due to other factors, including steroids, immune serum globulin therapy, radiation, chemotherapy, and leukemia. In combination, this information provides reliable support for each step of reasoning Dr. Burmeister used to conclude that if endotoxins have suppressed a person's immune system, the attenuated polio virus in the vaccine may overwhelm a person's immune system and develop into the polio disease. Dr. Malone is a medical doctor licensed to practice in South Carolina. He is on the faculty and staff of the medical school at the University of South Carolina and on the staff of the veteran's hospital in Charleston, South Carolina. He is a member of the Academy of Neurology, the American Society of Neurochemistry, the International Society of Neurochemistry, and the International Society of Pediatric Neurology. He has also had experience in treating children with acute poliomyelitis. Dr. Malone's testimony, based on various immunology studies that reported an immunosuppressive effect following the administration of endotoxins to healthy adults, reached the same conclusion as Dr. Burmeister. SLU asserts that but for cause was not established here because Danny is an individual who was susceptible to the polio disease and would have developed the disease from the vaccine regardless of SLU and Cardinal Glennon's failure to treat the abscess properly. SLU, therefore, contends that Danny's paralysis would have occurred regardless of whether SLU or Cardinal Glennon acted or did not act. However, both Dr. Malone and Dr. Burmeister testified without objection that if the abscess had been treated properly, Danny's immune system would not have been suppressed, the vaccine would have developed antibodies to the polio virus, and, as a result, Danny would not be paralyzed. In testing the sufficiency of the evidence, we must take Dr. Malone and Dr. Burmeister's testimony in the light most favorable to the plaintiff. Therefore, causation was a question for the jury, and the jury believed that Danny would not have developed polio but for the actions of SLU and Cardinal Glennon. This point is denied.
Defendant SLU contends that Danny's paralytic polio was not the natural and probable consequence of the failure to incise and drain the abscess because there is no previous case reported in which failure to incise and drain resulted in paralytic polio. In other words, defendant SLU argues that this result is not foreseeable and is, therefore, not causal. Many jurisdictions do incorporate some form of a foreseeability requirement into proximate cause. Proximate cause requires something in addition to a but for causation test because the but for causation test serves only to exclude items that are not causal in fact; it will include items that are causal in fact but that would be unreasonable to base liability upon because they are too far removed from the ultimate injury or damage. For example, carried to the ridiculous, but for the mother and father of the defendant conceiving the defendant and bringing him into this world, the accident would not have happened. However, obviously, this is not a basis for holding the mother and father liable. A few jurisdictions limit but for causation with a pure foreseeability test. Most of these jurisdictions find the origin of their authority in the famous case of Palsgraf v. Long Island Railroad Co., 248 N.Y. 339, 162 N.E. 99 (1928). [2] Missouri, like many other states, [3] has not applied a pure foreseeability test; we have generally said that the injury must be a reasonable and probable consequence of the act or omission of the defendant. Foley v. Hudson, 432 S.W.2d 205, 207 (Mo.1968); Floyd v. St. Louis Public Service Co., 280 S.W.2d 74, 78 (Mo.1955). This is generally a look back test but, to the extent it requires that the injury be natural and probable, it probably includes a sprinkling of foreseeability. To the extent the damages are surprising, unexpected, or freakish, they may not be the natural and probable consequences of a defendant's actions. If the facts involved an extended scenario involving multiple persons and events with potential intervening causes, then the requirement that the damages that result be the natural and probable consequence of defendant's conduct comes into play and may cut off liability. This type of fact situation is not present in this case; there were no other parties or potential intervening causes present. It was clear that any negligent treatment by the doctor or nurse would result in injury to the patient, Danny. SLU contends that the injuries are not foreseeable and, therefore, are not causal as a matter of law if a particular injury sustained by Danny is not foreseeable. However, no such requirement exists. It is sufficient for liability if a reasonable defendant could foresee the person who would be injured as opposed to the nature of the injury. As this Court has previously stated: It is of course unnecessary that the party charged should have anticipated the very injury complained of or anticipated that it would have happened in the exact manner that it did. All that is necessary is that he knew or ought to have known that there was an appreciable chance some injury would result. Tharp v. Monsees, 327 S.W.2d 889, 894 (Mo. banc 1959). Here, it was clear to everyone that if Danny received negligent medical care some injury would likely result to him. This meets traditional causation requirements and requires us to reject SLU's argument that the doctor or nurse needed to foresee that paralytic polio might reasonably be caused by the failure to incise and drain. As Prosser states: It is as if a magic circle were drawn about the person, and one who breaks it, even by so much as a cut on the finger, becomes liable for all resulting harm to the person, although it may be death. Id. § 43 at 291. For example, most states have a line of cases commonly referred to as thin skull cases. In Heppner v. Atchison, Topeka and Santa Fe Ry. Co., 297 S.W.2d 497 (Mo.1956), a railroad employee suffered a blow to his back when the train in which he was traveling lurched; this blow activated a dormant cancer in his adrenal gland which caused the cancer to spread throughout his body. Shortly after this incident, the railroad employee died from cancer. This Court in Heppner held that the jury could find that the railroad's negligence activated a latent disease and that the railroad was liable for all of the resulting harm that flowed from its negligence. Id. at 504. Just as in Heppner , where we did not require that the defendant foresee that its negligence would activate a latent disease in the plaintiff, we will not require Nurse Schwarz and Dr. Venglarcik to foresee that the failure to incise and drain would cause Danny's paralytic polio. Any time a physician or nurse acts negligently in the treatment of a patient, it is foreseeable that this may result in injury to the patient. Defendant SLU's contention that this Court must enter a judgment for SLU as a matter of law because no reasonable doctor or nurse could foresee that Danny would contract paralytic polio by reason of the failure to incise and drain Danny's abscess is without merit. The trial court was correct in determining that the requirement of foreseeability, to the extent that it exists under Missouri law, was met and the issue of causation was submissible to the jury.