Court Opinion

ID: 4445161
Source: CourtListenerOpinion
Date Created: 2019-10-08 20:00:55.776025+00
Date Added: 2024-06-11T14:27:57.993864
License: Public Domain

Case: 16-17147   Date Filed: 10/08/2019   Page: 1 of 69

                                                                    [PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                   FOR THE ELEVENTH CIRCUIT
                     ________________________

                            No. 16-17147
                      ________________________

                 D.C. Docket Nos. 4:08-md-02004-CDL,
                         4:12-cv-00176-CDL

TERESA TAYLOR,

                                       Plaintiff – Appellee,

versus

MENTOR WORLDWIDE LLC,
MENTOR CORPORATION,

                                   Defendants – Appellants.

                      ________________________

                            No. 16-17245
                      ________________________

                 D.C. Docket Nos. 4:08-md-02004-CDL
                         4:12-cv-00176-CDL

In re: MENTOR CORP. OBTAPE TRANSOBTURATOR SLING PRODUCTS
LIABILITY LITIGATION.
__________________________________________________________________
               Case: 16-17147        Date Filed: 10/08/2019      Page: 2 of 69

TERESA TAYLOR,

                                                   Plaintiff – Appellant,

versus

MENTOR WORLDWIDE LLC,
MENTOR CORPORATION,

                                              Defendants – Appellees.

                               ________________________

                     Appeals from the United States District Court
                         for the Middle District of Georgia
                            ________________________

                                      (October 8, 2019)

Before TJOFLAT and JULIE CARNES, Circuit Judges, and KAPLAN,∗ District
Judge.

KAPLAN, District Judge:

         Teresa Taylor here sues Mentor Worldwide LLC (“Mentor”) and Mentor

Corporation 1 for compensatory and punitive damages for injuries she suffered as a

result of the surgical implantation of a polypropylene mesh sling manufactured by

Mentor to treat her stress urinary incontinence. The jury found Mentor liable to

Taylor for failure to warn both before and after implantation, defective design, and

negligence. It awarded $400,000 in compensatory and $4 million in punitive

∗
  The Honorable Lewis A. Kaplan, of the United States District Court for the Southern District of
New York, sitting by designation.
1
  Mentor Corporation merged into Mentor Worldwide LLC and consequently ceased to exist prior
to the filing of the complaint.

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damages. Mentor moved for judgment as a matter of law or, in the alternative, for a

new trial or to reduce the punitive damages award. The district court upheld the

jury’s verdict with respect to liability and compensatory damages, but concluded that

the punitive damages award exceeded Florida’s statutory cap and consequently

reduced the punitive damages award to $2 million.

      Mentor now appeals. It contends that it is entitled to judgment as a matter of

law because the district court erred in (1) receiving certain expert testimony on the

issue of specific causation and (2) applying an incorrect causation standard to

Taylor’s failure to warn claims. Mentor argues, in the alternative, that it is entitled

to a new trial on the basis of various evidentiary rulings by the district court or to an

amended judgment eliminating or further reducing the punitive damages award.

Taylor cross appeals, arguing that the district court erred in reducing the punitive

damages awarded by the jury. We find no error in the judgment and therefore affirm.

             I. BACKGROUND

      This is one of more than 800 cases that were consolidated by the Judicial Panel

on Multidistrict Litigation into the multidistrict proceeding known as In re Mentor

Corp. ObTape Transobturator Sling Products Liability Litigation, No. 4:08-MD-

2004 (CDL). The cases arise from claims of medical complications allegedly

associated with a polypropylene mesh sling manufactured by Mentor called ObTape.

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One such case, brought by Taylor, who was surgically implanted with ObTape in

2004 to treat stress urinary incontinence, was selected to go to trial as a bellwether.

      Taylor claimed defective design, negligence, and failure to warn both before

and after implantation of the ObTape. She contended that her ObTape implant

caused her to suffer from a thinning of her urethral wall and from chronic bladder

inflammation (also called cystitis). At trial, she endeavored to prove that her injuries

resulted from two design defects in the ObTape, namely, a small pore size, which

allegedly did not allow adequate tissue ingrowth, and an alleged propensity to

degrade and shed polypropylene particles in the body. She relied at trial on several

expert witnesses to establish both general causation – that is, that ObTape was

capable of causing the types of injuries from which she suffered – and specific

causation – that is, that the ObTape implanted in her in fact caused her injuries.

      We begin with an overview of the evidence offered and objections made at

trial to the extent such evidence and objections are relevant on appeal.

             A.     General Causation

                    1.     Porosity of ObTape

      Several witnesses testified, in their respective expert opinions, that ObTape’s

small pore size did not allow adequate tissue ingrowth, which in turn led to

inflammation, erosion, and infection.

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       One such witness was Dr. William Hyman, a professor emeritus of biomedical

engineering at Texas A&M University. Dr. Hyman testified that large pores are

better than small pores in a mesh sling implant such as ObTape. He explained that

the goal is for the tissue to grow into the implant and to “stabilize it and hold it in

place” in order to prevent the implant from “moving relative to the tissue.”

According to Dr. Hyman, if an implant has “big holes and relatively little material,”

the “[t]issue can grow through the holes, find other tissue on the other side, and

anchor it all in place, and that helps control erosion.”2 He testified also about the

ObTape sling in particular and opined that it had a “uniquely bad” design in part

because it had a small pore size as well as smaller numbers of pores. In other words,

according to Dr. Hyman, the small pore size of ObTape prevented adequate tissue

ingrowth, which then permitted the ObTape to move around the implant area and

cause erosion.3

       Dr. Andrew Siegel, a urologist, testified along similar lines, saying that, in his

experience with his patients, ObTape “didn’t develop the typical tissue ingrowth and

incorporation that [he] had come to expect with some of the previous generation

2
  Dr. Hyman explained that erosion occurred when tissue was “essentially . . . rubbed through by
[a] foreign object.”
3
  He explained also that the small pores in ObTape trapped bacteria and prevented the body from
fighting infection.

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sling materials” and that the implant’s pores were not big enough to allow adequate

tissue ingrowth.

                    2.    Tendency to Degrade

      Dr. Ahmed El-Ghannam, a professor of biomaterials at the University of

North Carolina, testified on the degradation theory. He said that he had conducted

a series of scientific experiments on ObTape, including an electron microscope

examination of the product after immersing it in a physiological solution, a Fourier

Transform Infrared Spectroscopy, a gas chromatography/mass spectrometry

analysis of a physiological solution after the ObTape had been immersed in it, a

differential scanning calorimetry, and an x-ray diffraction analysis. Each analysis,

he said, confirmed that ObTape, although intended to be an inert, permanent

material, had a propensity to degrade and shed polypropylene particles in the body.

He testified that this degradation and shedding of particles sparked a reaction by the

body’s immune system, causing the body continuously to release hydrogen peroxide

– a strongly acidic fluid – in order to destroy the implant. The response by the body’s

immune system caused tissue inflammation, erosion of tissue and, in some cases,

infection. If the ObTape were inert, he testified, it still would stimulate the body’s

immune system, but because of the size of the sling, the body would form a fibrous

capsule around the implant to encase it which, in turn, would cause the immune

system to stop attacking the foreign object.

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      Dr. El-Ghannam testified further that it was not a matter of whether

degradation would occur, but when. He opined that any patient implanted with

ObTape would suffer the effects of degradation because, after an initial incubation

period during which the rate of degradation would be slow, the rate of degradation

would increase dramatically, necessitating the removal of the ObTape.

             B.     Specific Causation

      On the question of specific causation, Taylor proffered Dr. William Porter, a

urogynecologist, as an expert witness to show that ObTape in fact caused the chronic

inflammation and pain she claimed to have suffered. In order to explain the

significance of Dr. Porter’s testimony at trial, it is useful first to explain the opinions

given in both his expert report and deposition.

       Taylor disclosed Dr. Porter as a causation expert and provided an expert report

prior to trial as required by Rule 26. In his Rule 26 report, Dr. Porter opined “to a

reasonable degree of medical and scientific probability that [Taylor’s] injuries were

caused by complications attributable to the Mentor ObTape product at issue in this

case.” In support of that opinion, he noted that medical literature indicated the

ObTape had a higher incidence of erosion than did other such slings. Moreover, that

same literature revealed that ObTape had a smaller pore size than did competing

products, which increased the likelihood of infection.            Dr. Porter noted that

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complications generally associated with implantation of ObTape included, among

other things, “chronic inflammation of tissue” and “erosion of mesh into tissues.”

The resulting injuries included vaginal and pelvic pain, inflammation, and bladder

problems.

      In summary, the report indicated that Dr. Porter had concluded, based on his

physical examination of Taylor and a review of her medical records, that she suffered

pain and chronic inflammation that was primarily attributable to ObTape’s small

pore size and to a “tightening/contraction” process that resulted from ObTape’s

faulty design. Dr. Porter reached his conclusion that ObTape was the culprit largely

through a process of elimination. He considered other possible causes for Taylor’s

maladies but, upon examining her, was largely “able to rule out these other potential

causes (except Arias Sling)” because Taylor’s symptoms started after placement of

the ObTape. He therefore concluded “within a reasonable degree of medical

certainty, that the most likely cause of her . . . chronic inflammation is the ObTape.”

      In his deposition, Dr. Porter expressed less confidence in the opinions

described above. In response to questions by defense counsel, he conceded that none

of Taylor’s medical records showed an erosion of her ObTape. He conceded also

that there could be causes other than ObTape for Taylor’s chronic bladder

inflammation. Indeed, at one point in his deposition, Dr. Porter stated that he could

not say “to a reasonable degree of medical probability” that her ObTape caused her

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chronic inflammation. Further, Dr. Porter expressed skepticism about Dr. El-

Ghannam’s degradation theory.

      At trial, Taylor’s counsel asked Dr. Porter to assume that ObTape does

degrade, as Dr. El-Ghannam had opined and testified. Mentor objected that the

assumption would pose an improper hypothetical, but the district court overruled the

objection. It ruled that Dr. Porter could answer questions based on the assumption

he had been asked to make and that the jury ultimately could decide whether to credit

Dr. El-Ghannam’s degradation theory. Assuming Dr. El-Ghannam’s theory was

valid, and based also on the absence of anything else in Taylor’s medical history that

could explain her chronic bladder inflammation, Dr. Porter testified that the

inflammation of her bladder most likely was caused by ObTape.

      Later in his trial testimony, Dr. Porter stated his opinion that ObTape caused

a thinning of Taylor’s urethral tissue, which he described as an “erosion” of the

urethra. Dr. Porter had not opined on Taylor’s urethral thinning in his report or

deposition, but he had noted that her medical history indicated that her urethra had

thinned near the site of the ObTape and that relevant literature had indicated a greater

incidence of erosion of the mesh into tissues and of bladder problems as a result of

using ObTape. Dr. Porter conceded that his opinions had “evolved and changed” in

this respect as a result of his having gone over Taylor’s medical records “with a fine-

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tooth comb” and answering some of the questions Taylor’s attorneys had posed to

him after his deposition.

      At the conclusion of Dr. Porter’s direct examination, Mentor moved to strike

his testimony. It argued that the opinions offered by Dr. Porter at trial were not

disclosed in his Rule 26 report and that they differed from his deposition testimony.

Specifically, Mentor noted that Dr. Porter had said during his deposition that he

didn’t believe in degradation. In addition, Mentor pointed out that Dr. Porter never

had mentioned “urethral erosion” prior to trial and that he had said in his deposition

that Taylor’s bladder inflammation was not caused by ObTape. It stated also that if

the court were unwilling to strike the testimony, counsel would like an overnight

continuance to prepare its cross-examination of Dr. Porter. It never asked for a

mistrial.

      The district court denied Mentor’s motion to strike Dr. Porter’s testimony, but

granted the alternative relief it requested: the opportunity to prepare overnight for

Dr. Porter’s cross-examination. Defense counsel cross-examined Dr. Porter the

following day. Mentor’s attorney pointed out the inconsistencies between the

doctor’s deposition testimony and his trial testimony and probed also the urethral

erosion issue. Specifically, in response to Mentor’s questions, Dr. Porter admitted

that he could not rule out the surgical injection of Durasphere as a potential cause of

Taylor’s urethral thinning and acknowledged that the surgeon who actually had

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observed Taylor’s urethra had opined that it was the Durasphere that caused this

problem.

      Notably, in his Rule 26 report, his deposition, and his trial testimony, Dr.

Porter based his conclusion that the ObTape had caused Taylor’s injuries on the fact

that he had ruled out all other potential causes. On cross, however, Mentor was able

to elicit a concession from the doctor that not only was Durasphere a possible culprit,

but also that there were other possible causes, including Taylor’s hysterectomy and

corresponding post-menopausal state as well as the subsequent surgical insertion of

an Aris sling.

      Mentor’s counsel also elicited from Dr. Porter an admission that he had not

personally seen any evidence to support Dr. El-Ghannam’s degradation theory. Dr.

Porter even stated that he did not believe in the theory that the mesh sling shed

polypropylene particles. More than that, defense counsel prompted Dr. Porter to

admit that he himself had inserted into hundreds of patients non-ObTape mesh-type

slings that Dr. El-Ghannam likewise had decried as degradable: an admission that

suggested that Dr. Porter remained skeptical of the theory.

      Mentor renewed its motion to strike Dr. Porter’s testimony, arguing that the

opportunity to prepare for cross overnight had failed to alleviate the prejudice

resulting from Dr. Porter’s previously undisclosed opinions. The district court

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denied the motion, concluding that Mentor had done “a fine job in that cross-

examination” such that it was “clear . . . there was no prejudice.”

             C.    The Jury Verdict

      At the conclusion of the nine-day trial, Mentor moved pursuant to Rule 50(a)

of the Federal Rules of Civil Procedure for judgment as a matter of law. The district

court reserved. The jury then returned a verdict with the following specific findings:

      1. The ObTape implanted in Taylor had a design defect that was a legal cause

         of her injuries.

      2. Mentor failed to provide Taylor’s physician with an adequate warning

         about ObTape prior to her implant surgery, and the failure to provide that

         adequate pre-implant warning was a legal cause of Taylor’s injuries.

      3. Mentor failed to provide Taylor’s physician with an adequate warning

         about ObTape after her implantation surgery, and the failure to provide

         that adequate post-implant warning was a legal cause of the injuries.

      4. Mentor was negligent with respect to the ObTape used in Taylor’s

         implantation surgery, and that negligence was a legal cause of her injuries.

      5. Taylor proved by clear and convincing evidence that punitive damages

         should be awarded against Mentor; that Mentor had a specific intent to

         harm her at the time of Taylor’s injuries and did in fact harm her; and that

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           Mentor was motivated solely by unreasonable financial gain and actually

           knew about both the unreasonable danger of the conduct and the high

           likelihood of injury resulting from the conduct.

      The jury awarded Taylor $400,000 in compensatory and $4 million in punitive

damages.

              D.    Mentor’s Post-Trial Motions

      Following trial, Mentor renewed its motion for judgment as a matter of law

under Rule 50(b) and moved in the alternative for a new trial under Rule 59 or to

amend the judgment to reduce the punitive damage award to no more than $1.2

million.

      The district court issued a thorough opinion in which it denied Mentor’s

motions for judgment as a matter of law and for a new trial but reduced the punitive

damage award to $2 million (and thus the total judgment to $2.4 million) after

concluding that the evidence at trial was insufficient to support the jury’s finding

that Mentor had the requisite “specific intent.”          In re Mentor Corp. ObTape

Transobturator Sling Prods. Liab. Litig., No. 4:08-MD-2004 (CDL), 4:12-cv-176

(Taylor), 2016 WL 6138253 (M.D. Ga. Oct. 20, 2016).

      Mentor and Taylor each appealed. Mentor argues that it is entitled to:

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             (1) Judgment as a matter of law both because the district court (A) erred

                 in failing to strike Dr. Porter’s testimony insofar as it expressed

                 previously undisclosed opinions, and (B) applied an incorrect

                 causation standard to Taylor’s failure to warn claims;

             (2) A new trial because the district court erred in:

                    A. admitting (i) testimony by Dr. El-Ghannam on degradation

                        theory absent evidence of the dose-response relationship, (ii)

                        evidence of vaginal erosion injuries experienced by other

                        women who were implanted with ObTape, (iii) evidence of

                        Mentor’s decision to take ObTape off the market in violation

                        of the district court’s in limine ruling and remedying that

                        violation with a curative instruction, and (iv) evidence of

                        foreign regulatory action related to ObTape, and

                    B. excluding evidence of the Food and Drug Administration’s

                        510(k) clearance of ObTape; and

             (3) An amended judgment eliminating the punitive damage award or

                 reducing it pursuant to Florida statutory limits.

      Taylor argues that the jury verdict of $4 million should be reinstated because

the district court erred in concluding that the evidence offered at trial was insufficient

to support the jury’s finding that Mentor had a specific intent to harm her.

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             II. DISCUSSION

             A.     Motion for Judgment as a Matter of Law

      We review de novo a district court’s ruling on a motion for judgment as a

matter of law, considering the evidence and the reasonable inferences drawn

therefrom in the light most favorable to the non-moving party. Eghnayem v. Boston

Scientific Corp., 873 F.3d 1304, 1313 (11th Cir. 2017) (citing Middlebrooks v.

Hillcrest Foods, Inc., 256 F.3d 1241, 1246 (11th Cir. 2001)). Judgment as a matter

of law is “appropriate only if the evidence is so overwhelmingly in favor of the

moving party that a reasonable jury could not arrive at a contrary verdict.” Id.

(quoting Middlebrooks, 256 F.3d at 1246) (internal quotation marks omitted). A

district court’s evidentiary rulings, however, are reviewed “only for a clear abuse of

discretion” and must be affirmed “unless we find that the district court has made a

clear error of judgment, or has applied the wrong legal standard.” Id. (quoting

United States v. Brannan, 562 F.3d 1300, 1306 (11th Cir. 2009)) (internal quotation

marks omitted).

      Mentor asserts that it is entitled to judgment as a matter of law or,

alternatively, to a new trial because the district court failed to strike Dr. Porter’s

testimony to the extent he offered opinions at trial that had not been disclosed in his

Rule 26 report. Notably, Mentor does not argue that it was entitled to judgment as

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a matter of law if the testimony properly was admitted. Because Mentor’s motion is

based entirely on the district court’s evidentiary ruling, we review for abuse of

discretion. 4

       Mentor’s argument is based on Rule 26 of the Federal Rules of Civil

Procedure, pursuant to which parties are obliged for any expert witness they plan to

call at trial to provide a written report containing, among other things, “a complete

statement of all opinions the witness will express and the basis and reasons for

them.” Fed. R. Civ. P. 26(a)(2)(B)(i). Rule 26 imposes a duty to supplement an

expert report that is “incomplete or incorrect.” Fed. R. Civ. P. 26(e). Mentor argues

that Taylor violated this duty with respect to Dr. Porter because of the

inconsistencies between his trial testimony and his Rule 26 report.

4
 We assume without deciding that Mentor properly preserved its objection to the admission of Dr.
Porter’s testimony. Rule 103(a) of the Federal Rules of Evidence provides:
       “A party may claim error in a ruling to admit . . . evidence only if the error affects a
       substantial right of the party and . . . a party, on the record: (A) timely objects or moves to
       strike; and (B) states the specific ground, unless it was apparent from the context . . . .”
Fed. R. Evid. 103(a); see also United States v. Hawkins, 905 F.2d 1489, 1493 (11th Cir. 1990) (“A
defendant must specifically and timely object at trial to claimed errors.”).
Mentor’s only objections during the course of Dr. Porter’s testimony were with respect to his
testimony that, based on the assumption that the polypropylene degrades, Taylor’s inflammation
was caused by the ObTape. When that question initially was posed to Dr. Porter, Mentor objected
first on the ground that the question was an improper hypothetical and then on the ground that Dr.
Porter was “just taking the assumption to now a medical diagnosis from a materials man.” The
question of a deviation from Dr. Porter’s expert report was not raised until after the direct
examination was completed, when Mentor first moved to strike. While it might be argued that
Mentor waived the point by failing to timely and specifically object, we need not reach this
question because we conclude that the district court did not abuse its discretion in admitting Dr.
Porter’s testimony.

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          We hold that the district court did not abuse its discretion in not striking Dr.

Porter’s testimony.

          As an initial matter, we note that the only true inconsistency between Dr.

Porter’s Rule 26 report and his trial testimony had to do with the “urethral erosion”

issue. Although Dr. Porter expressed doubt about Dr. El-Ghannam’s degradation

theory during his deposition, it was not inconsistent either with Dr. Porter’s Rule 26

report or with his deposition testimony for him to (a) assume that Dr. El-Ghannam’s

theory was valid and then (b) respond to a hypothetical question based on that

assumption. Further, Dr. Porter clearly opined in his Rule 26 report that ObTape

caused or at least contributed to Taylor’s chronic bladder inflammation.              His

deposition testimony on that point was more equivocal, offering a prime opportunity

for impeachment at trial. But Dr. Porter’s trial testimony as to causation was not

inconsistent with his Rule 26 report, which was the basis for Mentor’s motion to

strike.

          As to the urethral erosion issue, we have no doubt that Dr. Porter’s Rule 26

report should have been supplemented prior to trial to flesh out his “evolved”

opinion on that issue. We do not condone Taylor’s conduct in failing to make that

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required disclosure. But striking Dr. Porter’s testimony was not the only viable

response under the circumstances.5

       Rule 37 gives a trial court discretion to decide how best to respond to a

litigant’s failure to make a required disclosure under Rule 26. See Fed. R. Civ. P.

37(c)(1) (stating that “[i]n addition to or instead of [the] sanction [of exclusion]” the

court may: (1) order payment of the expenses caused by the failure, (2) “inform the

jury of the party’s failure,” and (3) “impose other appropriate sanctions”). The

district court’s decision to allow Mentor additional time to prepare for Dr. Porter’s

cross-examination, rather than striking his testimony entirely, was not an abuse of

that discretion.

       An abuse of discretion occurs only when the district court relies on a clearly

erroneous finding of fact or an errant conclusion of law, or improperly applies the

law to the facts. Adams v. Austal U.S.A., LLC, 754 F.3d 1240, 1248 (11th Cir. 2014).

The district judge here correctly stated and properly applied the governing legal

principles. His decision on the motion to strike was based on his factual finding that

5
  We acknowledge our dissenting brother’s concern with the possibility that failing to make the
required disclosure was part of a deliberate strategy to employ “ambush tactics” at trial. In fact,
the dissent goes so far as to say that “Porter’s reversal was almost certainly fraudulent—and
Taylor’s counsel helped to induce it.” Dis. Op. at Part II.B. The district court, however, made no
such finding, and it is not for us so to determine in the first instance. The district court acted well
within the bounds of its discretion by analyzing the specific Rule 26 violation at issue—and to the
extent necessary for its harmlessness analysis, the motivations for such violation—and
determining that exclusion was not warranted in this instance. We do not agree that our failure to
upset the trial judge’s permissible exercise of discretion in this respect “invites the procedural
abuse that [Rule 37(c)(1)] is meant to discourage.”
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the nondisclosure at issue was “harmless” given the additional time Mentor had to

prepare for Dr. Porter’s cross-examination.6 In re Mentor Corp., 2016 WL 6138253,

at *6 n.3. That finding was not clearly erroneous. Again, the only previously

undisclosed part of Dr. Porter’s opinion was his statement that Taylor had a “urethral

erosion” – a term that he clarified in his cross-examination referred to a “thinning”

of her urethral tissues. Any unfair surprise as to that issue was minimal because

“erosion” generally was a topic of extensive pretrial discovery and Dr. Porter

specifically disclosed in his Rule 26 report his belief that ObTape could cause

“erosion of mesh into tissues or organs.” 7 Further, Dr. Porter indicated in his Rule

6
  The district court’s use of the word “prejudice” rather than “harmless” does not warrant a
different result. Mentor points to the district court’s conclusion during trial that because Mentor
had additional time to prepare and then conducted a “Clarence Darrow”-like cross examination of
Dr. Porter, “[i]t was clear . . . there was no prejudice.” Mentor maintains that the district court
applied the wrong legal standard – prejudice rather than harmlessness – and thereby abused its
discretion. This argument is unavailing. As an initial matter, the district court in fact tracked the
language of Rule 37 in its post-trial order, concluding that any failure to disclose by Taylor was
“harmless” given Mentor’s receipt of extra time and effective cross examination. In re Mentor
Corp., 2016 WL 6138253, at *6 n.3. In any event, we do not find that the district court applied
the wrong standard at trial. We have said in the past that the importance of compliance with the
disclosure rules in Rule 26 is grounded in the need “to allow both sides in a case to prepare their
cases adequately and to prevent surprise.” Reese v. Herbert, 527 F.3d 1253, 1266 (11th Cir. 2008)
(internal quotation marks and citations omitted). The district court’s decision to resolve the Rule
26 disclosure issue by giving Mentor additional time to prepare for Dr. Porter’s cross-examination
reflects the court’s intention to protect precisely those interests that Rules 26 and 37 were designed
to protect.
7
  Greater concern perhaps would have been warranted if Dr. Porter’s trial testimony had involved
a new and more elaborate, fleshed-out explanation of reasons why one reasonably could conclude
that ObTape caused Taylor’s bladder injuries. Had it done so, defense counsel would have been
at a much greater disadvantage in cross-examining him.
Nor is the Court persuaded by Mentor’s reliance on Tenbarge v. Ames Taping Tool Systems, Inc.,
190 F.3d 862 (8th Cir. 1999), an Eighth Circuit product liability case in which the Circuit held that
a new trial was warranted after an expert witness for the defense testified to previously undisclosed
opinions on the cause of the plaintiff’s injuries. Id. at 864-65. Even if Tenbarge were binding on
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26 report that Taylor’s medical history showed that her urethra was very thin where

the ObTape had been removed that he had found during his own examination that

Taylor had “an irregular trapezoid shape mesh along the urethra. It feels that the

edges have rolled.” This description was suggestive of an injury to the urethral

tissues posited by Dr. Porter to have been caused by ObTape.

        We conclude that the trial court acted well within the bounds of its discretion

in allowing the jury to consider Dr. Porter’s testimony relating to specific causation.

Mentor was not entitled to judgment as a matter of law.8

this Court, the district court there denied the plaintiff’s request for additional time to further depose
the expert witness. Here, Mentor did not ask for additional time to depose Dr. Porter. Rather, it
asked for an overnight continuance to prepare for cross-examination, and that request was granted.
8
  Mentor argues also that it was entitled to judgment as a matter of law because Taylor failed to
present enough evidence for the jury to conclude that she suffered injuries as a result of Mentor’s
failure to warn either before or after implantation of the increased risks of erosion and infection
associated with ObTape. There is some disagreement between the parties as to whether the verdict
form provided to the jury was a general verdict or a special verdict under Rule 49 of the Federal
Rules of Civil Procedure. Were it necessary to resolve this question, it might warrant close
consideration. See Mason v. Ford Motor Co., Inc., 307 F.3d 1271, 1274-75 (11th Cir. 2002). But
the point is immaterial. The verdict form asked the jury to determine whether each of a design
defect, negligence, or pre- or post-failure to warn was a legal cause of Taylor’s injuries. The form
then asked the jury, in the event that it found that any of the four was a legal cause of Taylor’s
injuries, to determine the appropriate amount of compensatory damages. It follows from our
conclusion that Dr. Porter’s testimony was properly considered by the jury that Mentor is not
entitled to judgment as a matter of law with respect to Taylor’s design defect and negligence
theories of recovery. Accordingly, we need not reach Mentor’s arguments related to recovery
under a failure-to-warn theory. See Stewart & Stevenson Servs., Inc. v. Pickard, 749 F.2d 635,
644-45 (11th Cir. 1984); King v. Ford Motor Co., 597 F.2d 436, 439 (11th Cir. 1979).

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                 B.      Motion for a New Trial

          “‘We review the denial of a motion for a new trial only for an abuse of

discretion.’” Walter Int’l Prods., Inc. v. Salinas, 650 F.3d 1402, 1407 (11th Cir.

2011) (citing St. Luke’s Cataract & Laser Inst., P.A. v. Sanderson, 573 F.3d 1186,

1201 n.16 (11th Cir. 2009)). “Deference ‘“is particularly appropriate where a new

trial is denied and the jury’s verdict is left undisturbed.”’” Id. (quoting St. Luke’s,
573 F.3d at 1201 n.16 (quoting Rosenfield v. Wellington Leisure Prods., Inc., 827
F.2d 1493, 1498 (11th Cir. 1987))).                 A trial court’s decisions regarding the

admissibility and reliability of expert testimony also are reviewed for abuse of

discretion, United States v. Frazier, 387 F.3d 1244, 1258 (11th Cir. 2004) (en banc)

(citing Gen. Elec. Co. v. Joiner, 522 U.S.136, 141-43 (1997)), and will only be

reversed if they are “manifestly erroneous.” Id. (quoting Joiner, 522 U.S. at 142)

(internal quotation marks omitted); see also United States v. Brown, 415 F.3d 1257,

1264-66 (11th Cir. 2005).

          Mentor argues, pursuant to Daubert v. Merrell Dow Pharmaceuticals, Inc.,

509 U.S. 579 (1993), that it is entitled to a new trial because the district court abused

its discretion in admitting the general causation testimony given by Dr. El-

Ghannam.9 It asserts that Dr. El-Ghannam’s testimony on the degradation and

shedding of the ObTape mirrors testimony on substance toxicity and that it therefore

9
    Mentor properly preserved this objection at trial.
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was necessary for Dr. El-Ghannam to address the “dose-response relationship” – that

is, how much of the substance was necessary to create a risk of harm to Taylor.

       Mentor relies entirely on a group of toxic tort cases involving allegedly toxic

drugs and chemicals. In particular, Mentor concentrates its attention on an analogy

to McClain v. Metabolife International, Inc., 401 F.3d 1233 (11th Cir. 2005), a toxic

tort case involving a weight loss supplement called Metabolife 356. In McClain, we

reversed a jury verdict and remanded against Metabolife after concluding that the

district court erroneously had admitted the plaintiffs’ expert testimony on causation.

The plaintiffs there alleged that the supplement, which contained ephedrine and

caffeine, caused them to suffer from heart attacks and strokes. In such cases, given

the “importance of individual responses to toxins,” a plaintiff must demonstrate both

the level of exposure to the allegedly harmful chemical that is hazardous to a human

being and the amount of the chemical to which the plaintiff was exposed. Id. at

1241-42 (citations omitted).10 The evidence at trial was sufficient to find that

ephedrine – and specifically the amount of ephedrine in Metabolife 356 – was found

in hundreds of over-the-counter products then available to the public. In addition,

10
  The rationale behind this methodology is that in the case of a toxic chemical, “[o]ften ‘low dose
exposures – even for many years – will have no consequence at all, since the body is often able to
completely detoxify low doses before they do any damage.’” McClain, 401 F.3d at 1242 (quoting
David L. Eaton, Scientific Judgment & Toxic Torts – A Primer in Toxicology for Judges and
Lawyers, 12 J.L. & POL’Y 1, 13 (2003)). Moreover, “‘for most types of dose-response relationships
following chronic (repeated) exposure, thresholds exist, such that there is some dose below which
even repeated, long-term exposure would not cause an effect in any individual.’” Id. (quoting
Eaton, supra, at 16).
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one of the expert witnesses at trial testified that the effects of the supplement would

“vary from patient to patient” and in fact might not be harmful at all. This evidence

signaled that the dose-response relationship was particularly relevant in the case of

Metabolife 356. Id. at 1241. We therefore concluded that the expert witnesses’

failure to opine on the dose of Metabolife 356 required to injure someone was fatal

in the face of a Daubert challenge. Id. at 1241, 1252.

      The case before us is markedly different. The dose-response relationship is

not implicated here. The logic of McClain therefore is not transferrable to this case.

In McClain, the missing piece – among others – was how much ephedrine and

caffeine were required to start a chain reaction leading to a stroke or heart attack.

That piece was important because there evidently was a level of ephedrine and

caffeine that a person could consume safely. But in this case, Dr. El-Ghannam

testified that all ObTape degrades and that any polypropylene particles it sheds spark

a response by the body’s immune system, which leads to inflammation and erosion.

There was no suggestion that there was a level of degradation that would not cause

those harmful effects.

      We are not persuaded that Dr. El-Ghannam’s testimony about “an incubation

period” warrants a different result. His testimony was not that the ObTape would

not cause inflammation or other harm to the patient during such incubation period.

Rather, he testified that the injuries would take a longer period of time to manifest.

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But it was only a matter of time – a question of when, not whether, the patient would

suffer harm from the ObTape. As he opined, in any patient, “degradation at one

point would cause the infection, the degradation at one point would cause the

erosion, the degradation at one point would cause the failure of the implant.” In this

case, which is focused on the physiological response to a design defect in a medical

device, the dose-response relation is not implicated 11 and there was no abuse of

discretion in admitting the testimony.

       We have considered Mentor’s remaining evidentiary challenges and conclude

that the district court at no point exceeded the bounds of its discretion. Mentor

therefore was not entitled to a new trial.

11
  The only case involving a medical device to which Mentor points is Kilpatrick v. Breg, Inc., 613
F.3d 1329 (11th Cir. 2010). There, we affirmed the district court’s dismissal of negligence and
product liability claims related to the use of a pain pump that had been inserted into the patient’s
shoulder and administered bupivacaine, an anesthetic, intra-articularly. The plaintiff had offered
expert testimony that the use of pain pumps to administer bupivacaine intra-articularly could cause
glenohumeral chondrolysis (a complete breakdown of cartilage in the shoulder joint), id. at 1336,
but the expert based his conclusion on literature that was insufficient to satisfy the reliability
threshold of Daubert. Id. at 1337-41. There we highlighted one study upon which the expert
purportedly had relied, which had examined the connection between the use of intra-articular pain
pumps, bupivacaine, and chondrolysis in rabbit cartilage, and concluded that the study could not
support the expert’s opinion as to causation. We so concluded because the study acknowledged
that no data existed as to the impact of intra-articular administration of bupivacaine on human
cartilage and that the study could not explain the possible differences in dose-response relationship
between rabbits and humans. Id. at 1338-39. Although the pain pump indeed was a medical
device, the need for testimony on the dose-response relationship followed from the plaintiff’s
causation theory that his injuries were caused by a certain method of administering a certain
chemical – not by the physical design of the pain pump itself.

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             C.    Punitive Damages

      Finally, the parties dispute the propriety of the punitive damages awarded in

this case. The jury found that Taylor proved by clear and convincing evidence that

punitive damages should be awarded against Mentor; that at the time of Taylor’s

injuries, Mentor had a specific intent to harm her and did in fact harm her; and that

Mentor was motivated solely by unreasonable financial gain and actually knew

about both the unreasonable danger of the conduct and the high likelihood of injury

resulting from the conduct. It then awarded her $4 million in punitive damages. On

Mentor’s motion, the district court reduced the punitive damages award to $2

million, concluding that the evidence presented at trial was insufficient for the jury

to conclude that Mentor acted with specific intent to harm.

      Mentor argues that the evidence at trial was insufficient to warrant any

punitive damage award and Taylor challenges the district court’s reduction. We

review the propriety of punitive damages de novo. Myers v. Cent. Fla. Invs., Inc.,

592 F.3d 1201, 1212 (11th Cir. 2010).

      Under Florida law, “[a] defendant may be held liable for punitive damages

only if the trier of fact, based on clear and convincing evidence, finds that the

defendant was personally guilty of intentional misconduct or gross negligence.” Fla.

Stat. § 768.72(2). The statute defines the terms as follows:

             “‘Intentional misconduct’ means that the defendant had actual
             knowledge of the wrongfulness of the conduct and the high probability
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             that injury or damage to the claimant would result and, despite that
             knowledge, intentionally pursued that course of conduct, resulting in
             injury or damage. . . .

             “‘Gross negligence’ means that the defendant’s conduct was so reckless
             or wanting in care that it constituted a conscious disregard or
             indifference to the life, safety, or rights of persons exposed to such
             conduct.”

Id. § 768.72(2)(a)-(b).

      Florida imposes also various statutory caps on punitive damages. Punitive

damages may not exceed the greater of three times the amount of compensatory

damages or $500,000, except that (1) punitive damages may not exceed the greater

of four times the amount of compensatory damages or $2 million if “the fact finder

determines that the wrongful conduct proven under this section was motivated solely

by unreasonable financial gain and determines that the unreasonably dangerous

nature of the conduct, together with the high likelihood of injury resulting from the

conduct, was actually known by the managing agent, director, officer, or other

person responsible for making policy decisions on behalf of the defendant” and (2)

there is no cap on punitive damages if “the fact finder determines that at the time of

injury the defendant had a specific intent to harm the claimant and determines that

the defendant’s conduct did in fact harm the claimant.” Id. § 768.73(1).

                    1.    Availability of Punitive Damages

      The district court concluded that Taylor “presented sufficient evidence for a

jury to find, based on clear and convincing evidence, that Mentor was grossly
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negligent with regard to the risks of ObTape – both its porosity and its propensity to

degrade.” In re Mentor Corp., 2016 WL 6138253, at *11. We agree.

       We are not persuaded by Mentor’s argument that the jury improperly

considered “[e]vidence of erosions and infections purportedly experienced by others

through different causal mechanisms” in awarding punitive damages. 12 Mentor

contends that because Taylor suffered from a thinning of her urethral wall, the

evidence at trial pertaining to women who had suffered from vaginal erosion

purportedly because of ObTape’s small pore size could not serve as a proper basis

for punitive damages.

       We conclude that this distinction is immaterial. The evidence at trial was

sufficient for the jury to find that the pores in ObTape were too small to allow

adequate tissue ingrowth, which in turn permitted the implant to move around and

rub against the nearby tissue until that tissue eroded. From Dr. Hyman’s testimony,

it would have been reasonable to conclude that the movement of the ObTape could

have eroded any nearby tissue – whether vaginal or urethral. We agree with the

12
   It is true that the “Constitution’s Due Process Clause forbids a State to use a punitive damages
award to punish a defendant for injury that it inflicts upon nonparties or those whom they directly
represent.” Philip Morris USA v. Williams, 549 U.S. 346, 353 (2007). Nor may a jury “base its
award upon ‘dissimilar’ acts of a defendant.” Id. at 356 (citation omitted); see also State Farm
Mut. Auto. Ins. Co. v. Campbell, 538 U.S. 408, 422-23 (2003). But “[e]vidence of actual harm to
nonparties can help to show that the conduct that harmed the plaintiff also posed a substantial risk
of harm to the general public and so was particularly reprehensible.” Philip Morris USA, 549 U.S.
at 355; see also id. at 357. It is the burden of the district court to prevent “unreasonable and
unnecessary risk” of jury confusion in this regard. Id. at 357.
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district court that the evidence presented at trial permitted a reasonable juror to

conclude that Taylor, who suffered from a thinning of her urethral wall, had “an

erosion-type movement of the ObTape through her bodily tissue, even though it did

not become completely exposed.” In re Mentor Corp., 2016 WL 6138253, at *6.

Accordingly, the evidence permitted the inference that poor tissue ingrowth in fact

caused the thinning of Taylor’s urethral wall and therefore that vaginal erosion and

the thinning of her urethral wall resulted from the same design defect in the porosity

of the ObTape. Accordingly, the district court did not err in admitting evidence of

vaginal erosion experienced by other women who had been implanted with ObTape.

      Having dispensed with Mentor’s evidentiary argument, we see no reason to

disturb the jury’s finding that Mentor’s conduct warranted punitive damages.

Indeed, Mentor does not present any arguments to the contrary. The district court

set forth an extensive overview of evidence in the record that permitted a reasonable

juror to conclude that Mentor (1) did not conduct sufficient product testing,

including tests as to degradation despite it being well known that heat and pressure

cause polypropylene to degrade, (2) knew of the relatively high rate of complications

associated with ObTape but nonetheless concealed or materially understated those

risks, and (3) ignored warnings from both Mentor employees and physicians outside

of the company. Id. at *11-12. We conclude that the record was sufficient to

authorize punitive damages under Florida law.

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                   2.     Unreasonable Financial Gain & Actual Knowledge

      Mentor next argues that punitive damages should have been remitted to $1.2

million (three times the compensatory damage award) because the evidence was

insufficient to show that Mentor’s wrongful conduct was “motivated solely by

unreasonable financial gain” or “that the unreasonably dangerous nature of the

conduct, together with the high likelihood of injury resulting from the conduct, was

actually known” by the relevant decisionmakers at Mentor.

      On appeal, Mentor states that “the district court did not, and cannot, identify

any evidence that the alleged flaws in Mentor’s manufacturing process that

purportedly caused ObTape to degrade were motived purely by unreasonable

financial gain.” But the district court had no opportunity to do so because Mentor

raises the question for the first time on appeal. Before the district court, Mentor

argued only that Taylor had “introduced no evidence at trial that, at the time of her

implant, anyone at Mentor – let alone anyone with policy-making authority – was

aware of any injuries experienced due to alleged flaws in ObTape’s manufacturing

process that cause degradation and polypropylene particle-shedding.”

      “As a general matter, ‘issue[s] not raised in the district court and raised for the

first time in an appeal will not be considered by this [C]ourt.’” Cita Trust Co. AG

v. Fifth Third Bank, 879 F.3d 1151, 1156 (11th Cir. 2018) (quoting Access Now, Inc.

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v. Sw. Airlines Co., 385 F.3d 1324, 1331 (11th Cir. 2004)) (alteration in Cita Trust).13

Accordingly, the point is deemed to have been abandoned. In any event, we note

that after Taylor made this argument in her response brief on appeal, Mentor did not

revisit the question in its reply brief. We take this to be a concession that Mentor

indeed waived the issue of whether Mentor’s conduct was “motived solely by

unreasonable financial gain.”

          On the question of actual knowledge, the district court held that “a jury could

conclude that ObTape had a higher risk of erosion and infection than similar mesh

products due to its physical characteristics, including its porosity” and that “Mentor

executives knew about the risks but decided not to disclose them to anyone so that

Mentor could continue selling ObTape.” In re Mentor Corp., 2016 WL 6138253, at

*13.

13
     We have permitted issues to be raised for the first time on appeal in five circumstances, namely:
          “First, an appellate court will consider an issue not raised in the district court if it involves
          a pure question of law, and if refusal to consider it would result in a miscarriage of justice.
          Second, the rule may be relaxed where the appellant raises an objection to an order which
          he had no opportunity to raise at the district court level. Third, the rule does not bar
          consideration by the appellate court in the first instance where the interest of substantial
          justice is at stake. Fourth, a federal appellate court is justified in resolving an issue not
          passed on below ... where the proper resolution is beyond any doubt. Finally, it may be
          appropriate to consider an issue first raised on appeal if that issue presents significant
          questions of general impact or of great public concern.”
Cita Trust Co. AG, 879 F.3d at 1156 (quoting Access Now, Inc., 385 F.3d at 1332). However,
none of these circumstances apply to this case.

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      To the extent that Mentor again argues that the district court erred by focusing

on irrelevant evidence of vaginal erosion injuries, that point is rejected for the

reasons stated above. Furthermore, the district court’s opinion is supported by the

extensive evidence at trial that Mentor employees and executives knew that ObTape

was associated with serious risks of complications and actively attempted to conceal

or understate those risks. For example, after one of Taylor’s witnesses, Dr. Michel

Cosson, wrote an editorial on the risks associated with ObTape, Mentor decided not

to respond to the article because it assessed that doing so “might trigger . . . another

article from Cosson, with more solid facts, and details of the . . . ObTape’s serious

cases.” Moreover, in August 2005, two Mentor employees wrote a report on

“ObTape Erosion and Infections” in which they detailed the various problems with

ObTape – including its propensity to lead to chronic inflammation, its small pore

size and the consequent risk of increased rates of erosion and infection, and the fact

that it was made out of heat-welded polypropylene – and recommended that Mentor

take ObTape off the market. The chief executive officer of Mentor’s French division

knew about the report, but nonetheless ordered the authors to maintain “full radio

silence.”

      This evidence was sufficient to permit a reasonable juror to conclude that

Mentor executives actually knew that ObTape posed serious risks of injury and

actively decided to withhold that information from the public.

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                    3.    Specific Intent

      The final issue on appeal is whether Mentor had “a specific intent to harm the

claimant,” in which case Florida law would permit uncapped punitive damages. This

is the sole issue on which the district court did not affirm the jury’s findings. Instead,

it concluded that the record was insufficient to support a finding of specific intent

and reduced the punitive award to $2 million pursuant to Fla. Stat. § 768.73(1)(b).

      The district court concluded that there was no evidence at trial that Mentor

had a “specific intent” to harm the women who were implanted with ObTape. With

neither party able to find Florida law interpreting “specific intent to harm the

claimant,” the court looked to a Georgia case, Viau v. Fred Dean, Inc., 418 S.E.2d
604 (Ga. Ct. App. 1992), in which the Georgia Court of Appeals interpreted a

similar, though not identical, “specific intent” provision in Georgia’s punitive

damages statute in the context of a drunk driver who had caused a wreck. The statute

then read, “if it is found that the defendant acted, or failed to act, with the specific

intent to cause harm, there shall be no limitation regarding the amount which may

be awarded as punitive damages.” 1987 Ga. Laws 919 (codified at O.C.G.A. § 51-

12-5.1(f)). The court in Viau relied on the Second Restatement of Torts, which stated

that the word “intent” was used “to denote that the actor desires to cause [the]

consequences of his act, or that he believes that the consequences are substantially

certain to result from it.” Viau, 418 S.E.2d at 608 (quoting Restatement (Second) of

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Torts § 8A (1965)). It concluded that while the drunk driver’s intent to drink and

drive amounted to a “conscious indifference to the consequences of driving while

intoxicated,” it did not establish “a specific intent that his driving while intoxicated

would cause harm.” Id.

      Relying on Viau, the district court here concluded that the evidence was

sufficient for a jury to conclude that Mentor acted with conscious disregard or

indifference to the safety of women receiving ObTape implants, but there was no

evidence to support a finding that Mentor acted with a specific intent that ObTape

would cause harm to the women who were implanted with it. In re Mentor Corp.,

2016 WL 6138253, at *14. Taylor challenges that decision on appeal.

      We assume without deciding that the district court articulated the proper

standard – that is, that a defendant acts with “specific intent to harm” if the defendant

acts “with the purpose of producing that consequence” or “knowing that the

consequence is substantially certain to result.” See Restatement (Third) of Torts:

Phys. & Emot. Harm § 1 (2010) (articulating materially identical definition of

“intent”). We assume also, again without deciding, that the statutory language

“specific intent to harm the claimant” does not limit uncapped awards of punitive

damages to cases in which a defendant knew the identity of the claimant and

intended specifically to harm that claimant. Rather, we assume that the district court

properly evaluated whether the evidence was sufficient to find that Mentor acted

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with specific intent to harm “the women who were implanted with ObTape.” In re

Mentor Corp., 2016 WL 6138253, at *14.14

       Even under this broad interpretation of the statute, however, we conclude that

the evidence at trial was insufficient to support the jury’s finding of specific intent.

       Taylor relies on three pieces of evidence. First, she points to evidence that

“Mentor executives knew the French Ministry of Health conducted a survey of

products and determined ObTape had complication rates five times higher than

similar products.” Second, she highlights evidence that “Mentor ‘certainly knew’

that ObTape was causing an abnormally high number of complications.” Third, she

points to evidence that “Mentor received a report stating: ‘based on the information

explained in detail below, we recommend today that sales of OBTAPETM be stopped’

and recommending discontinuance due to an increase in the frequency and severity

of complications.”

14
   Although we do not reach the question here, we note that the district court’s interpretation is
appealing. One could imagine absurd results from a requirement that a defendant know the precise
identity of the claimant in advance of causing injury. Indeed Section 1 of the Restatement (Third)
of Torts limits tort liability to “situations in which the defendant has knowledge to a substantial
certainty that the conduct will bring about harm to a particular victim, or to someone within a small
class of potential victims within a localized area.” Restatement (Third) of Torts: Phys. & Emot.
Harm § 1 cmt. e (2010); cf. Lawnwood Med. Ctr. Inc. v. Sadow, 43 So. 3d 710, 725-26 (Fla. Dist.
Ct. App. 2010) (describing “specific intent” provision of Florida punitive damages statute as
“eliminat[ing] mathematical proportionality with compensatory damages . . . in cases of
intentionally malicious harmful misconduct” without emphasizing familiarity with specific
claimant). We nevertheless neither endorse the view expressed in the Restatement nor express an
opinion on whether a group of end users of the same defective device would constitute a “small
class of potential victims within a localized area.”

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      We conclude that this evidence was not a sufficient basis for a finding of

“specific intent to harm.” Florida’s punitive damages statute distinguishes between

situations in which “the unreasonably dangerous nature of the conduct, together with

the high likelihood of injury resulting from the conduct, was actually known by the

managing agent, director, officer, or other person responsible for making policy

decisions on behalf of the defendant” and those in which “at the time of injury the

defendant had a specific intent to harm the claimant and determines that the

defendant’s conduct did in fact harm the claimant.” If this distinction is to have any

meaning, the evidence to which Taylor points evinces only a finding that Mentor

knew that there was a high likelihood of injury. To be substantially certain that

someone will be harmed as a result of wrongful conduct requires a belief much closer

to total certainty, in this case, that anyone who used an ObTape would be harmed.

Evidence that Mentor knew of a high incidence of injury does not reach this

threshold. We therefore affirm the district court’s reduction of the punitive damages

award to $2 million.

             III. CONCLUSION

      The judgment appealed from is AFFIRMED.

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JULIE CARNES, Circuit Judge, concurring specially:

       I concur in the decision to uphold the district court’s judgment awarding

plaintiff Teresa Taylor compensatory and punitive damages pursuant to the jury’s

verdict finding Mentor liable to Taylor for injuries she suffered after she was

implanted with ObTape. As to the question that has prompted a dissent—whether

the district court should have struck the testimony of one of plaintiff’s experts, Dr.

Porter—I write separately to discuss the points raised by Judge Tjoflat.

       I share Judge Tjoflat’s chagrin that plaintiff’s counsel failed to alert Mentor

prior to trial that Dr. Porter’s opinion as to the cause of Taylor’s injuries had, since

his deposition, “evolved” in a way that bolstered the doctor’s conclusion that

Mentor’s product had caused Taylor injuries. 1 My dissenting colleague

understandably worries that an affirmance here will send a bad signal that counsel

can get away with failing to alert the opposing side when an expert witness

changes his mind concerning a material matter on which he has been deposed.

       If that were what we were holding, it would also give me pause, but my

reasons for concurring are much narrower and rest on the particular objection made

by defense counsel when it moved to strike. At bottom, I agree with the author of

the majority opinion, Judge Kaplan, that the district court did not abuse its

1
  Albeit part of the evolution was a devolution, as Dr. Porter defaulted back to an opinion
expressed in his expert report.
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discretion when it refused to strike the testimony, but instead granted the

alternative remedy specifically requested by Mentor: an overnight continuance to

prepare its cross-examination of Dr. Porter. Indeed, so close do I find the legal

question to be that the deferential abuse of discretion standard, as applied to the

district court’s granting of a request by defense counsel for alternative relief,

constitutes the tie-breaker for me.

I.    Abuse of Discretion Standard

      As noted in both the majority and dissenting opinions, our review of the

district court’s ruling on Mentor’s motion to strike Dr. Porter’s testimony is

governed by the abuse of discretion standard. See Knight through Kerr v. Miami-

Dade Cty., 856 F.3d 795, 808 (11th Cir. 2017). Deference to the district court is

the hallmark of that standard, which requires us to affirm the denial of Mentor’s

motion to strike unless the ruling is “based on an error of law” or “reflects a clear

error of judgment.” In re Hubbard, 803 F.3d 1298, 1307 (11th Cir. 2015). Indeed,

“our review of evidentiary rulings by trial courts on the admission of expert

testimony is very limited,” McCorvey v. Baxter Healthcare Corp., 298 F.3d 1253,

1257 (11th Cir. 2002) (internal quotation marks omitted) and we must “defer to the

district court’s evidentiary ruling unless that ruling is manifestly erroneous.” Quiet

Tech. DC-8, Inc. v. Hurel-Dubois UK Ltd., 326 F.3d 1333, 1340 (11th Cir. 2003)

(internal quotation marks omitted). See also Michigan Millers Mut. Ins. Corp. v.

                                           37
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Benfield, 140 F.3d 915, 921 (11th Cir. 1998) (“It is very much a matter of

discretion with the trial court whether to permit the introduction of [expert]

evidence, and we will not reverse the decision of the trial court regarding the

exclusion or admission of such evidence unless the trial court’s decision is

manifestly erroneous.” (internal quotation marks omitted)).

      In short, the abuse of discretion standard recognizes that there is a range of

permissible conclusions a district court may reach on an evidentiary issue, and

consequently that “there will be occasions in which we affirm the district court

even though we would have gone the other way had it been our call.” United

States v. Frazier, 387 F.3d 1244, 1259 (11th Cir. 2004).

II.    Rule 37(c)(1)’s Sanctions When A Party Fails to Provide Information
       That Is Required To Be Disclosed in Discovery Pursuant to Rule 26

      Rule 37(c)(1) states that:

      If a party fails to provide information or identify a witness as required by Rule
      26(a) or (e), the party is not allowed to use that information or witness to
      supply evidence . . . at a trial, unless the failure was substantially justified or
      is harmless. In addition to or instead of this sanction, the court, on motion and
      after giving an opportunity to be heard:

             (A)    may order payment of the reasonable expenses, including
                    attorney’s fees, caused by the failure;

             (B)   may inform the jury of the party’s failure; and

             (C)   may impose other appropriate sanctions, including any of the
                   orders listed in Rule 37(b)(2)(A)(i)-(vi).

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Fed. R. Civ. P. 37(c)(1). Rule 26(a)(2) requires the disclosure of the identity of

any expert witness a party may use at trial, accompanied by a written report that

contains “a complete statement of all opinions the witness will express and the

basis and reasons for them.” Fed. R. Civ. P. 26(a)(2). Pursuant to Rule 26(e), and

importantly for this case, the expert’s report and deposition must be supplemented

“in a timely manner” if a party learns the report or deposition “is incomplete or

incorrect.” Fed. R. Civ. P. 26(e).

       The district court concluded that Dr. Porter’s testimony should not be

excluded because the failure to supplement Dr. Porter’s proffered opinions could

be remedied by acceding to Mentor’s request for an overnight continuance to

prepare for Mentor’s cross-examination. 2 That Mentor requested—and received—

this alternative remedy is key to my assessment of its current argument that the

district court erred by not striking the testimony altogether. But I address first the

question whether, absent Taylor’s showing of harmlessness as a result of her

failure to alert Mentor to one of her expert’s “evolution,” the district court was

required to automatically, and without the exercise of any further discretion, strike

the testimony in question.3

2
  Notably, Mentor did not request an opportunity to re-depose Dr. Porter prior to questioning
him before the jury. Mentor likewise did not request a mistrial.
3
   Not all of Dr. Porter’s testimony would necessarily have been subject to exclusion, as much of
it was consistent with his deposition testimony.
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      The dissent reads Rule 37(c)(1) to mandate, as an automatic sanction, the

exclusion of trial evidence that was not earlier disclosed in violation of Rule 26,

absent a showing of harmlessness by, and substantial justification for, the non-

disclosure. The dissent posits that a harmless non-disclosure under Rule 37(c)(1)

must: (1) be a mistake rather than a deliberate or fraudulent attempt to gain a

litigation advantage and (2) involve information that is already known to the

opposing party. Concluding that the non-disclosure here was neither a mistake nor

was it harmless, the dissent would find reversible error in the district court’s failure

to strike the expert’s testimony.

      Rule 37(c)(1) does not define the term harmless, but the Advisory

Committee notes to Rule 37 provide support for the dissent’s extrapolation of these

two elements. The examples of harmless non-disclosures set out in the Advisory

Committee notes all involve an “inadvertent” omission of information that was

available to the opposing party. See Rule 37 advisory committee notes. More

generally, the Advisory Committee notes suggest that the harmlessness exception

is intended to “avoid unduly harsh penalties in a variety of situations.” Id.

      At the same time, though, the text of the rule also offers support for a

conclusion that exclusion is not automatically required, even if the omission is not

harmless. That is, although Rule 37(c)(1) states, in its first sentence, that a party

who fails to provide information as required by 26(e) “is not allowed to use that

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information . . . at a trial, unless the failure was substantially justified or is

harmless,” the next sentence provides: “In addition to or instead of this sanction,

the court” may impose “other appropriate sanctions.” Fed. R. Civ. P. 37(c)(1);

Fed. R. Civ. P. 37(c)(1)(C) (emphasis added). In other words, given that text, one

can also argue that exclusion is not automatically required by the rule.

        In fact, there is a split between the circuit courts on this question. According

to a recent and very thorough district court opinion, three circuits—the Second,

Sixth, and Seventh—have concluded that the absence of substantial justification or

harmlessness does not automatically result in exclusion, whereas four circuits—the

First, Fourth, Eighth, and Ninth— provide for automatic, or near-automatic,

exclusion under the same circumstances. See Pitts v. HP Pelzer Auto. Sys., Inc.,

2019 WL 2448821, at *5 n.7, __ F.R.D. __ (S.D. Ga. June 20, 2019) (Hall, C.J.).4

        Although it picks up on some language from our caselaw that arguably

suggests that exclusion is not automatic even without a showing of harmlessness,

Pitts acknowledges that the Eleventh Circuit has not squarely decided this issue.

Id. at *5. Nor do we do so today. This is so because, although I am concurring in

the affirmance of the district court’s decision not to exclude the expert’s testimony,

I am doing so based on the specific request for relief made by defense counsel for

4
  The Pitts decision also collects district court cases from within this circuit, noting a split not
just between districts, but also within districts. Pitts, 2019 WL 2448821, at *5 n.8.
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Mentor and on what I consider to be a ruling on this request that constituted a

proper exercise of the district court’s discretion.

III.   The District Court Properly Exercised Its Discretion When It Granted
       One of Defendant Mentor’s Two Alternative Requests for Relief

       Whenever one is considering whether a trial court has properly exercised its

discretion, one must look at the circumstances that the court was facing when

called on to make a decision. Here, immediately at the conclusion of Dr. Porter’s

direct examination, defense counsel asked the court to strike the expert’s

testimony, given that some of his testimony consisted of new opinions. Plaintiff’s

counsel responded that Plaintiff had always taken the position that the ObTape

caused inflammation and that Dr. Porter’s testimony was merely an evolution of

that theory based upon the hypothetical given to him at trial based on another

expert’s testimony. Following that response, and without waiting for any

interjection by the court as to its leaning, defense counsel offered:

       If the Court is not going to grant our motion, we would ask for the
       alternative form of relief that we at least be given the night to prepare a
       cross. Getting these new opinions literally on the day of and then
       expecting to cross him on the fly is completely improper. So that’s the
       alternative . . . .

Both counsel then disputed whether Dr. Porter’s trial testimony had contradicted

his deposition testimony, with Plaintiff’s counsel arguing that the expert had

merely responded to a hypothetical question with regard to the degradation issue,

and, as to urethral thinning, the expert’s trial testimony was consistent with his
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overall deposition testimony that, because the expert could provide no other likely

reason for any of Plaintiff’s symptoms, the thinning was also likely caused by the

ObTape.

      At the end of this brief exchange, the district court indicated that it would

not strike the expert’s testimony, but that it would grant defense counsel’s

alternative request for an overnight recess to allow it further preparation before

cross-examining the doctor. So, the question is whether the district court abused

its discretion when it granted Mentor one of the two alternative requests for relief it

made. I say no. The district court was in the middle of a lengthy and complex trial

and not made privy to the legal briefing we have now received about Rule 37,

advisory committee notes, the distinction between the concepts of prejudice and

harmlessness, a sharp circuit split, or the like. Instead, the court was responding to

a litigant who had a beef and who had asked for one of two remedies. The court

awarded that litigant one of its requested remedies.

      Notably, in its contemporaneous objection requesting relief, defense counsel

never argued to the district court that Rule 37 required, as a mandatory sanction,

that the court strike the testimony unless there was a finding of harmlessness. That

defense counsel paired its request to strike with an alternative request for a recess

surely suggested to the district court that striking the testimony was not mandatory.

For defendant Mentor to now suggest that the court erred by not intuiting a

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mandatory obligation to strike—when none was articulated by defense counsel—

asks us to examine the court’s exercise of discretion on facts that were not before

it. Just as it is not sporting to ambush opposing counsel with undisclosed expert

testimony, it is likewise unfair to seed the record with an appellate issue not aired

before the district court at the time that it has been asked to rule.5

        Further, nothing that occurred after the district court granted the recess and

after defense counsel cross-examined Dr. Porter reasonably suggested that the

court should retroactively strike the doctor’s testimony. Mentor had an

opportunity on cross to point out Dr. Porter’s changing opinions. And, as the

district court noted, its cross-examination of the expert was quite effective.

        The dissent notes that granting only an overnight continuance deprived

Mentor of the opportunity to: (1) obtain an amended expert report containing Dr.

Porter’s revised opinions, (2) depose Dr. Porter a second time concerning his

revised opinions, and (3) present rebuttal testimony. But Mentor presented rebuttal

testimony. And, for understandable strategic reasons, it never requested an

amended expert report or a chance to re-depose Dr. Porter. As to a new expert

report, an updated expert report from Dr. Porter would have been identical to his

5
  And counsel for Mentor could have purposely decided not to go for the gusto by pushing hard
on a motion to strike Dr. Porter’s testimony, given that counsel was aware that it would be
calling, as its own expert rebuttal witness, Dr. Klutke, who testified for the first time at trial that
he had experienced bowel perforations with the procedure that was used to implant mesh slings
before ObTape was introduced.
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original report—which is to say, Dr. Porter would have concluded in the updated

report that ObTape likely caused Taylor’s chronic inflammation and other

complications because her symptoms began only after she was implanted with

ObTape and there did not seem to be any other explanation for them.

      And evidently Mentor did not need an updated report to effectively respond

to Dr. Porter’s “evolved” opinions, each of which was rebutted by extensive

testimony from multiple experts. For example, defense expert Dr. Klutke testified

that there was no evidence Taylor had a urethral erosion and that Taylor’s

inflammation, urethral thinning, and other maladies were most likely caused by

Durasphere or the hormonal changes and vaginal atrophy associated with Taylor’s

hysterectomy, not by the ObTape. Defense expert Dr. Juma likewise testified that

Taylor did not have a urethral erosion and that her other symptoms could be

attributed to Durasphere and atrophic vaginitis.

      As for an opportunity to re-depose Mentor, presumably Mentor did not ask

for another deposition because it did not want a second deposition of Dr. Porter.

That decision makes sense from Mentor’s perspective because the original

deposition provided Mentor with the most helpful deposition testimony it could

hope to get from Dr. Porter in terms of disproving causation. A second deposition

would have given Dr. Porter an additional opportunity to clarify and rehabilitate

his testimony. Thus, it is understandable that Mentor chose to rest its defense on

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the existing record, which gave it an opportunity to focus on undermining Dr.

Porter’s credibility by pointing out the inconsistencies between the testimony Dr.

Porter had just given the jury and the testimony Dr. Porter provided in his prior

deposition, as well a chance to confront the doctor with other possible causes of

Taylor’s injuries. As Mentor apparently recognized, its strategy likely would have

been thwarted by conducting a second deposition of Dr. Porter.

IV.   Conclusion

      Like the dissent, I agree that we should not encourage the kind of conduct

exhibited by Taylor’s counsel. And given the particular facts of this case and the

narrow ground on which I concur, I do not believe we have done so. Certainly, the

discussion in the majority, concurring, and dissenting opinions should put all

parties on notice that they act at their own peril when they ignore their duties under

Rule 26 and Rule 37. We leave for another day a more dispositive ruling as to the

circumstances under which a litigant’s violation of Rule 37(c)(1) should result in

automatic exclusion of undisclosed evidence.

      For the above reasons, I concur in the decision to affirm the district court.

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TJOFLAT, Circuit Judge, dissenting:

       Today’s majority opinion contains two serious legal errors. First, it applies

the wrong legal standard to determine whether Dr. Porter’s trial testimony should

have been excluded under Federal Rule of Civil Procedure 37(c)(1). Second, even

assuming the majority’s preferred legal standard, the opinion botches the analysis

in concluding that Taylor’s Rule 26 violation was not prejudicial.

       But the opinion does more than that. By neutering Rule 37(c)(1) and the

“self-executing,”1 “automatic sanction” 2 of exclusion, the majority gives the green

light to Taylor’s “ambush tactics.” See Licciardi v. TIG Ins. Grp., 140 F.3d 357,

359 (1st Cir. 1998). Taylor’s Rule 26 violation wasn’t an honest or harmless

mistake—by convincing Dr. Porter to “evolve” his position on Taylor’s

inflammation and urethral erosion without filing an amended report, Taylor’s

counsel denied Mentor a meaningful opportunity to respond. Whereas Rule

37(c)(1) clearly calls for the exclusion of an expert witness’s testimony in these

circumstances, the majority reads the rule to allow a district court to excuse a

party’s Rule 26 violation so long as the opposing party erases the prejudice

through cross-examination. Because the majority misapplies the applicable law

       1
        Fed. R. Civ. P. 37(c)(1) advisory committee’s note to 1993 amendment [hereinafter
“Rule 37 committee note”].
       2
           Id.
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and, in so doing, stamps its imprimatur on Taylor’s unscrupulous trial tactics, I

respectfully dissent.

                                               I.

                                               A.

       Under Rule 26, a party seeking to call an expert “must disclose” the identity

of the expert and provide a written report that “must contain” not only “a complete

statement of all opinions the witness will express and the basis and reasons for

them,” but also “the facts or data considered by the witness in forming them.” Fed.

R. Civ. P. 26(a)(2)(B)(i)–(ii) (emphases added). If a party does not comply with

this disclosure obligation, Rule 37 says that the witness’s testimony must be

excluded “unless the failure was substantially justified or is harmless.” Fed. R.

Civ. P. 37(c)(1); see also Finley v. Marathon Oil Co., 75 F.3d 1225, 1230 (7th Cir.

1996) (“The sanction of exclusion is thus automatic and mandatory unless the

party to be sanctioned can show that its violation of Rule 26(a) was either justified

or harmless.” (emphases added)). The burden is on the rule-breaking party to show

harmlessness. 3 See Knight through Kerr v. Miami-Dade County, 856 F.3d 795,

812 (11th Cir. 2017) (noting that plaintiffs had “not carried their burden” under

Rule 37(c)(1) of showing substantial justification); Yeti by Molly, Ltd. v. Deckers

       3
          The Court’s opinion in this case does not alter this burden because Judge Carnes’s
special concurrence resolves this case on the narrow ground that the objecting party was granted
the alternative relief it requested.

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Outdoor Corp., 259 F.3d 1101, 1107 (9th Cir. 2001) (“Implicit in Rule 37(c)(1) is

that the burden is on the party facing sanctions to prove harmlessness.”).

      In finding that the “overnight continuance” was sufficient to remedy

Taylor’s Rule 26 violation, the District Court concluded that the violation was

“harmless.” In re Mentor Corp. ObTape Transobturator Sling Prods. Liab. Litig.,

Nos. 4:08-MD-2004 (CDL), 4:12-cv-176 (Taylor), 2016 WL 6138253, at *6 n.3

(M.D. Ga. Oct. 20, 2016) (citation omitted). Despite reciting the correct standard,

the District Court analyzed the violation as if it were determining prejudice rather

than harm. This was reversible error because “[h]armlessness . . . is the key under

Rule 37, not prejudice.” Sommer v. Davis, 317 F.3d 686, 692 (6th Cir. 2003).

      The District Court failed to appreciate the distinction between these two

standards, and on appeal Taylor pooh-poohs it as nothing but word games.

Appellee’s Br. at 29 (“Reversing the District Court because at trial it found ‘no

prejudice’ instead of ‘harmlessness’ would exalt form over substance and require

the use of magic words.”). But the question is not whether the “harm” and

“prejudice” standards are different in a purely semantic sense. The question

instead is whether Rule 37(c)(1)’s specific harm standard differs from ordinary

prejudice analysis. As the advisory committee notes explain, the meaning of harm

in the Rule 37(c)(1) context is different from the meaning of prejudice:

            Limiting the automatic sanction [of exclusion] to violations
      “without substantial justification,” coupled with the exception for
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        violations that are “harmless,” is needed to avoid unduly harsh
        penalties in a variety of situations: e.g., the inadvertent omission from
        a Rule 26(a)(1)(A) disclosure of the name of a potential witness
        known to all parties; the failure to list as a trial witness a person so
        listed by another party; or the lack of knowledge of a pro se litigant of
        the requirement to make disclosures. In the latter situation, however,
        exclusion would be proper if the requirement for disclosure had been
        called to the litigant’s attention by either the court or another party.

Rule 37 committee note (emphases added). The advisory committee’s note

“strongly suggests that ‘harmlessness’ involves an honest mistake on the part of a

party coupled with sufficient knowledge on the part of the other party.” Sommer,
317 F.3d at 692 (citation omitted); see also Gagnon v. Teledyne Princeton, Inc.,

437 F.3d 188, 197 (1st Cir. 2006) (noting that the examples in the advisory

committee note “suggest a fairly limited concept of ‘harmless’”). Put differently,

in order for the automatic sanction of exclusion not to apply to a Rule 26 violation,

two conditions must obtain: (1) the nondisclosure must be a mistake, and (2) the

undisclosed information must already be known to the opposing party or parties. 4

        4
         The advisory committee’s examples illustrate these requirements. Consider the first
two examples: “the inadvertent omission from a Rule 26(a)(1)(A) disclosure of the name of a
potential witness known to all parties; [and] the failure to list as a trial witness a person so listed
by another party.” Rule 37 committee note. In each of these examples, the Rule 26 violation
was an accident, and the opposing party was not harmed because it already knew the omitted
information—the witness was “known to all parties” in the first example and “so listed by
another party” in the second.
        The third example suggests a more lenient standard for pro se litigants insofar as it does
not require that the second condition be satisfied. See Rule 37 committee note (listing “the lack
of knowledge of a pro se litigant of the requirement to make disclosures” as the third example of
harmlessness). But the violation in the third example is still a mistake, and the advisory
committee explains that exclusion should still apply if “the requirement for disclosure had been
called to the [pro se] litigant’s attention.” Id.

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       Taylor’s conduct satisfies neither condition. Dr. Porter’s “evolved” opinion

at trial was not a mistake: it resulted from his “having gone over Taylor’s medical

records ‘with a fine-tooth comb’ and answering some of the questions Taylor’s

attorneys had posed to him after his deposition.” Maj. Op. at 9. Nor could it

possibly have been a surprise to Taylor’s counsel given the considerable price tag

for Dr. Porter’s testimony. And, as I detail at greater length below, the new

information in Porter’s trial testimony was not already known to Mentor. Indeed,

it directly contradicted Dr. Porter’s previous statements—statements on which

Mentor based its defense strategy. The Dr. Porter who appeared at trial was, in

effect, not the Dr. Porter whom Mentor had deposed. He was a brand new expert

witness whose identity Taylor had not disclosed.

                                                      B.

       The majority writes that “Rule 37 gives a trial court discretion to decide how

best to respond to a litigant’s failure to make a required disclosure under Rule 26.”

Maj. Op. at 18. And so it does. Rule 37 says that “[i]n addition to or instead of

[the sanction of exclusion], the court” “may order payment of the reasonable

expenses, including attorney’s fees, caused by the failure,” “may inform the jury of

       Taylor was represented by counsel. By not automatically excluding Dr. Porter’s
testimony, the District Court treated Taylor more leniently than it should treat a pro se litigant
under the rule.

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the party’s failure,” and “may impose other appropriate sanctions.” Fed. R. Civ. P.

37(c)(1). By highlighting this language, the majority implies that even though

Taylor’s Rule 26 violation might not be substantially justified or harmless, the

District Court did not abuse its discretion by ordering a sanction other than

exclusion.

      The advisory committee notes illustrate, however, that the discretion to order

an alternative sanction is reserved for a specific subset of Rule 26 violations. As

the committee explains:

             Preclusion of evidence is not an effective incentive to compel
      disclosure of information that, being supportive of the position of the
      opposing party, might advantageously be concealed by the disclosing
      party. However, the rule provides the court with a wide range of other
      sanctions—such as declaring specified facts to be established,
      preventing contradictory evidence, or, like spoliation of evidence,
      allowing the jury to be informed of the fact of nondisclosure—that,
      though not self-executing, can be imposed when found to be
      warranted after a hearing.

Rule 37 committee note. These alternative sanctions are meant to address Rule 26

violations that the threat of automatic exclusion cannot effectively deter, e.g.,

nondisclosure of unfavorable information. But they are wholly inappropriate in the

mine-run of Rule 26 violations where the threat of exclusion is a sufficient

deterrent. Taylor’s failure to supplement Dr. Porter’s opinion is one such case: the

threat of exclusion, if credible, is enough to incentivize a party to update its

expert’s Rule 26 report. Thus, the District Court should have granted Mentor’s

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motion to strike because it did not have discretion under Rule 37(c)(1) to order an

alternative sanction.

       At bottom, the District Court abused its discretion by misconstruing the

relevant standard under Rule 37(c)(1). See, e.g., Glock v. Glock, Inc., 797 F.3d
1002, 1006 (11th Cir. 2015) (“A district court abuses its discretion if it applies an

incorrect legal standard . . . .” (quoting FTC v. AbbVie Prods. LLC, 713 F.3d 54, 61

(11th Cir. 2013))). Under a proper interpretation of Rule 37(c)(1), Dr. Porter’s

testimony—a deliberate deviation from his expert report that caught Mentor

completely by surprise—was not harmless. Accordingly, Dr. Porter’s testimony

should have been excluded, and Mentor should be entitled to judgment as a matter

of law.

                                                 II.

       But let’s assume that the District Court’s harmlessness-means-prejudice

standard was correct. Even in this scenario, the District Court erred in finding that

Taylor’s Rule 26 violation was harmless (read: not prejudicial) and thus abused its

discretion. See id. (“A district court abuses its discretion if it . . . applies the law in

an unreasonable or incorrect manner . . . .” (quoting AbbVie Prods. LLC, 713 F.3d

at 61)). The District Court’s prejudice analysis also disregarded the second harm

Mentor suffered: the denial of an opportunity to obtain discovery on the

motivations underlying Dr. Porter’s reversal. See infra Parts II.B & II.C.

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                                               A.

       Two aspects of Dr. Porter’s trial testimony flatly contradicted his report and

deposition: 5 his opinion that ObTape caused Taylor’s bladder inflammation, and

his opinion that ObTape caused Taylor’s urethral erosion.

       As to the former, Dr. Porter said in his deposition that ObTape “may

contribute” to Taylor’s inflammation, but then admitted that he “can’t say it’s

caused [by ObTape].” Later in the deposition, he further admitted that “[t]he only

thing that currently we could somewhat relate to her ObTape would be maybe

some of the tenderness on examination along the mesh.” (emphasis added).

Perhaps most damning, when asked whether he could say to a reasonable degree of

medical probability that Taylor’s bladder inflammation was caused by ObTape, Dr.

Porter admitted, “I can’t.” With respect to alternative explanations for Taylor’s

inflammation, Dr. Porter admitted that he couldn’t “tell you if it’s the Aris [a later-

implanted urethral sling] or the ObTape.”

       Fast forward to the trial. Prompted by counsel, Dr. Porter adopted Dr. El-

Ghannam’s degradation theory, which he had previously rejected. He then

       5
         The majority assumes that the inconsistency between Dr. Porter’s trial testimony and his
expert report was the only basis for Mentor’s motion to strike. Maj. Op. at 17. But Mentor’s
motion to strike refers to the contradiction between Porter’s trial testimony and both his report
and his deposition. And, as Rule 26(e)(2) states, “For an expert whose report must be disclosed
under Rule 26(a)(2)(B), the party’s duty to supplement extends both to information included in
the report and to information given during the expert’s deposition.” Fed. R. Civ. P. 26(e)(2)
(emphases added). Inconsistencies between Dr. Porter’s trial testimony and deposition were thus
fair game for Mentor’s motion to strike.

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stated—not in conditional language indicating a hypothetical response, but in

straightforward unconditional language6—“I believe that the ObTape has probably

caused that inflammation. . . . More likely than not.” Dr. Porter also denied, again

in unconditional language, that there was “anything in [Taylor’s] medical history

that . . . could explain the inflammation,” once again flatly contradicting his prior,

unsupplemented testimony.

       But it gets worse. On the topic of urethral erosion—one of the two injuries

from ObTape Taylor asserted—Dr. Porter’s report noted that Taylor’s medical

records “reveal[ed] no erosion of [the] urethra.” Dr. Porter’s story stayed

consistent during his deposition, when he acknowledged that Taylor’s medical

records disclosed no evidence of erosion. Mid-trial, however, Dr. Porter opined

that “to a degree of medical certainty, I feel that ObTape . . . was the cause of the

thinning of the tissue damaging the urethra itself.” Asked whether this

phenomenon could be termed “erosion,” Dr. Porter responded, “This would be

erosion thinning the wall. It would be thinning erosion, exposure of the mesh.”

       6
           The way Dr. Porter responded to the hypothetical almost certainly affected the way the
jury received his testimony. Typically, in response to a question describing an “unreal”
“hypothetical condition,” an answer contains the word “would” to denote the shift in tense.
Conditional, Educ. First, https://www.ef.edu/english-resources/english-grammar/conditional/
(last visited Mar. 20, 2019) [https://perma.cc/ GUW9-U2QR]. So when Taylor’s counsel asked
Dr. Porter to opine whether Taylor’s inflammation was caused by the ObTape based on the
hypothetical assumption that ObTape degrades, Dr. Porter should have said that the ObTape
“would” cause the inflammation if the degradation theory were true. Instead, however, Dr.
Porter simply said, “I believe that the ObTape has probably caused [Taylor’s] inflammation,”
omitting any indication that he was responding to a hypothetical.

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And when Taylor’s counsel stated the question in stronger, more graphic terms—

asking whether ObTape “had eaten away at the urethral wall and made it very

thin”—Dr. Porter responded that it had.

      This was no mere “evolution” in Dr. Porter’s opinion. This was a complete

about-face. Dr. Porter was not the expert Mentor encountered at the pretrial

deposition. He was a new expert, one whose identity Taylor deliberately withheld.

                                          B.

      Now for the harm. Rule 26(e)(2) required Taylor’s counsel to supplement

their discovery “both to information included in [Dr. Porter’s] report and to

information given during [his] deposition,” and that supplementation was required

“by the time [Taylor’s] disclosures under Rule 26(a)(3) [were] due.” Fed. R. Civ.

P. 26(e)(2). Taylor’s nondisclosure deprived Mentor of its right to an amended

report containing Dr. Porter’s “opinions . . . and the basis and reasons for them,”

“the facts or data considered . . . in forming them,” and “any exhibits . . . used to

summarize or support them.” See Fed. R. Civ. P. 26(a)(2)(B)(i)–(iii). Further,

under Rule 26(b)(4), Mentor could depose Dr. Porter “only after” his report was

provided. Thus, not only was Mentor entitled to a new report, but Mentor was also

entitled to an opportunity to redepose Dr. Porter and to obtain evidence to rebut Dr.

Porter’s new opinions, such as the testimony of an expert witness.

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       But that’s only what Mentor was entitled to concerning the subjects of

urethral erosion and inflammation. In these circumstances, Mentor was also

entitled to probe the reasons for Porter’s last-minute reversal. Rule 26(b)(4)(C)

allows a party to depose the opposing party’s expert regarding communications

between the expert and the opposing party to the extent the communications

               (i) relate to compensation for the expert’s study or testimony;

              (ii) identify facts or data that the party’s attorney provided and
       that the expert considered in forming the opinions to be expressed; or

              (iii) identify assumptions that the party’s attorney provided and
       that the expert relied on in forming the opinions to be expressed.

Fed. R. Civ. P. 26(b)(4)(C)(i)–(iii). Here, however, Mentor was entitled to even

more. Because Porter’s reversal was almost certainly fraudulent 7—and because

Taylor’s counsel induced it, a fact that they weren’t particularly shy about 8—

Mentor was entitled to communications that Rule 26(b)(4) would normally

protect.9 That means that Mentor was entitled to the communications between

       7
          Taylor’s presentation of Dr. Porter’s reversal was fraudulent for the following reason:
Taylor knew that Mentor was expecting to counter the opinions Dr. Porter disclosed in his report
and deposition. In not disclosing Porter’s new opinions, Taylor induced Mentor into relying to
its detriment on the fact that Porter would adhere to the opinions he gave in his report and on
deposition. The non-disclosure was fraudulent because it constituted a false statement that Dr.
Porter’s opinions had not changed and was made with the intent that Mentor rely on the false
representation.
       8
        On direct examination of Dr. Porter, Taylor’s counsel explained that, once the case was
scheduled for trial, counsel requested that Dr. Porter thoroughly review the records and answer
some of counsel’s questions.
       9
        Communications between expert witnesses and counsel are typically protected from
discovery. See Fed. R. Civ. P. 26(b)(4)(C) advisory committee’s note to 2010 amendment
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Taylor’s counsel and Dr. Porter regarding the nature of counsel’s request that Dr.

Porter go over Taylor’s records with “a fine-tooth comb,” as well as the “questions

[counsel] had” about those records.

       Of course, Mentor was never given this discovery. Instead, the District

Court granted an “overnight continuance”—after a full day of proceedings—so

that Mentor could prepare its cross-examination of Dr. Porter. The majority argues

that this continuance was enough to ameliorate Mentor’s harm. Maj. Op. at 18–20.

But even assuming that’s true with respect to the harm caused by Dr. Porter’s new

testimony, the continuance certainly wasn’t enough to address the harm Mentor

suffered by being denied the communications between Taylor’s counsel and Dr.

Porter. Instead, Mentor was left to cross-examine Dr. Porter about his reversal at

its own peril. And Mentor did so completely blind: because it was not afforded

time to seek new discovery or even to depose Dr. Porter on his change of heart,

(“Rule 26(b)(4) is amended to provide work-product protection against discovery regarding draft
expert disclosures or reports and—with three specific exceptions—communications between
expert witnesses and counsel.”). But these protections are relaxed when the communications
pertain to fraud. See Drummond Co. v. Conrad & Scherer, LLP, 885 F.3d 1324, 1335 (11th Cir.
2018) (“The crime-fraud exception allows a party . . . to obtain discovery that otherwise would
be protected by the attorney-client privilege or the attorney work product doctrine.”).
        I am convinced that Mentor could make out a showing of fraud on the Court, that is, a
showing of “an unconscionable plan or scheme which is designed to improperly influence the
court in its decision.” See Rozier v. Ford Motor Co., 573 F.2d 1332, 1338 (5th Cir. 1978)
(citation omitted); see also Bonner v. City of Prichard, 661 F.2d 1206, 1209 (11th Cir. 1981) (en
banc) (adopting as precedent all decisions of the former Fifth Circuit prior to October 1, 1981).

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whatever Dr. Porter said in response to Mentor’s cross-examination was the final

word.

                                              C.

        The District Court held that Dr. Porter’s completely new trial testimony did

not prejudice Mentor because Mentor’s counsel “did a fine job” cross-examining

Dr. Porter.10 And on appeal, the majority concludes that Mentor was not

prejudiced by Taylor’s Rule 26 violation because the subject of Dr. Porter’s

testimony—urethral erosion—“generally was a topic of extensive pretrial

discovery” that Dr. Porter had addressed in his Rule 26 report. Maj. Op. at 19. I

explained above how that’s simply not the case: Dr. Porter’s testimony at trial was

a 180-degree reversal from his Rule 26 report and deposition. Let’s not pretend

that Dr. Porter’s U-turn was anything less.

        Moreover, as I explained above, Mentor was harmed not only by denial of

discovery concerning Dr. Porter’s new opinions, but also by the denial of

discovery concerning how those new opinions were formed and an opportunity to

prepare a rebuttal. Mentor was thus left to cross-examine Dr. Porter completely in

the dark. The District Court did not factor this into its harm analysis, and the

        10
         In so holding, the District Court impermissibly shifted the burden of showing
harmlessness from Taylor, the rule-breaking party, to Mentor, the victim. See Knight through
Kerr, 856 F.3d at 812; Yeti by Molly, 259 F.3d at 1107.

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majority similarly excludes it from consideration. But in holding that Taylor’s

Rule 26 violation was harmless, the District Court necessarily had to conclude that

the outcome would not have been different if Mentor had been given the discovery

it was entitled to.

       This, I submit, is an impossible conclusion to reach because we simply

cannot assess in the abstract whether the error—i.e., Taylor’s Rule 26 violation—

was prejudicial. To be sure, we can and do assess most trial errors for harm in this

way. But where an error “affects the framework within which the trial proceeds,”

the error is structural and “defies analysis by harmless error standards.” Weaver v.

Massachusetts, 582 U.S. __, __, 137 S. Ct. 1899, 1907–08 (2017) (alterations

omitted) (citation omitted). Taylor’s Rule 26 violation, which denied Mentor

discovery it was entitled to under the Federal Rules of Civil Procedure,

fundamentally altered “the framework within which the trial proceed[ed].” See id.

(citation omitted).

       As the Supreme Court recently explained in Weaver v. Massachusetts, an

error is structural if the “effects of the error are simply too hard to measure.” See

id. A classic example of this kind of structural error is denial of the Sixth

Amendment right to counsel of one’s choice. Because the “effect of the violation

cannot be ascertained” 11 given the manifold ways one lawyer’s performance might

       11
            Id. at 1908 (citation omitted).

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differ from another’s, the error is deemed structural and removed from harmless-

error analysis. This is true regardless of whether the alternative counsel retained

was effective, or whether the denial caused prejudice to the defendant. United

States v. Gonzalez-Lopez, 548 U.S. 140, 148, 126 S. Ct. 2557, 2563 (2006).

       Although Mentor’s rights to a new report and to depose Dr. Porter are not as

weighty as those protected by the Sixth Amendment, the conclusion is the same.

Because it is simply impossible to measure prejudice, the error must be removed

from traditional harmless-error analysis.12

       To illustrate the point, consider the series of mental hoops a court would

need to jump through to determine prejudice in this case. First, the court would

have to determine how Mentor would have responded to a timely filed, updated

report. Would Mentor have redeposed Dr. Porter? Lined up a rebuttal witness?

Filed a new Daubert motion? All three? Second, the court would have to consider

how Mentor’s hypothetical response would affect Taylor’s burden to prove

specific causation. This would be a truly herculean feat of mental gymnastics.

The court would have to consider not only the merits of Mentor’s hypothetical

responses, but also how those responses would affect the jury’s receptiveness to

Dr. Porter’s testimony.

       12
          It is perhaps for this reason that the advisory committee sought to apply a more
categorical, Rule 37(c)(1)-specific harm standard. See supra Part I.A.

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       And then, of course, the court would have to repeat this analysis with respect

to the communications between Taylor’s counsel and Dr. Porter that Mentor was

entitled to. How would Mentor have responded? What would Mentor have

uncovered? How would Mentor’s response have affected the jury’s perception of

Dr. Porter’s credibility?

       Suffice it to say, a court could not perform this analysis with any reasonable

degree of certainty. And no court should have to, because this error was

structural.13

                                                     III.

       The consequences of the majority’s opinion stretch far beyond the

immediate and substantial harm to Mentor. By endorsing the District Court’s

decision, the majority effectively rewrites Rule 37(c)(1) and invites the procedural

abuse that the rule is meant to discourage. If Taylor’s egregious Rule 26 violation

doesn’t deserve the automatic sanction of exclusion, what does?

       13
          Admittedly, structural error typically arises in appellate review of criminal convictions.
But the Supreme Court has not limited structural error to the criminal context. And other courts,
including two of our sister circuits, have found structural error in civil suits. See M.L. v. Fed.
Way Sch. Dist., 394 F.3d 634, 648 (9th Cir. 2005); Dilley v. Alexander, 603 F.2d 914, 923–24
(D.C. Cir. 1979); Doyle v. United States, 599 F.2d 984, 995–96 (Ct. Cl. 1979), amended on other
grounds sub nom. In re Doyle, 609 F.2d 990 (Ct. Cl. 1979).
        Notably, in each of these cases the error was the denial of a statutory, rather than
constitutional, right. Here, we have a right created by the Federal Rules of Civil Procedure,
which is equivalent to a statutory right given that the Federal Rules are approved by Congress
under the Rules Enabling Act. See 28 U.S.C. § 2072.

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       From now on, a party dissatisfied with its expert’s deposition or report will

be incentivized to engage in the following tactic. Counsel will first have a

conversation with the expert encouraging him to reexamine the basis for his

opinion; this, counsel hopes, will lead to the expert’s “evolved” understanding of

the point at issue. But counsel won’t then supplement the expert’s report, as

mandated by Rule 26(e)(2). Why would he? If exclusion under Rule 37(c)(1) no

longer serves as a credible threat, counsel would be much better off ambushing

opposing counsel at trial. Why? Because few judges—especially in cases as

difficult and protracted as this—will order a true continuance to allow the expert to

be redeposed. And now that automatic exclusion is off the table for even the most

egregious Rule 26 violations, the victimized party’s only recourse will be cross-

examination in which the victimized party will be saddled with the burden of

proving harmlessness.

       Does this sound familiar? It should. And now that this behavior has

received the majority’s seal of approval, I fear that this is not the last we’ll see of

this trick.

       And it’s not just procedural abuse that the majority’s opinion encourages.

By condoning the admission of expert testimony at trial even when it deviates

dramatically from the expert’s pretrial report and deposition, the majority

inadvertently welcomes junk science into the courthouse.

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       Here’s why. In cases involving highly technical subject matter, counsel

invariably retain expert witnesses. And in those cases, opposing counsel invariably

move for a Daubert hearing—or at least they should. See City of Tuscaloosa v.

Harcros Chems., Inc., 158 F.3d 548, 564 n.21 (11th Cir. 1998) (recognizing that

Daubert hearings, while not “required by law or by rules of procedure, . . . are

almost always fruitful uses of the court’s time and resources in complicated

cases”). Even if neither party moves for a Daubert hearing, the district court still

has the duty to act as a gatekeeper to “ensure that any and all scientific testimony

or evidence admitted is not only relevant, but reliable.” Daubert v. Merrell Dow

Pharms., Inc., 509 U.S. 579, 589, 113 S. Ct. 2786, 2795 (1993). But when an

expert witness changes his theory from one in his report to another at trial, he is

effectively able to bypass this gatekeeping function. For the same reasons that a

district court in these circumstances would likely not order a true continuance, the

district court would be even less inclined to pause the trial to hold a Daubert

hearing. As a result, counsel can introduce new theories at trial—even when that

move is deliberate and intended to mislead the opposing party, because apparently

intent no longer matters 14—that would not have passed evidentiary muster at an

earlier stage.

                                                IV.

       14
            See supra Part I.A; Maj. Op. at 17–18.

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      As the world becomes increasingly complex, so too do the disputes that find

their way into the federal courts. Amid this complexity, the role of expert

witnesses—people we rely on to explain complicated and technical subjects—

becomes more critical. In this case, for example, the only evidence of specific

causation was an expert’s testimony. Without it, Taylor stood no chance of

prevailing. And without experts, it would simply be impossible for lay juries to

understand the nature of an increasingly large fraction of the disputes the bar

litigates today.

      It is precisely because expert witnesses are so critical that we must insist on

full, timely disclosure of their opinions. The drafters of Rule 26 understood this.

In adding an expert-witness disclosure requirement to Rule 26, the drafters hoped

to give parties a “reasonable opportunity to prepare for effective cross examination

and perhaps arrange for expert testimony from [their own] witnesses” by requiring

disclosure of testimony “sufficiently in advance of trial.” Fed. R. Civ. P. 26(a)(2)

advisory committee’s note to 1993 amendment. And—lest unwitting parties be

ambushed by an expert’s later “evolved” opinion—the drafters included a

continuing obligation to supplement an expert’s testimony along with the party’s

pretrial disclosures. Perhaps most important, the drafters gave this obligation teeth

by providing for exclusion of expert testimony when an expert’s untimely change

of opinion is not harmless or substantially justified. This regime—the pretrial

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disclosure requirements, duty to supplement, and serious penalties for failure to

follow the rules—“is consonant with the federal courts’ desire to ‘make a trial less

a game of blindman’s buff and more a fair contest with the basic issues and facts

disclosed to the fullest practical extent.’” Thibeault v. Square D Co., 960 F.2d
239, 244 (1st Cir. 1992) (quoting United States v. Proctor & Gamble Co., 356 U.S.
677, 682, 78 S. Ct. 983, 986–87 (1958)).

      Today’s majority opinion seriously weakens this regime.

      Today’s majority opinion also flies in the face of over 80 years of federal

discovery practice. “The purpose of our modern discovery procedure is to narrow

the issues, to eliminate surprise, and to achieve substantial justice.” Greyhound

Lines, Inc. v. Miller, 402 F.2d 134, 143 (8th Cir. 1968) (emphasis added). As the

Second Circuit put it, “The basic purpose of the federal rules, particularly those

concerning discovery and disclosure, is to eliminate trial by ambush . . . .” Ginns

v. Towle, 361 F.2d 798, 801 (2d Cir. 1966) (emphasis added). In contrast with the

pre-Federal Rules practice of discovery—where “fact-revelation w[as] performed

primarily and inadequately by the pleadings” and “[i]nquiry into the issues and the

facts before trial was narrowly confined and . . . often cumbersome in method” 15—

the new Federal Rules were designed to hone the legal and factual issues and to

      15
           Hickman v. Taylor, 329 U.S. 495, 500–01, 67 S. Ct. 385, 388 (1947).

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prevent surprise. As the Supreme Court explained just nine years after the Rules’

adoption:

      The new rules, [in contrast to the prior federal practice], restrict the
      pleadings to the task of general notice-giving and invest the
      deposition-discovery process with a vital role in the preparation for
      trial. The various instruments of discovery now serve (1) as a device .
      . . to narrow and clarify the basic issues between the parties, and (2) as
      a device for ascertaining the facts, or information as to the existence
      or whereabouts of facts, relative to those issues. Thus[,] civil trials in
      the federal courts no longer need be carried on in the dark. The way is
      now clear . . . for the parties to obtain the fullest possible knowledge
      of the issues and facts before trial.

Hickman v. Taylor, 329 U.S. 495, 501, 67 S. Ct. 386, 388–89 (1947).

Mentor did all that it could to “ascertain[] the facts” of this case. It did all

that it could to “obtain the fullest possible knowledge of the issues and facts

before trial.” It did everything it could to play by the discovery rules. And

yet, Mentor was ultimately left “in the dark” by Taylor’s counsel, by the

District Court, and now—regrettably—by this Court.

                              *             *              *

      In closing, to understand just how significantly Mentor has been wronged

today, consider what we would do if this case were criminal rather than civil.

Under Federal Rule of Criminal Procedure 16(a)(1)(G), the government has a duty

to “give to the defendant a written summary of any [expert] testimony that the

government intends to use.” Fed. R. Crim. P. 16(a)(1)(G). The government’s

summary must include the expert witness’s “opinions, the bases and reasons for
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those opinions, and the witness’s qualifications.” Id. As with the Civil Rules, the

government has the continuing duty to inform the defendant of changes to the

expert’s opinion. Id. 16(c). And, like Civil Rule 37(c), Criminal Rule 16

empowers the district court to “prohibit [a non-compliant] party from introducing

the undisclosed evidence.” Id. 16(d)(2)(C).

      Now imagine this were a criminal trial. The government identifies Dr.

Porter as an expert witness. Mentor obtains Dr. Porter’s summary, deposes Dr.

Porter and—based on the information obtained—builds its defense. All seems to

go as planned until, mid-trial, Dr. Porter changes his tune in a way that prejudices

Mentor. Moreover, the circumstances of the reversal indicate that the government

induced Dr. Porter to change his opinion. Mentor moves for a mistrial citing the

prejudicial and deliberate Rule 16 violation. The district judge denies Mentor’s

motion, and Mentor appeals. Now the case is before our Court. What result?

      Reversal. See United States v. Chastain, 198 F.3d 1338, 1348 (11th Cir.

1999) (“[W]here it is apparent . . . that the defense strategy may have been

determined by the failure to disclose, there should be a new trial.” (citation

omitted) (second and third alterations omitted)). Reversal, and perhaps—because

of the violation’s deliberateness—a citation of criminal contempt for the

prosecution. But over on the civil side—with the same degree of prejudice and the

same degree of deliberateness—we inadvertently reward this behavior.

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       Why is that? Why do we tolerate in a civil case the same kind of behavior

that would require reversal in a criminal case? It seems that we have two standards

of ethics and professionalism—one for criminal cases, and another, significantly

more lenient standard for civil cases. Lawyers do without a hint of shame in a civil

case what they would never think to do in a criminal one. This bifurcated sense of

what ethics and professionalism require of the bar is sadly nothing new. But what

is new—and what is made worse by today’s majority opinion—is the extent to

which we will let civil lawyers get away with behavior that would be unthinkable

in a criminal trial.

       Respectfully, I dissent.

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