Court Opinion

ID: 9766334
Source: CourtListenerOpinion
Date Created: 2023-08-29 04:42:10.58256+00
Date Added: 2024-06-11T07:30:20.664077
License: Public Domain

CERCONE, Judge
(dissenting):
Since I do not agee that our prior decision in Hamil v. Bashline, 224 Pa.Super. 407 (1973), allocatur denied, 224 Pa.Super. XXXVI, substantially altered the law in Pennsylvania, I vigorously dissent. I remain convinced that our decision was consonant with well recognized tort principles of causation.
At the outset I should note that one quotation from the lead opinion by Judge Price highlights the reason for our difference with respect to the law applicable to the instant case.
“It may be that no expert can ever testify that a person would have survived a heart attack. If it is wrong to forbid recovery under such circumstances, then the fault lies not within the requirement that expert testimony be certain, but within the requirement that there be a causal link between defendant’s conduct and plaintiff’s harm.”
*256To suggest that it is “wrong to forbid recovery,” and then to lay the blame upon the tort theory of causation, is to misapprehend what “cause” means in its jurisprudential sense and to imply that the appellate courts are a sterile branch of the government of this Commonwealth.
Causation in the jurisprudential sense of that term does not involve the kind of mechanistic standard which is necessary to the inductive methodology of a scientist. In the law, causation standards involve considerations of policy which relegate theories of “but for causation” useless as anything more than starting points in the inquiry whether a defendant should be liable for the injuries sustained by a plaintiff. It would be difficult, if not impossible, to find a legal scholar who believes that causation in the law can be, or should be, limited to scientific precision. As one of many commentators has explained:
“The essential weakness of the but-for test is the fact that it ignores the irresistible urge of the trier to pass judgment at the same time that he observes. It is an intellectual strait jacket to which the human mind will not willingly submit. The test was discredited even for philosophical usage by David Hume, its originator.” 1
Furthermore, in the law there is one class of cases where “but-for” causation simply fails altogether, yet liability attaches. The landmark decision of this class is Anderson v. Minneapolis, St. P. & S.S.M.R. Co., 146 Minn. 430, 179 N.W. 45 (1920). In that case two fires merged to cause the destruction of plaintiff’s property, but only one fire was due to the negligence of the defendant. The testimony clearly established that the fire for which defendant was not responsible would have destroyed plaintiff’s property anyway. Obviously, one cannot say that “but for defendant’s negligence the damage to plaintiff’s property would not have occurred,” for the facts refuted that proposition. Nevertheless, the defendant was held *257liable and the rule established has found general acceptance:2 “The defendant’s negligence is a cause of the event if it was a material element and a substantial factor in bringing it about. Whether it was such a ‘substantial factor’ is for the jury to determine, unless it is so clear that reasonable men could not differ.”3 The reason for such a rule, again, lies in policy. One who suffers physical injury and the economic tragedy it brings about bears a hard burden. The victim is, because of the injury, least able to carry its cost; and, in view of his plight, society demands relief. From this demand springs the policy that the burden shifts from the victim to another if the other’s part in the occurrence of the harm was sufficient that it appears that he ought to pay for it.4 It is this subjective element of “oughtness” which both limits and extends liability in a fashion which Procrustean notions of but-for causation are simply incapable of explaining.
Section 323 of the New Restatement of Torts, of course, establishes a standard to determine whether a particular kind of defendant’s conduct is negligent. It leaves open to further proof the question of whether the increased “risk of harm” was a substantial factor in bringing about the harm. Professor Prosser, in this regard, points to the example of the man who throws a lighted match into a forest fire as a paradigm case of when an increased risk of harm cannot reasonably be determined to be a substantial factor in causing any ensuing harm.5 In the vast majority of the cases, however, *258the question of whether the defendant’s negligence was, more likely than not, a substantial factor in bringing about the harm is a question for the jury 6
The issue in the instant case is whether sufficient evidence was presented from which the jury might conclude that it was more likely than not that defendant’s negligence was a substantial factor in causing decedent’s heart attack to be fatal. It is clear to me that the evidence was sufficient for that purpose. As one commentator has explained:
“Whenever it can be said with fair certainty that the rule of conduct relied upon by the plaintiff was designed to protect against the very type of risk to which the plaintiff was exposed, courts have shown very little patience with the efforts of defendant to question the sufficiency of proof on cause.” 7
On the contrary, when such proof is given, most courts impose an extremely strict standard of rebuttal evidence on the defendant,8 and virtually no court would conclude that plaintiff has not made out a case for the jury.9 In the instant case the evidence fairly indicated that the defendant negligently failed to diagnose and treat a heart attack, that defendant’s negligence increased the risk that Mr. Hamil would die of a heart attack, and that Mr. Hamil in fact died of a heart attack. Defendant’s rebuttal? Mr. Hamil may have died of a heart attack even if the hospital had not been negligent. To be sure, the jury *259might have concluded that Mr. Hamil’s demise was so nearly inevitable when he entered the hospital that the hospital’s negligence was not a substantial factor in bringing about his death. But, to hold that the proof was so insufficient that the trial court should have directed a verdict for defendant is not only unsupported by legal theory, but ignores the vast weight of the decided case law. When the law requires knowing the unknowable, matters of policy and factual likelihood are so inextricably involved that cases may rarely be taken from the jury.10
The mainstay of tort casebooks discussing this point is Reynolds v. Texas & Pac. Ry., 37 La.Ann. 693, 698 (1895). In that case a fat woman was hurrying down the steps of a negligently unlighted stairwell in a railroad station. She stumbled and fell, thereby sustaining serious injuries. On appeal the court stated:
“[Wjhere the negligence of the defendant greatly multiplies the chances of accident . . .■ and is of a character naturally leading to its occurrence, the mere possibility that it might have happened without the negligence is not sufficient to break the chain of cause and effect.”
The rule found increasing support in a variety of fact situations; for, when the harm suffered by plaintiff is the very harm which defendant’s duty was designed to prevent, courts have not required the plaintiff to further prove that defendant’s compliance with its duty would have been availing. The following situations highlight that proposition: a woman fell overboard and drowned —no proof required that providing a rope on deck would have saved her;11 A boy drowned in a swimming pool— *260no proof required that a lifeguard on duty would have saved him;12 a man was injured when his car collided with a train — no proof required that the man would have heard a train whistle and avoided the collision;13 and, a woman was injured as a result of a fire in a multistory garment factory — no proof required that the woman would have reached an additional fire escape had one been provided.14 In all these cases the defendant sought to avoid liability by demanding that the plaintiff show that “but-for” the defendant's negligence the plaintiff would not have been injured. In all those cases the courts eschewed the need for the plaintiff to offer any such proof.
Nowhere, however, is such a strategem employed by defendants more commonly than in medical malpractice cases.15 Nevertheless, the legal trends and the clear weight of authority now recognize that the purported defense is no defense at all. Numerous medical malpractice cases, which are indistinguishable from the instant case with respect to the genre of defense asserted, have readily found that plaintiff made out a sufficient case to reach the jury. In Hicks v. United States, 368 F.2d 626 (4th Cir. 1966) the court confronted the argument in the following context: A young female diabetic entered a naval dispensary suffering from acute abdominal pain. The doctor on duty negligently failed to diagnose the severity of hér condition — an intestinal blockage which would have required immediate surgery if the woman were to survive. The doctor prescribed medication and *261sent the woman home. Shortly thereafter the woman died of a massive hemorrhage caused by the blockage. The hospital’s defense was that there was no proof that the woman would have survived even if surgery had been performed. The circuit court responded:
“When a defendant’s negligent action or inaction has effectively terminated a person’s chance of survival, it does not lie in the defendant’s mouth to raise conjectures as to the measure of the chances that he has put beyond the possibility of realization. If there was any substantial possibility of survival and the defendant has destroyed it, he is answerable. Rarely is it possible to demonstrate to an absolute certainty what would have happened in circumstances that the wrongdoer did not allow to come to pass.” Id. at 632. See also Harvey v. Silber, 300 Mich. 510, 2 N.W.2d 483 (1942).
In Rewis v. United States, 369 F.2d 595 (5th Cir. 1966) the court found the hospital liable for failing to diagnose aspirin poisoning resulting in an infant’s death. In so finding the court stated that there was no need for expert testimony to establish “to a reasonable degree of medical certainty” that prompt diagnosis would have saved the child’s life.
Perhaps Jeanes v. Milner, 428 F.2d 598 (8th Cir. 1970) offers the most dramatic example of the application of the rule. In that case a young boy was taken to a doctor because of a lump and soreness in his throat. When antibiotics failed to relieve the boy’s condition, further examinations led the treating physician to order biopsies. Due to negligence, the slides were not forwarded to the pathologist for more than a month and the boy’s condition worsened. Ultimately, the lump in the boy’s throat was diagnosed as malignant. Radio-therapy led to complete regression of the throat cancer, but by then the cancer was systemic and the boy subsequently died of a cancer in his stomach. Expert testimony for the plaintiffs established that during the delay in for*262warding the slides to the pathologist, the boy’s condition deteriorated from stage one to stage two cancer, reducing his chances for survival from thirty-five per cent to twenty-four percent. The circuit court found that sufficient evidence was presented to permit the jury to determine that the failure to promptly diagnose the boy’s condition was a substantial factor in bringing about his death.
In other cases, where a doctor or hospital did not subject a patient suffering from classic heart attack symptoms to an electrocardiogram, the courts have declined to require that the plaintiff prove with reasonable medical certainty that the decedent would have survived if his condition were properly diagnosed. See Brown v. United States, 419 F.2d 337 (8th Cir. 1969); O’Neill v. Montefiore Hospital, 11 A.D.2d 132, 202 N.Y.S.2d 436 (Sup.Ct. 1960).
Finally, even prior to our decision on the first appeal of the instant case, Pennsylvania law was not construed to require the result which the lead opinion suggests. In Schuler v. Berger, 275 F.Supp. 120 (E.D.Pa.1967), aff’d 395 F.2d 212 (3rd Cir. 1968), in affirming the judgment for plaintiff, the court expressly referred to its obligation to apply Pennsylvania law to the following facts: A young woman died some time after childbirth due to a negligent failure to diagnose peritonitis (caused by diverticulitis). In citing Hicks v. United States with approval, the court stated that the negligent diagnosis may be deemed to have caused the woman’s, death even though “it is not possible to demonstrate conclusively that the precaution would in fact have saved the victim.” Schuler v. Berger, 275 F.Supp. at 124. Nor has our former decision in the instant case been questioned as demarking a change in the law of this Commonwealth. See Rosario v. American Export-Isbrandtsen Lines, Inc., 395 F.Supp. 1192, 1210 (E.D.Pa.1975).16
*263In turning to the evidence presented in the instant case, Dr. Wecht, whose eminent qualifications were set forth in our previous opinion in this case, testified that had Mr. Hamil been subjected to an EKG and provided with the medication and facilities available at Bashline Medical Center, he would have had a seventy-five per cent chance for survival. Dr. Wecht also opined that “the substantial chances that Mr. Hamil would have had for survival were terminated, were taken away from him” because of the hospital’s negligence. What more positive proof of “causation” can reasonably be required by the law? Even if Dr. Wecht had only testified that Mr. Hamil’s chances for survival were reduced from three-in-four to one-in-four, the jury could nave concluded that it was twice as likely that Mr. Hamil died because of the negligent diagnosis rather than because his condition was necessarily fatal. In Christie v. Callahan, 75 U.S.App.D.C. 133, 124 F.2d 825, 827 (1941), Judge (later United States Supreme Court Justice) Kutledge noted:
“Malpractice is hard to prove. The physician has all of the advantage of position. . . . What therefore might be slight evidence when there is no such advantage, as in ordinary negligence cases, takes on greater weight in malpractice suits.”
The lead opinion in the instant case demands not less, but more.17
To conceive of an event without countless causes is impossible, and the but-for standard of causation alone pro*264vides no clue as to which of those causes is the legally responsible cause.18 I submit that the question of cause in this case asks whether a hospital ought to be legally responsible when its negligence increases the risk of harm to a patient, and the increased risk of harm can be said to be a substantial factor in bringing about that harm. As the cases and commentary cited above indicate, the clear weight of authority establishes that hospitals should be so held. A majority of this court has also agreed with that conclusion when this case was last before us. I find no reason to alter our judgment now, especially by further confusing an already confused, albeit critical, concept in the law of torts — causation.
Having determined that our decision and rationale in this case, when it was previously before us, rested on firm ground and should not be overruled, I now turn to appellant’s allegation that the trial court erroneously instructed the jury with respect to causation.
The hospital submitted a point for charge to the court which was adopted with minor modification. Over appellant’s objection the court charged:
“Unless it is certain that Mr. Hamil would have died without treatment, his chances for life were not terminated by any failure of the defendants to treat him and such failure cannot be considered a proximate cause of his death.”
Special interrogatories of the jury proved that the jury had found that the hospital was negligent, but that its negligence was not a proximate cause of the decedent’s death. Given the special interrogatories, obviously, if the charge was erroneous, and was not cured by other portions of the court’s instructions, we must grant appellant a new trial.
The charge as given was based upon Hicks v. United States, supra, where the expert testimony demonstrated *265that the deceased had no chance for survival once the doctor failed to diagnose the intestinal blockage — immediate surgery offered the only hope. However, as the other cases discussed above establish, there is no requirement that the victim, or his heirs, show that the harm which befell him was the only possible effect of the defendant’s negligence. Most notably, in Jeanes v. Milner, supra, plaintiff’s evidence established that decedent still had a twenty-four per cent chance of survival even after the diagnosis of cancer was negligently delayed. Surely, everyone would have been astounded in Reynolds v. Texas & Pac. Ry., supra, had the court required the portly Ms. Reynolds to prove that it was impossible for her not to have fallen down the steps once the stairwell was darkened. Such a principle of inevitability is simply unknown to the law of torts.
Indeed, the trial judge seems to have recognized that the charge, if literally read, was error, and has not attempted to justify it on that basis. Rather, the judge characterized it as a “grammatical nightmare,” which could only be understood to mean “Since it is certain that Mr. Hamil would have died . . .” instead of “Unless it' is certain that Mr. Hamil would have died. . . . ” I cannot agree. The charge, standing alone, can only be sensibly read to mean that the jury could not return a verdict for plaintiff if they found that Mr. Hamil had any chance for survival when he left the hospital. Since the principle set forth in Hicks is not limited to the facts of that case, the charge was erroneous.
I am mindful of the proposition set forth in Black v. A. E. Troutman Co., 385 Pa. 138, 140, 122 A.2d 201, 202 (1956) where the Court said:
“In determining whether a court’s instructions to the jury are erroneous we must consider that charge as a whole, and if it is not misleading we will not reverse, even though there be some inaccuracies or misstate*266ments. Error cannot be predicated upon isolated excerpts, if, when read with the remainder of the charge, a true and correct charge is revealed. . . . ”
With that in mind appellee refers us to other areas of the court’s thirty-six page charge which, it asserts, cures any error committed by incorporating appellee’s suggested point for charge. While the court correctly charged the jury that to be liable the hospital’s negligence must have been a substantial factor in bringing about Mr. Hamil’s death, nothing in the charge militated against the conclusion that the jury necessarily must have drawn from the erroneous point — to be a “substantial factor,” the hospital’s negligence must have terminated whatever chance Mr. Hamil had for survival. Although it appears that the court did not realize the full implication of the suggested point when it charged the jury,19 I cannot ignore the substantial likelihood (especially in light of the special interrogatories) that the error contributed to the verdict. Therefore, reluctantly I would reverse and remand for a new trial.
For the foregoing reasons I would refuse to overrule our prior decision in Hamil v. Bashline, 224 Pa.Super. 407, 307 A.2d 57 (1973), and would reverse and remand for a new trial.
SPAETH, J., joins in this dissenting opinion.

. Malone, Ruminations on Cause-in-Fact, 9 Stan.L.Rev. 60, 66-67 (1956).

. Restatement of Torts, Second §§ 431, 433; W. Prosser, Law of Torts 240 (4th ed. 1971).

. The rule applies regardless of whether the “concurring” cause originated negligently or naturally. See Restatement of Torts, Second § 432, Illustration 4.

. Small, Gaffing at a Thing Called Cause: Medico-Legal Conflicts in the Concept of Causation, 31 Tex.L.Rev. 630, 654 (1953).

. W. Prosser, supra note 2.

. Id. at 251.

. Malone, supra note 1, at 93. See also W. Prosser, supra note 2, at 242.

. Id.

. W. Prosser, supra note 2, at 242.
Indeed, in a case which will be further discussed in the text below, a federal circuit court determined that such proof estops the defendant from showing that the harm would have occurred without its negligence. See Hicks v. United States, 368 F.2d 626, 632 (4th Cir. 1966).

. Malone, supra note 1, at 71-72.

. Zinnel v. United States Shipping Bd. Emergency Fleet Corp., 10 F.2d 47 (2d Cir. 1925). Therein the court stated: “We cannot say that there was no likelihood that a rope three feet above the deck . . . would not have saved the [woman]. *260.” Id. at 49. Accord, Kirincich v. Standard Dredging Co., 112 F.2d 163 (3rd Cir. 1940).

. Rovegno v. San Jose Knights of Columbus Hall, 108 Cal.App. 591, 291 P. 848 (1930).

. New Orleans & N. E. Ry. v. Burge, 191 Miss. 303, 2 So.2d 825 (1941).

. Kohn v. Clark, 236 Pa. 18, 84 A. 692 (1912).

. See D. Harney, Medical Malpractice § 4.1 (1973).

. Similarly, although the denial of allocatur from a Superior Court order remanding this case for a new trial does not neces*263sarily constitute approval by the Supreme Court of the rationale espoused in support of that order, it is likely that the Supreme Court would have granted allocatur had our former decision substantially altered the law as the lead opinion suggests in order to avoid its application in cases like Rosario v. American Export-Isbradtsen Lines, Inc., supra.

. Indeed, one commentator suggests that it is futile for the law to require more of a medical expert than Dr. Wecht offered in the instant case. “To aggravate aggravation, to accelerate acceleration, to make the inevitable more inevitable are foreign to the expert in medicine.” Small, supra note 4.

. W. Prosser, supra note 2, at 239.

. Obviously, since Dr. Wecht testified that other people in Mr. Hamil’s condition might have survived despite the hospital’s negligence, the court would have directed a verdict for appellee if it fully subscribed to the position set forth in the point for charge.