Court Opinion

ID: 1068778
Source: CourtListenerOpinion
Date Created: 2013-10-09 19:31:16.755047+00
Date Added: 2024-06-11T15:41:08.348621
License: Public Domain

IN THE COURT OF APPEALS OF TENNESSEE
                              AT JACKSON
                                 September 17, 2002 Session

       PATSY MITCHELL, ET UX. v. DR. JAMES ENSOR, M.D., ET AL.

                 A Direct Appeal from the Circuit Court for Shelby County
                  No. 98798 T.D. The Honorable D'Army Bailey, Judge

                  No. W2001-01683-COA-R3-CV - Filed November 18, 2002

        Patient brought medical malpractice action against physician and medical group, including
allegations that physician failed to obtain the informed consent of female patient prior to
administration of a testosterone injection. The circuit court entered judgment on a jury verdict in
favor of physician and medical group. Patient appealed. We affirm and remand.

   Tenn. R. App. P. 3; Appeal as of Right; Judgment of the Circuit Court Affirmed and
                                       Remanded

W. FRANK CRAWFORD , P.J., W.S., delivered the opinion of the court, in which ALAN E. HIGHERS,
J. and DAVID R. FARMER , J., joined.

Robert A. McLean, Memphis, For Appellants, Patsy and Steve Mitchell

Albert C. Harvey, Elizabeth T. Collins, Memphis, For Appellees, Dr. James Ensor, M.D. and
Memphis Internal Medicine, P.L.L.C.

                                            OPINION

        Plaintiffs’ complaint alleges that Dr. James Ensor, M.D., and his employer, Memphis Internal
Medicine, committed medical malpractice when Dr. Ensor negligently presented and administered
a 2cc injection of Depo-Testosterone for the treatment of plaintiff’s diminished libido and failed to
obtain informed consent prior to administering the injection. Depo-Testosterone is a male hormone
traditionally “indicated for replacement therapy in the male in conditions associated with symptoms
of deficiency or absence of endogenous testosterone.” Quoting from the complaint, plaintiff
specifically averred the following:

                      13. The Defendant James K. Ensor, M.D., engaged in a
               course of conduct that was inconsistent with and deviated from that
               degree of care and skill, and to failed [sic] possess that degree of
               knowledge, as ordinarily exercised and possessed by physicians
engaged in the practice of internal medicine in Memphis, Shelby
County, Tennessee and similar communities engaged in the
administration of hormone replacement therapy by failing to follow
appropriate and accepted procedure for post-menopausal hormone
replacement therapy in the following respects:

(a) by undertaking to administer post-menopausal hormone therapy
when he was not qualified to do so and by failing to refer the Plaintiff
Patsy Mitchell to a physician who was so qualified;

(b) by not requesting or performing any diagnostic tests or screenings
prior to the administration of testosterone therapy, including but not
limited to a blood test to determine the Plaintiff Patsy Mitchell’s
serum androgen level;

(c) by engaging in course of treatment which he knew or should have
known would be harmful to the Plaintiff Patsy Mitchell;

(d) by ordering an excessive dosage of Depo-Testosterone under the
circumstances;

(e) by failing to adhere to the manufacturer’s guidelines in
administering Depo-Testosterone to the Plaintiff Patsy Mitchell;

(f) by administering Depo-Testosterone to the Plaintiff Patsy Mitchell
when the use of Depo-Testosterone has not been approved by the
United States Food and Drug Administration under such
circumstances;

(g) by failing to counsel the Plaintiff Patsy Mitchell on the risks and
benefits of, and alternatives to hormone replacement therapy.

                *                       *                       *

The Defendant James K. Ensor, M.D., failed to exercise that degree
of care and skill, and to possess that degree of knowledge, as
ordinarily exercised and possessed by physicians engaged in the
practice of internal medicine in Memphis, Shelby County, Tennessee
and similar communities by failing to reasonably inform the Plaintiff
Patsy Mitchell of the serious nature of hormone replacement therapy
and of the risks of virility, including hirsutism and clitoromegaly, that
could result from the administration of male sex hormones such as
Depo-Testosterone to a female patient.

                                  -2-
                                     *                            *                           *

                  As a direct and proximate result of the Defendants’ negligence and/or
                  recklessness in administering Depo-Testosterone to the Plaintiff Patsy
                  Mitchell, the Plaintiff Patsy Mitchell has suffered and will in the
                  future continue to suffer signs of virility, including but not limited to
                  permanent disfigurement, hirsutism, clitoromegaly, and painful
                  intercourse, and psychological injuries, which would not have
                  otherwise have occurred in the absence of Defendants’ negligence.

        In their answer to this complaint, Dr. Ensor and Memphis Internal Medical admitted treating
Mrs. Mitchell’s developing asexual disposition with a 2cc intramuscular injection of Depo-
Testosterone. Defendants denied any negligent act or omission in the care of Mrs. Mitchell, instead
asserting that “they acted according to their best medical judgment and in conformity with the
applicable standard of care.” Defendants admitted a discussion with Mrs. Mitchell regarding her
diminished libido, and maintained that Dr. Ensor “discussed the use of Depo-Testosterone”with Mrs.
Mitchell prior to ordering administration of the injection.

        Plaintiff Patsy Mitchell is a middle-aged woman of limited education with a storied history
of medical and physical ailments. The following facts are uncontroverted. Mrs. Mitchell first sought
treatment from Dr. Ensor in 1995.1 Over the course of roughly four years, Dr. Ensor acted as Mrs.
Mitchell’s primary caregiver, treating her for numerous medical complaints, including gout,
osteoarthritis, chronic bronchitis, hypertension, chronic sinus, high cholesterol, and irritable bowel
syndrome. Mrs. Mitchell’s medical records indicate that Dr. Ensor, and several treating physicians
prior to him, administered hormone therapy to Mrs. Mitchell for complications potentially related
to patient’s menopausal condition. These records also reveal that Mrs. Mitchell suffered adverse
reactions to several of the hormone treatments.

        On January 5, 1998, Mrs. Mitchell visited Dr. Ensor for treatment of a bloated abdomen.2
At the time of the visit, Dr. Ensor was practicing with Memphis Internal Medicine. Mrs. Mitchell
was accompanied by her husband, plaintiff Steve Mitchell. During the visit, Dr. Ensor examined
Mrs. Mitchell’s stomach for the purpose of evaluating the patient’s complaints of stomach bloating.
From his examination, Dr. Ensor determined that further tests were necessary and thereby scheduled
Mrs. Mitchell for a barium enema and colon study.

        The parties fiercely dispute the nature of the events or conversations immediately preceding
the injection. According to Mr. Mitchell’s testimony, after the examination, he approached Dr.
Ensor with a written list of Mrs. Mitchell’s health complaints. Mr. Mitchell’s involvement in

         1
          At the time of M rs. Mitchell’s initial 1995 visit, Dr. Ensor was employed as an internal medicine physician
with Peabody Health Care.

         2
           Plaintiff Patsy Mitchell testified on direct examination that she also sought treatment for chest pains from Dr.
Enso r on he r January 5 visit. How ever, p laintiffs’ complaint does not identify chest pains as a reason for this visit.

                                                           -3-
keeping a current list of Mrs. Mitchell’s medical complaints was a common practice of the plaintiff
couple. At the bottom of the list, Mr. Mitchell had scribbled the word “sex.”3 Mr. Mitchell pointed
to the word and asked Dr. Ensor “Can you give her something for this?” Dr. Ensor indicated to Mr.
Mitchell that he could do something to help with this concern. Soon thereafter, Lynn Dunlap, R.N.,
entered the room and administered an injection of Depo-Testosterone to Mrs. Mitchell. Mr. Mitchell
testified that Dr. Ensor failed to discuss the purpose or contents of the injection with either plaintiff.
Most significantly, plaintiffs allege that Dr. Ensor failed to notify Mrs. Mitchell of the known side
effects of Depo-Testosterone, specifically clitoromegaly.

        In his deposition and direct testimony, Dr. Ensor paints a distinctly different portrait of the
events leading up to the injection. Dr. Ensor testified that after his examination of Mrs. Mitchell,
he was approached by Mr. Mitchell. While standing in the entryway to the examining room, Mr.
Mitchell pointed to the “sex” reference scribbled on the card. Dr. Ensor testified that Mr. Mitchell
expressed concern with regard to his wife’s developing asexuality, and asked if there was anything
Dr. Ensor could do about this condition. Before agreeing to treat Mrs. Mitchell’s diminished libido,
Dr. Ensor testified that he asked Mrs. Mitchell, “Do you know what he’s talking about,” in reference
to his conversation with her husband. According to his testimony, Dr. Ensor believed that Mrs.
Mitchell was aware of the nature of her husband’s concern because she was close enough to overhear
the conversation. Dr. Ensor’s account of the pre-injection conversation is supported by a statement
in plaintiffs’ Complaint that reads:

                   On or about January 5, 1998, the Defendant James K. Ensor, M.D.,
                   asked the Plaintiff Patsy Mitchell how her hormones were ‘doing,’ to
                   which she responded that she was experiencing a diminished libido.
                   Thereafter, the Defendant James K. Ensor, M.D., told her that he
                   would get her something for the problem.

Dr. Ensor further asserts, and plaintiffs dispute, that he explicitly informed Mrs. Mitchell of her
husband’s concern regarding her developing asexuality.

        In his testimony, Dr. Ensor noted that Mrs. Mitchell nodded acknowledgment of her
understanding of Mr. Mitchell’s concern. Dr. Ensor admitted in his deposition that he did not warn
Mrs. Mitchell about all conceivable side effects of Depo-Testosterone, instead advising his patient
only with regard to the possible onset of pedal edema (swelling of the foot), gradual hair loss, and
acne breakout. The record indicates that Dr. Ensor did not warn Mrs. Mitchell about clitoromegaly
as a possible side effect of Depo-Testosterone.

      The evidence is clear that Dr. Ensor, in response to Mr. Mitchell’s request, ordered nurse
Dunlap to administer a 2cc (400mg.) injection of Depo-Testosterone to Mrs. Mitchell. For

         3
            Plaintiff Steve Mitchell testified on cross examination that he never showed the paper to his wife and that she
was unaware of the fact that he intended to complain about her diminished libido to Dr. Enso r. In fact, M r. Mitchell
testified that he intentionally hid his complaint from his wife.

                                                           -4-
approximately one month following the shot, Mrs. Mitchell suffered no adverse side effects to the
Depo-Testosterone. Plaintiffs’ first became aware of Mrs. Mitchell’s alleged negative reaction to
the drug in February of 1998. While engaged in intimate relations with her husband, Mrs. Mitchell
felt a “stinging” sensation in her clitoris. She asked Mr. Mitchell to look at what was causing her
discomfort. At his wife’s urging, Mr. Mitchell made a closer examination of Mrs. Mitchell’s private
region and discovered that her clitoris was enlarged to the point that it resembled a male penis.4
Plaintiffs were alarmed by Mrs. Mitchell’s condition, and telephoned Dr. Ensor’s office the
following day to find out the name of the injected drug. Immediately after obtaining this
information, Mr. Mitchell drove to a local drug store and obtained a package insert for Depo-
Testosterone.

        Neither the manufacturer’s package insert for Depo-Testosterone nor the discussion in the
Physicians Desk Reference (PDR) were introduced as an exhibit in the case. However, the testimony
elicited from all of the expert witnesses is to the effect that neither the package insert nor the PDR
show clitoromegaly (clitoral enlargement) as a known side effect of the drug.

        Despite the discomfort and concern Mrs. Mitchell suffered as a result of her condition, she
failed to seek immediate medical attention. Mrs. Mitchell did not inform Dr. Ensor of her clitoral
enlargement, nor did she return for further examination. From February of 1998 through April of
1998, Mrs. Mitchell sought the medical attention of twelve different physicians for various physical
ailments unrelated to her enlarged clitoris, yet Mrs. Mitchell never revealed her condition to any of
these doctors, and never sought treatment specifically for clitoromegaly. Finally, on May 12, 1998,
Mrs. Mitchell sought the opinion and care of Floyd Shrader, M.D., in treating her clitoral
enlargement.

        Prior to her visit of May 12, 1998, Dr. Shrader had treated Mrs. Mitchell on a regular basis
from 1978 until 1993. Dr. Shrader treated Mrs. Mitchell as her general physician, not as a specialist
in internal medicine. The record provides that Dr. Shrader had some training in internal medicine,
but was not qualified as a specialist in this area.

         During direct examination, Dr. Shrader noted that his general physical examination of Mrs.
Mitchell revealed that she “had developed a clitoral enlargement or a clitoral hypertrophy that
measured about two inches in length, and this is a markedly enlarged clitoris.” Dr. Shrader testified
that it was his opinion that this condition was “directly due to the large amount of male hormone that
[Mrs. Mitchell] received in the injection.” Upon receiving Dr. Shrader’s diagnosis, plaintiffs’ sought
no further medical advice or expertise regarding Mrs. Mitchell’s condition.

         4
           Mrs. M itchell’s testimony as to exactly when she be gan to notice side effects is inconsistent. On direct
examination at trial, M rs. M itchell testified that she felt a “stinging” sensation when she urinated, a condition that
surfaced roughly three or four weeks after the injection. However, in her deposition, Mrs. M itchell testified that the first
time she felt any pain in her clitoris was during February 1998 intercourse with her husband.

                                                            -5-
         On January 4, 1999, Patsy and Steve Mitchell brought an action against Dr. Ensor, Memphis
Internal Medicine, and Jane Doe,5 alleging medical malpractice in the administration of the Depo-
Testosterone injection and for failure to obtain plaintiff’s informed consent for the injection of the
dosage. Mr. Mitchell’s claim was loss of consortium for the past and future loss of his wife’s
services, society, and companionship. A trial on this action commenced on April 2, 2001.
Defendants moved for a directed verdict at the close of plaintiffs’ proof and renewed the motion at
the conclusion of all the proof. The motion was denied, and after the close of proof, plaintiffs
submitted a list of twelve special jury instructions to the court. Instruction No. 10 requested the
court to instruct the jury on the doctrine of informed consent, but plaintiffs’ request for an informed
consent instruction was denied. The case was submitted to the jury on the negligence theory of
liability against the defendants for the prescription and administration of the drug. On April 12,
2001, the jury returned a verdict for defendants, and the court subsequently entered judgment on the
jury verdict.

        Plaintiffs filed a motion for a new trial pursuant to Rule 59.02 of the Tennessee Rules of
Civil Procedure. In an order entered June 15, 2001, the trial court denied plaintiffs’ motion. Patsy
and Steve Mitchell have appealed, and present the following issues as stated in their brief:

                  1.       Whether or not the court erred when it refused to instruct the
                           jury on lack of informed consent.
                  2.       Whether or not the court erred when it failed to strike the
                           direct testimony of Dr. Ensor because it was not within a
                           reasonable degree of medical certainty.
                  3.       Whether or not the court erred when it allowed the defense
                           expert, Jack Sanford, M.D., to present alternative causes for
                           Mrs. Mitchell’s condition that were not within a reasonable
                           degree of medical certainty.
                  4.       Whether or not the verdict is contrary to the weight of the
                           evidence.

                                                          I.

        The first issue we are asked to examine is whether the trial court erred in refusing to instruct
the jury regarding the lack of informed consent. The trial court should instruct the jury upon every
issue of fact and theory of the case raised by the pleadings and supported by the proof. Street v.
Calvert, 541 S.W.2d 576 (Tenn. 1976); Underwood v. Waterslides of Mid-America, 823 S.W.2d
171, 178 (Tenn. Ct. App. 1991). More specifically, where a requested special instruction is a correct
statement of the law, is not included in the general charge, and is supported by the evidence

         5
            In their comp laint, plaintiffs alleged that Jane Doe’s administration of Depo-T estosterone was negligent
because the as yet unidentified nurse knew or should have known that the injection would cause Mrs. Mitchell harm.
Plaintiffs later amended the January 4 complaint to name Lynn Dunlap, R.N. as the “Jane Doe” defendant. On March
15, 200 1, defendants filed a motio n for sum mary judgm ent to dismiss D unlap as a de fendant in this action. Shortly
thereafter, the action against Dunlap was vo luntarily dismissed by plaintiffs.

                                                         -6-
introduced at trial, the court should give the instruction. Underwood, 823 S.W.2d at 178. When the
denial of a request which ought to have been given prejudices the rights of the requesting party, the
judgment should be reversed. Nashville C. & St. L. Ry. Co. v. Jackson, 187 Tenn. 202, 213 S.W.2d
116 (1948).

        Despite the diligent efforts of their counsel, plaintiffs were twice denied a jury instruction
on the doctrine of informed consent. The trial judge decided to omit an informed consent instruction
from the general charge, voicing two specific concerns as the basis for his refusal:

               As you can see, I’ve bounced all over this morning, and I’m back now
               to saying I’m not going to give the informed consent, in part because
               of the uncertainty of the law as it relates to whether you could use it
               in medicine administration.

               And, two, because of the serious question that I do have as to whether
               the risks complained of or the damage complained of in this case is
               even remotely within the realm of the risks that are contemplated by
               the disclosure charge.

        After the court’s rejection of the general informed consent charge, plaintiffs’ counsel
presented the judge with a special instruction on informed consent and medical negligence.
Acknowledging that the court had ruled on the lack of informed consent issue, counsel maintained
that the instruction was necessary to address the issue of Dr. Ensor’s alleged breach of the standard
of care. Finding no merit to plaintiffs’ counsel’s distinction between the lack of informed consent
and medical negligence charges, the court refused to allow the instruction. Plaintiffs’ proposed
instruction reads as follows:

               No. 10. Second Allegation of Negligence: 1) Lack of Informed
               Consent: It is the duty of a physician to obtain the consent of a patient
               before beginning a course of treatment. Consent may be express or
               it may be implied from the conduct of the parties. Failure to obtain
               the consent makes the physician responsible for an injury caused by
               the treatment even if the physician is not otherwise liable. T.P.I. 3 -
               Civil 6.25.
                       Reality of Consent - duty to disclose. A physician is required
               to disclose the relevant information necessary to make an intelligent
               and informed decision regarding the proposed treatment. Disclosures
               required are those that physicians in good standing under similar
               conditions in the same or similar community would make having due
               regard for the patient’s physical, mental and emotional condition.
               T.P.I. 3 - Civil 6.30.
                       The Mitchell’s also contend that Dr. Ensor failed to
               reasonably advise the plaintiff, Patsy Mitchell, about the

                                                 -7-
               administration of a shot of 400 mg. of Depo-Testosterone and the
               possible masculinizing side effects of that drug, such as hair growth,
               deepening of the voice, clitoral enlargement, and if you find that a
               reasonable person, in the same position as Mrs. Mitchell, would not
               have consented to the injection of Depo-Testosterone if adequately
               informed of one or more of these possible side effects, and that the
               shot of testosterone was the legal cause of Mrs. Mitchell’s injuries,
               then the plaintiffs have met their burden and proved negligence by
               Dr. Ensor. In your decision, you may consider the characteristics of
               Mrs. Mitchell, including her idiosyncrasies, fears, age, and medical
               condition. T.P.I. 3 - Civil 3.50 Modified; Ashe v. Radiation
               Oncology Assocs., 9 S.W.3d 119 (Tenn. 1999); German v.
               Nichopoulos, 577 S.W.2d 197 (Tenn. Ct. App. 1978), overruled on
               other grounds.

        In determining whether the trial judge erred in denying plaintiffs’ request for an informed
consent instruction, we must first ascertain whether the proposed jury instruction was a correct
statement of the law. The trial judge, in explaining his decision to deny plaintiffs’ instruction, noted
that he was not convinced that this case even involved the issue of informed consent.

       Plaintiffs’ instruction generally outlines a medical malpractice action premised on the
doctrine of informed consent and appears to be a correct statement of the law.

        T.C.A. § 29-26-118 provides:

                Proving inadequacy of consent. - In a malpractice action, the
                plaintiff shall prove by evidence as required by § 29-26-115(b) that
                the defendant did not supply appropriate information to the patient in
                obtaining informed consent (to the procedure out of which plaintiff’s
                claim allegedly arose) in accordance with the recognized standard of
                acceptable professional practice in the profession and in the specialty,
                if any, that the defendant practices in the community in which the
                defendant practices and in similar communities.

        In Ashe v. Radiation Oncology Assocs., 9 S.W.3d 119,121 (Tenn. 1999), the Court
distinguished a lack of informed consent claim from a medical battery claim involving the
performance of an unauthorized medical procedure. According to the Court, “[a] lack of informed
consent claim typically occurs when the patient was aware that the procedure was going to be
performed but the patient was unaware of the risk associated with the procedure.” Id. (quoting
Blanchard v. Kellum, 975 S.W.2d 522, 524 (Tenn. 1998)). Tennessee courts have consistently
recognized the distinction drawn in Ashe that a physician’s failure to inform a patient of risks
associated or inherent in the treatment provides the foundation for a lack of informed consent claim.

                                                  -8-
See Church v. Perales, 39 S.W.3d 149, 159 (Tenn. Ct. App. 2000); Mitchell v. Kayem, 54 S.W.3d
775, 779 (Tenn. Ct. App. 2001).

        It is well established in Tennessee that an objective standard is to be applied in assessing
causation in medical malpractice informed consent cases. See Ashe, 9 S.W.3d at 123-24. Under the
objective standard, the court must consider informed consent from the perspective of a reasonable
person in the patient’s position, and whether “a reasonable person in the patient’s position would
have consented to the procedure or treatment in question if adequately informed of all significant
perils.” Id. at 124. As drafted, plaintiffs’ charge properly instructs the jury to apply an objective
standard in assessing whether informed consent was present.

        The record indicates that the trial court refused to charge on the doctrine of informed consent
for two reasons: (1) the doctrine of informed consent does not apply to therapeutic treatment as
announced in Cary v. Arrowsmith, 777 S.W.2d 8, 21 (Tenn. Ct. App. 1989); and (2) for lack of
proof the defendants were not required to inform of the risk of the plaintiffs’ resulting injury.

        The plaintiff in Cary brought a malpractice action against a treating physician for negligence
and failure to obtain plaintiff’s informed consent to radial keratotomy surgery. Id. at 10. Adopting
the rational articulated in a Pennsylvania Superior Court decision, the Tennessee Court of Appeals,
Middle Section concluded that plaintiff’s issue of whether the trial court erred by refusing to allow
the jury to consider informed consent, on the basis that the “use of prescription medications ordered
for the care and treatment of a patient by his physician cannot form the basis for an action against
the physician for lack of informed consent,” was without merit. Id. at 21. The court’s ruling on this
issue was rooted in the following excerpt from the Pennsylvania decision.

                       To now expand the doctrine’s current applicability to cases
               involving the administration of therapeutic drugs would be to
               radically depart from, and indeed obliterate, the foundation upon
               which the [battery theory of informed consent] stands. Not only are
               we unpersuaded that such expansion is unnecessary...

                      [W]e are also of the particular opinion that, in the light of the
               day-to-day realities of providing professional medical care, traditional
               medical malpractice actions, sounding in negligence, are an adequate
               legal medium for compensating patients for the injurious
               consequences of therapeutic drug treatment.

Id. (quoting Boyer v. Smith, 345 Pa. Super. 66, 497 A.2d 646, 649 (Pa. Super. Ct. 1985)).

The court concluded its examination of the informed consent instruction issue by adopting a
modified version of the Pennsylvania Superior Court’s rule:

                                                 -9-
               We are of the opinion that the better rule is that a treating physician
               must obtain the patient’s informed consent for the medical treatment
               of the patient and not for each component part of the treatment
               process. The patient has an adequate legal remedy, i.e., a malpractice
               action sounding in negligence, for the injurious consequence of
               therapeutic drug treatment.

Cary, 77 S.W.2d at 21.

         After reviewing Cary and Boyer, we cannot agree with defendants’ argument that the
doctrine of lack of informed consent is strictly limited to operative surgical procedures. In Boyer,
the court’s limitation of the doctrine was premised on its interpretation of the Pennsylvania Supreme
Court’s decision in Gray v. Grunnagle, 423 Pa. 144, 155, 223 A.2d 663 (Pa. 1966). The court
interpreted Gray as a decision by the Pennsylvania Supreme Court to expressly ground “its adoption
of the informed consent doctrine upon the legal theory that the performance of a medical procedure
without a patient’s informed consent constitutes a technical assault or battery.” Boyer, 345 Pa.
Super. 66, 497 A.2d at 649 (construing Gray, 423 Pa. 144, 155, 223 A.2d 663 (Pa. 1966)).
According to the court, “to now expand the doctrine’s current applicability to cases involving the
administration of therapeutic drugs would be to radically depart from, and indeed obliterate, the
foundation upon which the Gray decision stands.” Boyer, 345 Pa. Super. 66, 497 A.2d at 649
(construing Gray, 423 Pa. 144, 155, 223 A.2d 663 (Pa. 1966)).

        As noted, the evidence in the record indicates that Mrs. Mitchell’s primary claim is one of
lack of informed consent. Our Supreme Court has distinguished the claims of battery and lack of
informed consent, in Ashe v. Radiation Oncology Assocs., 9 S.W.3d 119, 121 (Tenn. 1999). Our
Supreme Court stated:

                       This Court recently enunciated a distinction between a lack of
               informed consent case and a pure medical battery case. In Blanchard
               v. Kellum, 975 S.W.2d 522 (Tenn. 1998), this Court defined amedical
               battery as a case in which a doctor performs an unauthorized
               procedure. Id. at 524. A medical battery may typically occur when:
               (1) a professional performs a procedure that the patient was unaware
               the doctor was going to perform; or (2) the procedure was performed
               on a part of the body other than that part explained to the patient (i.e.,
               amputation of the wrong leg). Id. A lack of informed consent claim
               typically occurs when the patient was aware that the procedure was
               going to be performed but the patient was unaware of the risk
               associated with the procedure. Id.

Id. at 121.

                                                 -10-
It is at least questionable if Cary, in reliance upon Boyer, is applicable to the case at bar. As stated
by the Pennsylvania Superior Court, Pennsylvania’s limitation of the doctrine of informed consent
is grounded in the theory that performance of a medical procedure without consent is a battery. We
conclude that Cary is not controlling and an action for lack of informed consent in malpractice
actions premised on a physician’s failure to advise of associated treatment risks is not foreclosed.
Moreover, the court stated its rule to require a treating physician to obtain a patient’s informed
consent for medical treatment, but not for each component part of the treatment process. Cary v.
Arrowsmith, 777 S.W.2d 8, 21 (Tenn. Ct. App. 1989). The court proceeded to assert that a patient
who sustains injury from therapeutic drug treatment has a “malpractice action sounding in
negligence.” The Cary Court appears to limit its ruling to cases where the treatment process at issue
consists of multiple, distinct component parts.

        We also note that several cases in Tennessee succeeding Cary have incorporated language
suggesting that informed consent applies to both operative procedures and the administration of
medication. See Shadrick v. Coker, 963 S.W.2d 726, 732 (Tenn. 1998) (“Accordingly, the law
recognizes that a health care provider, such as a physician or surgeon, who proposes a treatment or
surgical procedure has a duty to provide the patient with enough information about the nature of the
treatment or procedure involved to enable the patient to make an intelligent decision and thereby give
an informed consent to the treatment or procedure.”) (citation omitted); Housh v. Morris, 818
S.W.2d 39, 41 (Tenn. Ct. App. 1991) (“A cause of action based on the lack of informed consent
stems from the basic premise that a patient should be allowed to form an intelligent choice about the
surgical and/or treatment procedures that he/she undertakes.”) (citations omitted); Bryant v.
McCord, No. 01A01-9801-CV-00046, 1999 WL 10085, at *7 (Tenn. Ct. App. Jan. 12, 1999) (“It
is well established in Tennessee that a physician has a duty to obtain the informed consent of his or
her patient before administering a treatment or performing a surgical procedure on the patient.”)
(citations omitted). While none of these cases specifically deal with therapeutic drug treatment or
the administration of medication, we can infer that the carefully chosen language of these courts
evinces an intent that the doctrine of informed consent can be applied to cases involving the
administration of medication as well as surgical procedures.

       As noted, the trial court also refused to charge the jury on the doctrine of informed consent,
because the proof did not warrant such a charge.

       “When the health care provider performs the treatment or procedure without the requisite
informed consent of the patient, liability attaches for the resulting injuries regardless of whether
those injuries resulted from negligence.” Shadrick v. Coker, 963 S.W.2d 726 (Tenn. 1998)
(emphasis supplied). In Shadrick, the Court said:

                        This is not to suggest, however, that a health care provider is
                required to enumerate in detail every aspect of the proposed treatment
                or procedure or discuss every possible thing that might go wrong in
                an effort to obtain the patient’s informed consent. “In the first place,
                to do so is humanly impossible. In the second place, if all the gory

                                                 -11-
               details of a proposed surgery were graphically explained to every
               patient and all possible medical maladies that might result were
               enumerated we doubt that a lay person would have the stomach to
               listen to it all; and if the patient did, would probably be in such a
               fearful state that no rational decision could be made.” Longmire v.
               Hoey, 512 S.W.2d 307, 310 (Tenn. Ct. App. 1974). Accordingly,
               health care providers are generally not required to disclose risks that
               are not material, such as those that are extremely unlikely to occur or
               one that a reasonable patient would not care to know due to its
               insignificance; risks that are obvious or already known by the patient;
               risks that are unforeseeable or unknowable; or where the patient’s
               medical condition renders discussion of the risks and benefits of the
               treatment or procedure impossible or medically inadvisable, such as
               in an emergency where the patient is unconscious or otherwise
               incapable of consenting, or where full disclosure would be
               detrimental to the patient’s total care, i.e., the patient is unduly
               alarmed or apprehensive to start with and additional information
               would overload the patient and jeopardize his or her physical or
               emotional well-being.
963 S.W.2d at 733 (citations omitted).

        In the instant case, the proof established that an enlarged clitoris has never been reported as
a side effect in medical literature as a result of one injection of any strength of testosterone. The
experts that testified on behalf of the defendant noted that they had never seen or known of such a
side effect occurring from such a procedure. The plaintiffs’ expert, Dr. Shrader, agreed that he was
not able to find any medical literature that described a case such as the present case and characterized
the plaintiff’s condition as “a rare condition.” Dr. Shrader did not testify that it was essential that
the plaintiff be advised of clitoral enlargement in order for her to consent to the treatment. We quote
from his cross-examination in the record:

                Q. The standard of care does not require a physician to list each and
                everything that’s possible because it’s a multitude of things, right?

               A. That is correct.

               Q. So what you do is explain the likely risks?

               A. That’s correct.

                Q. Not something that occurs rarely or only one time in a thousand?

                                                 -12-
                A. That’s correct. But, again, the standard of care requires that you,
                you know, when you initiate a drug that you do this. And in Mrs.
                Mitchell’s case, it was not done. She wasn’t informed of any risks of
                the Depo-Testosterone.

                Q. If the condition is as rare as you say it is, Doctor, no physician
                would warn a patient of that?

                A. But you do it in the general way of if you’re going to give a male
                hormone to a female. It behooves us to say this is a male hormone,
                these are male things that may happen to you. Now, no, I’m not
                saying I would tell every one of my patients you’re going to have a
                clitoris that grows two and a half inches, but I would tell them of the
                hair, the male changes.

                And in my experience, over 30 years now, in dealing with a lot of
                women in menopause, you tell them the male things and if they –
                most of them will not want to take the drug in the first place. And
                then those who do choose the drug, discuss it with them, what kind
                of male things. So that’s how you get informed consent.

        Under the state of the record before us, we conclude that the trial court correctly denied
plaintiffs’ special request for instruction concerning the lack of informed consent.

                                                    II.

        In their second issue for review, plaintiffs ask us to determine whether the trial court erred
when it failed to strike the direct testimony of Dr. Ensor regarding the applicable standard of care,
and whether or not he breached this standard because the testimony was not based on a reasonable
degree of medical certainty. Plaintiffs further assert that the trial court improperly re-opened direct
examination, after plaintiffs’ motion to strike, to allow defendants to correctly found Dr. Ensor’s
testimony on a reasonable degree of medical certainty. Plaintiffs contend that Dr. Ensor’s testimony
about the standard of care and his alleged breach of the standard was drawn from outside expertise
and experience, and not solely from his treatment of Mrs. Mitchell. On this basis, plaintiffs argue
that Dr. Ensor was testifying as an expert, not as the treating physician, and therefore, his testimony
must have been premised upon a reasonable degree of medical certainty.

         After reviewing plaintiffs’ objection at trial and their presentation of this issue in their brief,
we are persuaded that plaintiffs’ argument is premised not on whether Dr. Ensor was entitled to
testify as to the applicable standard of care or his alleged breach, but solely on the assertion that he
failed to incorporate the magic words “to a reasonable degree of medical certainty” into his
testimony. While we agree that an expert in a medical malpractice case is not allowed to base

                                                   -13-
causation opinions upon possibility or pure speculation, use of the “magic language” that the opinion
is to a reasonable degree of medical certainty is not necessary for admissibility.

       A pair of workers’ compensation opinions decided by a Special Workers’ Compensation
Appeals Panel of the Tennessee Supreme Court guide our decision. In Kayser-Roth Hosiery, Inc.
v. Johnson, No. 03S01-9212-CH-00109, 1994 WL 901454, at *1 (Tenn. Sp. Workers Comp. Apr.
5, 1994), the defendant appealed a trial court decision on the sole issue of whether the evidence
presented at trial was sufficient to establish the cause and permanency of defendant’s injury and
whether the trial court should have allowed supplemental testimony to determine the extent of
impairment when the defendant’s attorney failed to ask proper questions at the attending physician’s
deposition. Defendant asserted that he began to experience back problems as a result of his duties
as an employee of plaintiff. Id. The attending physician in this case testified at deposition that ‘it
was perhaps the event at Kayser Roth that was maybe the straw that broke the camel’s back.” Id.
at 4. The court attached the following footnote to the physician’s statement:

                 Although it has become the accepted practice for the medical expert
                 to testify that his opinions are accurate to a ‘reasonable degree of
                 medical certainty,’ there is nothing in the statute or the case law that
                 makes the recitation of such language the sine qua non of recovery,
                 when the medical evidence and other testimony sufficiently establish
                 causation.

Id. at *4 n.4.

The court considered the physician’s testimony as support for its finding “that the medical and lay
evidence in the record is sufficient to establish causation and that the medical testimony in the record
is sufficient to determine that the disability is permanent.” Id. at *3-4.

        The panel’s decision in Breeden v. Universal Bedroom Furniture, LTD., No. 03S01-9808-
CV-00094, 2000 WL 949364, at *1 (Tenn. Sp. Workers Comp. July 5, 2000), provides further
guidance on this issue. In Breeden, the plaintiff-employee initiated a workers’ compensation action
to recover medical and disability benefits for injuries allegedly suffered as a result of an accident at
defendant-employer’s place of business. Id. at *1-2. Defendant responded by filing a motion for
partial summary judgment. Id. at *1. Before rendering a judgment on the motion, the trial court
allowed or directed the plaintiff to conduct a supplemental deposition of the attending physician, Dr.
Megibow, to “see whether or not [Dr. Megibow] would state within a reasonable degree of medical
certainty that the plaintiff’s psychological (mental) condition was either aggravated or caused by the
[alleged work] accident....” Id.

       After reviewing Dr. Megibow’s supplemental deposition testimony, the court granted
defendant’s motion for partial summary judgment. Id. at *3-4. According to its order, the trial court
granted defendant’s motion because Dr. Megibow failed to “use the exact phrase ‘to a reasonable
degree of medical certainty,’” in testifying about the cause of plaintiff’s psychological injury. Id.

                                                  -14-
at *4. The trial court determined that the following exchange between plaintiff’s counsel and Dr.
Megibow did not satisfy the reasonable degree of medical certainty standard for expert opinions.

               A.      And the question was, with any degree of medical certainty
                       can I say this in fact is true?
               Q.      Yes.
               A.      I would say, yes, very much so.

Id.

       On appeal, the panel found that the trial court erred in granting defendant’s motion for partial
summary judgment. Id. at *6. Asserting that the Tennessee Court of Appeals has never clearly
enunciated whether the “magic words” must be uttered by an expert physician in order to allow the
admission of his or her testimony, the panel relied upon a dissenting opinion from a medical
malpractice case and an opinion from the Tennessee Court of Criminal Appeals to find that the trial
court improperly granted defendant’s motion. Id. at *4-6. The court cited the following passage
from Judge William Koch’s dissenting opinion in Moore v. Walwyn, No. 01A01-9507-CV-00295,
1996 WL 17143, at *12 (Tenn. Ct. App. Jan. 19, 1996) (Koch, J., dissenting):

               This Court has admonished lawyers to couch their medical expert’s
               conclusions in the language of T.C.A. § 29-26-115 in order to avoid
               just the sort of interpretive disputes that are involved in this case.
               Gambill v. Middle Tennessee Medical Centr., 751 S.W.2d 145, 148
               (Tenn. Ct. App. 1988). Careful practitioners have heeded this advice,
               but it is not always possible to frame expert conclusions in the precise
               words of the statute because of differences in the medical and legal
               vocabularies and frames of reference.

               Tennessee Code Annotated § 29-26-115 is not ‘holy writ,’ and it
               should never be so rigidly applied that it requires the ritualistic
               incantation of its precise terms in order to permit an injured party to
               maintain a malpractice claim against a health care provider. The
               courts should expect substantial adherence to the language of T.C.A.
               § 29-26-115 but should never abandon their judicial powers of
               reasonable interpretation and construction.

Breeden, 2000 WL 949364, at *5 (quoting Moore, 1996 WL 17143, at *12).

        The court also relied on Judge Wade’s opinion in State of Tennessee v. Young, No. 01C01-
9605-CC-00208, 1998 Tenn. Crim. App. LEXIS 566, at *1 (Tenn. Crim. App. May 22, 1998), as
support for the conclusion that the admissibility of expert medical testimony does not hinge on the
utterance of seven magic words.

                                                 -15-
                In criminal cases, experts have at times testified to the cause of
                injuries or other conditions close ‘to a reasonable degree of medical
                certainty.’ However, nothing in Tennessee law requires that those or
                any other specific words be recited in order for expert testimony to be
                admissible.

Breeden, 2000 WL 949364, at *6 (quoting Young, 1998 Tenn. Crim. App. LEXIS 566, at *62-63).

         It is settled law in Tennessee that “questions regarding the admissibility, qualifications,
relevancy and competency of expert testimony are left to the discretion of the trial court.” McDaniel
v. CSX Transp., 955 S.W.2d 257, 263 (Tenn. 1997). The ruling of a trial court on any or all of these
questions may only be overturned on appeal where there is a proven abuse of discretion. Id. On the
basis of the law set forth above, we find that a medical expert is not required to explicitly state that
his opinion is “to a reasonable degree of medical certainty.” Therefore, we hold that the trial judge
did not commit an abuse of discretion when he overruled plaintiffs’ motion to strike the testimony
of Dr. Ensor relating to the applicable standard of care and his alleged breach of this standard. The
trial judge did not err or commit an abuse of discretion by re-opening direct examination to permit
defendants the opportunity to establish Dr. Ensor’s testimony to a reasonable degree of medical
certainty.

        Plaintiffs’ second issue is without merit.

                                                  III.

        The third issue for review is whether the trial court committed an abuse of discretion by
allowing defense expert, Dr. Sanford, to testify as to alternate causes of Mrs. Mitchell’s condition.
Plaintiffs argue that Dr. Sanford’s testimony was speculative, and therefore not within a reasonable
degree of medical certainty as required. In their brief to this court, plaintiffs specifically assert that
(1) Dr. Sanford’s “speculative” opinions did not substantially assist the trier of fact pursuant to
Tennessee Rule of Evidence 702 because he did not have an opinion as to the actual cause of Mrs.
Mitchell’s condition and such opinions lacked the requisite scientific basis mandated by Tennessee
Rule of Evidence 703; (2) the trial judge incorrectly reasoned that Dr. Sanford’s alternate causes
testimony was presented, not to persuade the jury that one of the alternate causes was the actual
cause of Mrs. Mitchell’s condition, but only to educate the jury as to the context of the scientific
evidence surrounding the condition at issue; and (3) the judge’s limiting instruction was insufficient
to overcome the prejudice suffered by plaintiffs as a result of the admitted testimony.

        Tennessee Rule of Evidence 702 permits an expert to testify “in the form of an opinion or
otherwise,” only where the “scientific, technical, or other specialized knowledge” offered by the
witness will substantially assist the trier of fact. Tenn. R. Evid. 702. Rule 703 requires an expert’s
opinion to be supported by trustworthy facts or data “of a type reasonably relied upon by experts in
the particular field in forming opinions or inferences upon the subject.” Tenn. R. Evid. 703.

                                                  -16-
        Plaintiffs assert that Dr. Sanford’s admission that he did not know the specific cause of Mrs.
Mitchell’s condition rendered the expert’s testimony speculative, and therefore incapable of
substantially assisting the jury. Further fueling plaintiffs’ argument is their belief that Dr. Sanford’s
“alternate cause” theories were trenched in possibility rather than probability. Plaintiffs contend that
“[a] doctor’s testimony that a certain thing is possible is no evidence at all.” Lindsey v. Miami
Development Corp., 689 S.W.2d 856, 862 (Tenn. 1985) (quoting Palace Bar, Inc. v. Fearnot, 269
Ind. 405, 381 N.E.2d 858, 864 (Ind. 1978)) (emphasis supplied). “The mere possibility of a causal
relationship, without more, is insufficient to qualify as an admissible expert opinion.” Lindsey, 689
S.W.2d at 862 (quoting Kirschner v. Broadhead, 671 F.2d 1034, 1039 (7th Cir. Ind. 1982)).

         We disagree with plaintiffs’ assertion that Dr. Sanford’s opinions as to alternate causes
amounted to inadmissible speculation. Additionally, we take issue with plaintiffs’ classification and
interpretation of Dr. Sanford’s testimony as alternate cause theory aimed at convincing the jury that
one of the causes addressed was accountable for Mrs. Mitchell’s condition. While it is undisputed
that Dr. Sanford did not have an opinion, based on a reasonable degree of medical certainty, as to
the exact cause of Mrs. Mitchell’s enlarged clitoris, his opinions were not offered to prove causation
in this case. We agree with the judge’s interpretation of Dr. Sanford’s testimony, whereby he noted:

                So, if that be the case, then it would put the defense in the posture of
                saying, well, we don’t know what caused it, period, and I don’t know
                if that’s fair in terms of the evidence, because while they don’t know
                what caused it, this expert has some scientific opinions as to possible
                causes, not that he is trying to convince the jury as to these being
                possible causes, but he is trying to educate the jury to the current
                knowledge from his perspective as a scientist as to how this condition
                might arise – not to convince them of the ultimate fact, but simply to
                put it into context the nature of this scientific phenomenon.

        Our classification of Dr. Sanford’s alternate cause testimony as being rendered for the sake
of bringing to light other potential explanations for Mrs. Mitchell’s condition, but not to prove
ultimate causation, is supported by Dr. Sanford’s trial responses. At no point during his direct or
cross examination testimony did Dr. Sanford assert or opine that Mrs. Mitchell’s clitoral enlargement
was caused by the alternate causes to which he testified. Dr. Sanford testified that clitoral
enlargement is the known potential result of late onset congenital adrenal hyperplasia, the
overproduction of androgens by the ovaries, or an ovarian tumor. He discussed each of these
conditions generally, but never specifically associated Mrs. Mitchell’s clitoral enlargement with any
of these causes.

        The case law cited by plaintiffs to support their argument that Dr. Sanford’s testimony was
inadmissible speculation is distinguishable from the case at bar. In their brief, plaintiffs rely heavily
on the law set forth in Lindsey v. Miami Development Corp., 689 S.W.2d 856 (Tenn. 1985). In
Lindsey, the attending physician was questioned at trial about whether immediate medical care could

                                                  -17-
have prevented plaintiff’s death. Id. at 861. The Tennessee Supreme Court deemed the following
testimony speculative and inadmissible.

               Q. All right, do you hold any opinions as to whether or not a delay of
               any specified period of time would have made any difference in the
               final analysis?

               A. I can only speculate because we don’t have the final information
               which an autopsy would have provided as to where exactly the injury
               to the brain was, how excessive it was and whether it was an injury
               which would – in any event be nonsurvivable, whether it would be
               just a few hours or maybe a day or two.

Id.

        The physician’s testimony in Lindsey is directed at the actual cause or aggravation of
plaintiff’s injuries. Counsel specifically asked the expert to offer his opinion as to whether
immediate medical aid could have prevented plaintiff’s death. Id. Because the physician was unable
to introduce evidence to afford a reasonable basis for his opinion, the Supreme Court ruled the
testimony inadmissible. Id. at 862.

        Plaintiffs also cite in their brief to the cases of Primm v. Wickes Lumber Co., 845 S.W.2d
768 (Tenn. Ct. App. 1992), and Reel v. Crawley, 1994 WL 399566, at *1 (Tenn. Ct. App. Aug. 2,
1994). In each of these cases, the court found the testimony of the physician expert inadmissible
because it offered little more than a possibility upon which the jury could speculate. See Primm, 845
S.W.2d at 771; Reel, 1994 WL 399566, at *2. However, in both cases, the physician expert was
specifically asked whether the two events at issue were causally connected. See Primm, 845 S.W.2d
at 769-770; Reel, 1994 WL 399566, at *1 (“Doctor, do you associate Mr. Reel’s irregular heartbeat
in any fashion to the accident, the trauma or stress of that accident?”). Both physicians responded
with vague explanations of causation. See Primm, 845 S.W.2d at 769-770; Reel, 1994 WL 399566,
at *1 (“I think that irregular heart rhythms can develop due to any form of stress and being in an
automobile accident could have contributed to him having more irregular heart rhythms.”).

        Unlike the testifying physicians in Lindsey, Primm, and Reel, Dr. Sanford was never asked,
and never offered, his opinion as to whether Mrs. Mitchell’s enlarged clitoris was causally connected
to the alternate causes he addressed on direct examination. This distinction prevents Dr. Sanford’s
testimony from crossing the line of inadmissible opinion drawn in the aforementioned cases.

       The precise point in plaintiffs’ assertion of error was considered by the Court of Appeals of
Kentucky in Sakler v. Anesthesiology Assocs., P.S.C., 50 S.W.3d 210 (Ky. Ct. App. 2001). Sakler
is a medical malpractice case by the plaintiffs for Mrs. Sakler’s vocal cord paralysis which was
claimed to be caused by the negligence of the defendant in the use of an intubation tube during
surgery. After a jury trial, the jury returned a verdict for the defendant, and on appeal the Sakler’s

                                                -18-
first argument “is that the trial court committed reversible error by permitting a defense expert
witness to render an expert medical opinion based on ‘speculation’ and ‘possibility’ rather than
reasonable medical probability.” Id. at 212. The defense expert testified that there were multiple
conditions that could cause vocal cord paralysis and there is a possibility that any one of a number
of these things caused the problem. The plaintiffs argued that the opinion of a medical expert must
be based on reasonable medical probability and not speculation. The Court affirmed the ruling of
the trial court that the expert testimony at issue was admissible on behalf of defendant in a medical
malpractice case. In so holding, the Court said:

               We conclude that defendants in medical malpractice actions may
               introduce expert witness testimony to rebut a plaintiff’s expert
               witness testimony couched in terms of “reasonable medical
               probability,” even though the defendant’s expert witness’s testimony
               is couched only in terms of “possibility.” In so deciding, we are
               persuaded by the reasoning of the United States Court of Appeals for
               the First Circuit in the case of Wilder v. Eberhart, 977 F.2d 673 (1st
               Cir. 1992), cert. denied 508 U.S. 930 113 S. Ct. 2396, 124 L. Ed. 2d
297 (1993).

                       In Wilder, a plaintiff patient filed suit against her defendant
               doctor and clinic for medical malpractice, alleging the doctor’s
               surgical procedure caused her to suffer an esophageal injury. At trial,
               the plantiff’s expert witness testified that her injury was caused by the
               defendants’ medical negligence. Expert medical testimony on behalf
               of the defendants, however, was ruled inadmissible by the trial court
               because it could not be expressed in terms of “probability” as
               distinguished from “medical possibility.” In holding the trial court
               erred in excluding this testimony, the First Circuit reasoned as
               follows:

                       Proximate causation between negligence and the
                       injury complained of in a medical malpractice case
                       must be established by expert testimony. (Citation
                       omitted.) On the other hand, the defendant need not
                       disprove causation. Rather, he must produce credible
                       evidence which tends to discredit or rebut the
                       plaintiff’s evidence. (Citation omitted.) As the New
                       Hampshire Supreme Court recently stated in Tzimas
                       [v. Coiffures by Michael, 135 N.H. 498, 606 A.2d
1082, 1084 (N.H. 1992)], the plaintiff in a negligence
                       action bears the burden of producing evidence “to
                       prove that it is more likely than not that [plaintiff’s]
                       injury was “caused by the defendant’s negligence.

                                                 -19-
       (Citation omitted.) Defendant need not prove another
       cause, he only has to convince the trier of fact that the
       alleged negligence was not the legal cause of injury.
       (Citation omitted.) In proving such a case, a
       defendant may produce other “possible” causes of the
       plaintiff’s injury. These other possible causes need
       not be proved with certainty or more probably than
       not. To fashion such a rule would unduly tie a
       defendant’s hands in rebutting a plaintiff’s case,
       where as here, plaintiff’s expert testifies that no other
       cause could have caused plaintiff’s injury. The
       burden would then shift and defendant would then
       bear the burden of positively proving that another
       specific cause, not the negligence established by
       plaintiff’s expert, caused the injury. Certainly, this is
       much more than what should be required of a
       defendant in rebutting a plaintiff’s evidence.

                Were we to accept plaintiff’s argument that
       once a plaintiff puts on a prima facie case, a defendant
       cannot rebut it without proving another cause, the
       resulting inequities would abound. For example if
       ninety-nine out of one hundred medical experts agreed
       that there were four equally possible causes of a
       certain injury, A, B, C and D, and plaintiff produces
       the one expert who conclusively states that A was the
       certain cause of his injury, defendant would be
       precluded from presenting the testimony of any of the
       other ninety-nine experts, unless they would testify
       conclusively that B, C, or D was the cause of injury.
       Even if all of defendant’s experts were prepared to
       testify that any of the possible causes A, B, C or D,
       could have equally caused plaintiff’s injury, so long as
       none would be prepared to state that one particular
       cause, other than that professed by plaintiff more
       probably than not caused plaintiff’s injury, then
       defendant’s experts would not be able to testify at all
       as to causation.

Wilder, 977 F.2d at 676-677. n5 We agree with the First Circuit that
expert testimony of this nature is admissible on behalf of defendants
in medical malpractice cases in order to rebut the testimony of
plaintiffs upon whom the burden of proof rests.

                                 -20-
Id. at 213-214.

       The opinion in Wilder is well reasoned and we, like the Kentucky Court of Appeals in
Sakler, are persuaded by this reasoning. Accordingly, we adopt the holding expressed in Wilder and
Sakler as dispositive of this issue.

                                                    IV

        The final issue presented for review is whether the jury’s verdict was contrary to the weight
of the evidence.

        In Barnes v. Goodyear Tire & Rubber Co., 48 S.W.3d 698 (Tenn. 2000), our Supreme Court
reiterated the long established rule concerning review of a jury verdict. The Court said:

                          The standard of appellate review when reviewing a jury
                  verdict approved by a trial court is whether there is any material
                  evidence to support the verdict. Tenn. R. App. P., Rule 13(d). When
                  addressing whether there is material evidence to support a verdict, an
                  appellate court shall: (1) take the strongest legitimate view of all the
                  evidence in favor of the verdict; (2) assume the truth of all evidence
                  that supports the verdict; (3) allow all reasonable inferences to sustain
                  the verdict; and (4) discard all [countervailing] evidence. Crabtree
                  Masonry Co. v. C & R Constr., Inc., 575 S.W.2d 4, 5 (Tenn. 1978);
                  Black v. Quinn, 646 S.W.2d 437, 439-40 (Tenn. Ct. App. 1982).
                  Appellate courts shall neither reweigh the evidence nor decide where
                  the preponderance of the evidence lies. If the record contains “any
                  material evidence to support the verdict, [the jury’s findings] must be
                  affirmed; if it were otherwise, the parties would be deprived of their
                  constitutional right to trial by jury.” Crabtree Masonry Co., 575
S.W.2d at 5.

Id. at 704-705.

        There is material evidence in this record to support the jury’s verdict and, accordingly, we
find this issue without merit.

         The judgment of the trial court on the jury verdict is affirmed. The case is remanded to the
trial court for such further proceedings as may be necessary. Costs of the appeal are assessed to the
appellants, Patsy Mitchell and Steve Mitchell, and their surety.

                                                  __________________________________________
                                                  W. FRANK CRAWFORD, PRESIDING JUDGE, W.S.

                                                    -21-