Zuchowicz v. United States

United States Court of Appeals for the Second Circuit · 1998 · Torts

TortsCausationMedical malpracticeExpert testimonybut-for causesubstantial factorcausal linkproximate cause

Facts

At a Naval Hospital pharmacy, Patricia Zuchowicz was negligently given a Danocrine prescription directing her to take 1600 mg per day, twice the FDA-approved maximum dosage of 800 mg per day. After taking the overdose for a month and then 800 mg per day until late May 1989, she developed symptoms and was later diagnosed with primary pulmonary hypertension, a rare and fatal disease. The government stipulated that prescribing the 1600 mg dosage was negligent; the dispute was whether the overdose legally caused her illness and death. The plaintiff relied primarily on expert testimony from Dr. Matthay, who treated her and used differential etiology and timing, and Dr. Tackett, who offered a pharmacological mechanism linking the overdose to PPH.

Issue

Whether the district court clearly erred in finding that the negligent overdose of Danocrine was a substantial factor in causing Zuchowicz's primary pulmonary hypertension and death, and whether the district court abused its discretion in admitting the plaintiff's expert testimony on causation. Also, whether the district court's damages award lacked evidentiary support.

Rule

Under Connecticut law, a medical malpractice plaintiff must show that the defendant's negligent act was a substantial factor in producing the injury, which generally requires but-for cause, causal link, and proximate cause. Expert causation testimony must rest on more than surmise or conjecture and must express reasonable medical probabilities, but causation may be proved by circumstantial evidence, including differential etiology and timing. When a negligent act is wrongful because it increases the risk of a particular type of harm, and that very harm occurs, a factfinder may infer but-for causation; where a drug is negligently prescribed in an excessive, unapproved dosage and the drug is shown to have caused the injury, that showing generally permits the finder of fact to conclude that the excessive dosage was a substantial factor in producing the harm.

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One of 10 multiple-choice questions for this case. Pick an answer to see why.

At a military clinic in San Diego, a pharmacist negligently dispensed 300 mg daily of a hormone-based drug even though the approved maximum was 100 mg. After three weeks, Lena Ortiz developed a rare vascular lung condition. Her pulmonologist testified that, to a reasonable medical probability, the drug caused the condition because he ruled out secondary causes, excluded known alternative drug-related causes, and relied on the close timing between the overdose and symptom onset.

Under the majority's approach, is the evidence sufficient to support a finding that the drug caused Lena's condition?

Explanation. The majority held that expert testimony can establish causation when it rests on reasonable medical certainty/probability and uses accepted methods such as treatment history, differential etiology, exclusion of alternative causes, and temporal relationship. The expert need not eliminate all possible causes, and the absence of epidemiological evidence is not fatal where the condition is rare and the exposure uncommon.