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Material Contribution to Injury
Illustrative Cases: Bonnington , Bailey , O2 , Rahman , Fitzgerald
Factual Basis
This analysis is applied where:
- there are multiple factors (not all of which need to be tortious);
- the case is not one of overdetermination or pre-emption;
- it has been established that the tortious factor/s have had an actual effect^1 on the claimant’s position at trial; and either
- the injury is divisible in principle, but it is not possible to attribute constituent parts to particular factors on the facts of a given case ( Bonnington ); or
- the injury is indivisible ( Bailey , O2 , Rahman ).
A ‘material contribution to injury’ analysis is appropriate where it is more likely than not that at least one defendant’s breach has made a difference to the claim- ant’s outcome, but it is not possible to isolate the physical effects of individual breaches from one another. This impossibility precludes the application of basic causal principles. For instance, in a factual scenario like the one in Performance Cars Ltd v Abraham ,^2 there were two physically distinct instances of damage to the claimant’s car, each of which could be linked discretely to a particular defendant.^3 By contrast, those situations in which a court should resort to a ‘material contribu- tion to injury’ analysis are those where the fact^4 of a defendant’s contribution to
(^1) The question of what this amounts to is a contentious one and will be examined in detail below. In summary, under the NBA, a factor must have been a necessary one in the claimant’s injury occurring as and when it did in order to amount to a material contribution. This does not accord with the idea, expressed in Sienkiewicz v Greif [2011] UKSC 10, [2011] 2 AC 229 at [90] 265 (per Lord Phillips) and in Bonnington Castings v Wardlaw [1956] AC 613 (HL) at 621 (per Lord Reid) that such a factor need only have made a contribution in excess of a de minimis level in order to be deemed a material contribution. (^2) Performance Cars Ltd v Abraham [1956] 1 QB 33 (CA). (^3) In this case, such an exercise was a straightforward one because the damage to the claimant’s car occurred in two consecutive chronological stages, but this is not necessary for an injury to be divisible. Were a car to have been hit by two other vehicles simultaneously, it might of course still be possible to link separable parts of the total damage to each particular collision. (^4) In the sense of the claimant having proven, on the balance of probabilities, that but for the defend- ant’s breach, her natural course of events would have been unaffected.
Factual Basis 95
damage has been established, but there are other factors involved, and there is simply no means of discretely assigning constituent parts of that damage to par- ticular factors. In the case of indivisible injuries, this is because such damage is binary in nature and so cannot be broken down into constituent parts. In the case of injuries divisible in theory, the problem arises because it is not possible as a matter of evidence to identify any clean correspondence between constituent parts and multiple potential factors.
Injury Is Divisible in Principle but It Is Not Possible to Attribute
Constituent Parts to Particular Factors
The classic example of this category of case is Bonnington Castings v Wardlaw ,^5 in which the claimant contracted pneumoconiosis during the course of his employ- ment by the defendants. There were two factors identified as contributing to this disease: first, those particles of silica dust in the workplace atmosphere which had emanated from swing grinders and second, those particles of silica dust which had come from pneumatic hammers. Whilst both types of workplace machinery were the legal responsibility of the defendants,^6 they had only breached their duty in relation to the first, since there was no known or practicable means of reducing the dust escaping from the latter. This meant that the particular question for the court in this case was whether the dust resulting from the defendant’s breach could be causally linked to the claimant’s injury. The essence of this problem was identified by Lord Keith:
The disease is a disease of gradual incidence. Small though the contribution of pollution may be for which the defenders are to blame, it was continuous over a long period. In cumulo, it must have been substantial, though it might remain small in proportion. It was the atmosphere inhaled by the pursuer that caused his illness and it is impossible, in my opinion, to resolve the components of that atmosphere into particles caused by the fault of the defenders and particles not caused by the fault of the defenders, as if they were separate and independent factors in his illness. Prima facie the particles inhaled are acting cumulatively, and I think the natural inference is that had it not been for the cumulative effect the pursuer would not have developed pneumoconiosis when he did and might not have developed it at all.^7
The specific problem posed for the causal inquiry by Bonnington stems from the fact that each potential causal factor (ie the ‘innocent’ dust and the ‘guilty’ dust)
(^5) Bonnington Castings v Wardlaw [1956] AC 613 (HL). Although, as Lord Rodger states in Fairchild v Glenhaven Funeral Services [2002] UKHL 22, [2003] 1 AC 32 at [129] 100: ‘The idea of liability based on wrongful conduct that had materially contributed to an injury was... established long before Wardlaw. But Wardlaw became a convenient point of reference, especially in cases of industrial disease’. (^6) Covered specifically by regulation 1 of the Grinding of Metals (Miscellaneous Industries) Regulations 1925. (^7) [1956] AC 613 (HL) at 626 (per Lord Keith).
Factual Basis 97
quent award of damages, and the second is whether a material contribution to injury analysis is an application of, or an exception to, the But For test. The first question no doubt arises because, as we see from Bonnington , injuries which are divisible in principle will sometimes call for liability to be assessed on a material contribution to injury basis where that divisibility is not possible in prac- tice, but where there have been multiple potential causal factors. Facts such as those arising in Bonnington therefore occupy something of a halfway house. It is trite negligence law that, where possible, defendants should only be held liable for that part of the claimant’s ultimate damage to which they can be causally linked, as is clear from cases such as Thompson and Performance Cars. It is equally trite that, where a defendant has been found to have caused or contributed to an indi- visible injury, she will be held fully liable for it, even though there may well have been other contributing causes:^12
[I]t is... hard – and settled law – that a defendant is held liable in solidum even though all that can be shown is that he made a material, say 5%, contribution to the claimant’s indivisible injury. That is a form of rough justice which the law has not hitherto sought to smooth, preferring instead, as a matter of policy, to place the risk of the insolvency of a wrongdoer or his insurer on the other wrongdoers and their insurers.^13
Since the injury in Bonnington is theoretically divisible, it seems not to fit into this second category, but it can no more fit into the first because there is, as we have seen, no practical basis on which any sensible division could be made.^14 This was not a question which troubled the Court in Bonnington , since the defendants’ case was that they were not liable for the damage at all; they made no plea for any apportionment to be made on the basis that their breach of duty was not the only causal factor involved in triggering pneumoconiosis. The very fact, however, that no apportionment was made, has led to questions being asked subsequently as to whether that conclusion was the purely the result of the conduct of that particular case, or whether the same outcome would have occurred for substantive reasons, had the defendants requested that it be considered.^15 The answer is that there should be no apportionment in cases which require, on the basis outlined in this chapter, a material contribution to injury analysis. The argument that apportionment of damages is not appropriate in cases in which a defendant has materially contributed to an indivisible injury is both well estab- lished and easy to justify.^16 There is, however, no obvious or defensible reason why a different approach should be taken where a practical segmentation is no more feasible, despite the fact that the damage in question might be theoretically divisible
(^12) See, eg, Dingle v Associated Newspapers [1961] 2 QB 162 (CA) at 188 (per Devlin LJ), Hotson v East Berkshire Health Authority [1987] AC 750 (HL) at 783 (per Lord Harwich) and J Smith, ‘Causation – the Search for Principle’ [2009] Journal of Personal Injury Law 101, 103. See also Baldwin & Sons Pty Ltd v Plane (1998) 17 NSWCCR 434 (NSWCA), Bendix Mintex Pty Ltd v Barnes (1997) 42 NSWLR 307 (NSWCA) and Gates v Howard Rotavator Pty Ltd (2000) 20 NSWCCR 7 (NSWCA). (^13) Barker v Corus [2006] UKHL 20, [2006] 2 AC 572 at [90] 607–08 (per Lord Rodger). (^14) Stapleton, ‘Lords a’ Leaping’, above n 9 at 283. (^15) See, for example, Stapleton, ‘Unnecessary Causes’, above n 9 at 52. (^16) See nn 12 and 13 above.
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in nature.^17 As illustrated above, had the factors in Bonnington operated consecu- tively, the damage therein would have been both theoretically and practically divisible. This is because the cumulative nature of pneumoconiosis (which is what makes it divisible in theory) would have lent itself to being divided up chrono- logically according to the extent of its development during the period of exposure to each successive factor. A material contribution to injury approach would not therefore have been necessary because such facts would have been amenable to conventional causal analysis along the same lines as Thompson.^18 The very fact that such division was not possible is what makes it an appropriate case for analysis on the basis of material contribution to injury. Once this practical impossibility exists, there is no effective means of distinguishing between divisible and indivisible inju- ries, since a court is no more able sensibly to divide up the one than the other. A defendant who has been found to have materially contributed to such an injury, therefore, should be held liable for 100 per cent of the claimant’s damages.^19 The answer to the second question, of whether the material contribution to injury analysis is an application of, or an exception to, the But For test, can be made equally emphatically: it adheres to, and does not depart from, the basis of But For causation. As will become clear, the first stage of the NBA, which is based on aggregate But For causation, has still to be satisfied where a material contribu- tion to injury analysis is applied, just as it does in other types of case.
1 – Is it more likely than not that a defendant’s breach of duty changed the claimant’s normal course of events so that damage (including constituent parts of larger damage) occurred which would not otherwise have done when it did?
Under this analysis, a defendant’s breach has either to have part-caused an indivis- ible injury, or caused part of a (theoretically) divisible injury. Unless, however, a defendant has made a difference to the claimant’s course of events in this way, there will be no liability.^20
Injury Is Indivisible
An indivisible injury is one which cannot be broken down into separable constitu- ent parts. It is obvious, given this characteristic, why a quantification of respective
(^17) But see Sienkiewicz v Greif [2011] UKSC 10, [2011] 2 AC 229 at [90] 265 (per Lord Phillips). And, in order for a material contribution to injury analysis to be appropriate, the injury must by definition be one which cannot practically be divided up amongst discrete causal factors. (^18) [1984] QB 405 (QB) at 438. (^19) According to Jane Stapleton, this is the approach adopted by the US courts in asbestosis claims – see J Stapleton, ‘The Two Explosive Proof-of-Causation Doctrines Central to Asbestos Claims’ (2009) 74 Brooklyn Law Review 1011. This is also subject, as outlined below (see text to n 38) to a possible reduction in certain heads of damage if the court decides that the injury might have occurred at some point in the future owing to factors unrelated to the defendant’s breach of duty. (^20) This argument will be addressed fully below, where the case of Bailey v Ministry of Defence [2008] EWCA Civ 883, [2009] 1 WLR 1052 is discussed.
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stage of the NBA is clearly satisfied, since it is more likely than not that at least one defendant’s breach of duty changed the claimant’s normal course of events for the worse. The second stage, asked of the two defendants in turn, would also be satis- fied in each case, since the effects of both were still operative on the claimant when he suffered the damage for which he claimed. Contrary to the view of Laws LJ, the claimant’s psychiatric injury should properly have been classed as indivisible harm, since his ongoing suffering could not be disaggregated and assigned to sep- arate causes. Whilst Laws LJ gave detailed consideration to the question of whether the psychiatric injury resulting from the two defendants’ breaches could be said to be ‘the same damage’ for the purposes of the Civil Liability (Contribution) Act 1978, he ultimately held that it was not. His Lordship’s decision appeared to give much weight to
an absurd report confected jointly by the experts for the three parties, who tentatively divided up the victim’s present condition in terms of the two causes. They should not have been asked to do this, and their answer should have been ignored, for there is no scientific basis for any such attribution of causality: the claimant is not half-mad because of what the first defendant did and half-mad because of what the second defendant did, he is as mad as he is because of what both of them did. His mania is aetiologically indis- cerptible... 26
The conclusion then reached was that
on the evidence the respective torts committed by the defendants were the causes of distinct aspects of the claimant’s overall psychiatric condition, and it is positively estab- lished that neither caused the whole of it... one cannot... draw a rough-and-ready conclusion to the effect that this is really an indivisible injury and therefore ‘same dam- age’ within section 1(1) of the 1978 Act.^27
With respect, it is difficult to see how the claimant’s ultimate psychiatric damage could be divided into ‘distinct aspects’, and Weir’s analysis is the more coherent. Whilst Rahman did indeed suffer from more than one manifestation of mental trauma, in that he had PTSD, depression and phobia, it would be neither authen- tic nor feasible to regard these as having been the separate and discrete results of individual breaches of duty. Not only is it far more likely that the two defendants’ actions worked synergistically to bring about the claimant’s ongoing injury, but the tenor of more recent case law appears to support the view that such damage is indivisible.^28 For instance, Hale LJ in Hatton v Sutherland^29 refers to Rahman as a
On basic causation principles (see Ch 3), the first defendant is liable for all of the claimant’s damage up until the time the negligent operation was performed. Applying the NBA confirms this since, under its second stage of analysing the pre-operation damage (loss of earnings and removal expenses), the sec- ond defendant’s breach would be found (obviously) to be not yet operative on the claimant. See also Wright v Cambridge Medical Group [2011] EWCA Civ 669, [2013] QB 312 at [52] 328 and [129] 347. (^26) Weir, ‘The Maddening Effect’, above n 24 at 238. (^27) [2001] QB 351 (CA) at [23]–[24] 364–365. (^28) Although some heads of damage, such as the first three years’ loss of earnings and reasonable removal expenses, were attributed solely to the defendant employer since they pre-dated the effects of the negligent medical treatment. This is standard practice and, as such, is unremarkable. (^29) Hatton v Sutherland [2002] EWCA Civ 76, [2002] 2 All ER 1 at [37]–[40] 17–18.
Factual Basis 101
case involving indivisible injury,^30 as does Smith LJ in Dickins v O2 Plc.^31 In an extra-judicial context, this latter view is reiterated in no uncertain terms, when psychiatric damage is described as ‘ par excellence an indivisible injury’.^32 In one sense, Laws LJ concedes this in an indirect way when he says of the contentious report of the experts:
It is true that this agreed evidence does not purport to distribute causative responsibility for the various aspects of the claimant’s psychopathology between the defendants with any such degree of precision as would allow for an exact quantification by the trial court; no doubt any attempt to do so would be highly artificial. But the lack of it cannot drive the case into the regime of the 1978 Act to which, in principle, it does not belong... The fact-finding court’s duty is to arrive at a just conclusion on the evidence as to the respec- tive damage caused by each defendant, even if it can only do it on a broad-brush basis which then has to be translated into percentages.^33
In essence, what his Lordship prepares to do here is to apportion liability between defendants on a basis apparently unconnected to the factual matrix of the case. Such apportionment (one-quarter to the employers and three-quarters to the health authority) was instead carried out according to an apparently impression- istic account of the relative culpability of the defendants. Despite the strikingly heterodox nature of this approach, it was validated by obiter remarks made by Hale LJ in the Court of Appeal in Hatton^34 and, although the House of Lords expressly declined to offer a view on this point when they considered the same case,^35 the suggestion was implemented in Dickins v O2 Plc.^36 The claimant in Dickins was suing her former employer for psychiatric injury caused by excessive stress at work. The evidence suggested that she had been pro- moted to a position beyond her natural capabilities and that this had, over time, led to her suffering from mental health problems, variously characterised as anxi- ety and depression. Once the Court of Appeal accepted that her work problems stemmed from a breach of duty, it was faced with a potential problem of causation in that, besides the situation at work, the claimant had a vulnerable personality, and had suffered from mental health issues in the past. In addition to this, she suf- fered from IBS, was at the material time experiencing difficulties in her relation- ship with her partner (although the evidence was inconclusive as to whether these phenomena were causes or effects of her stress), and had also, during the relevant period, had to move out of her home for nine months as a result of flooding. There existed, therefore, several non-breach factors which could potentially have
(^30) [2002] EWCA Civ 76, [2002] 2 All ER 1 at [37] 17 and again at [40] 18. (^31) Dickins v O2 Plc [2008] EWCA Civ 1144, [2009] IRLR 58 at [45] 64. See also Weir, ‘The Maddening Effect’, above n 24 at 239, where he says of Rahman that ‘the harm was not incremental, but the indivis- ible result of a synergistic or catalytic concatenation of events’. (^32) Smith, ‘Causation’, above n 12 at 103. (^33) [2001] QB 351 (CA) at [23] 364. (^34) [2002] EWCA Civ 76, [2002] 2 All ER 1. (^35) [2004] UKHL 13, [2004] 2 All ER 385 at [63] 405 (per Lord Walker). (^36) [2008] EWCA Civ 1144, [2009] IRLR 58.
Factual Basis 103
Furthermore, Tony Weir points out that this is not ‘just a matter of aesthetics. Consequences ensue. If, in the present case, either defendant had been insolvent, the claimant would not have been fully indemnified’.^40 As both Smith and Sedley LJJ make clear,^41 full indemnity in such a case as this may well take the form of reduced damages, to account for the possibility of the same injury occurring in the future as a result of non-tortious causes. This is the orthodox legal approach, and is far superior to one which employs apportionment carried out on ‘the basis of speculation or guesswork’:^42
It is important conceptually to differentiate apportionment or divisibility from another perfectly common process in the assessment of loss, which is to take account of the vicis- situdes of life or contingencies as applicable to the individual claimant. If, for example, a claimant suffered from a natural disease from which he was likely to die in five years, the court would take that fact into account when limiting damages to a period of five years... In truth,... [this] is not apportionment at all – what the court is doing is tak- ing a snapshot of the claimant, at a point immediately prior to the accident, which incorporates at that time all the particular negative or positive factors in the claimant’s own past or future, as well as the future factors which might afflict persons generally. The court, when taking into account the contingencies and vicissitudes of life, makes its award in an attempt to reproduce the snapshot, the object being to restore the claimant, warts and all, to the position he was in before the tort was committed.^43
To understand exactly why this is so, it is necessary to consider the temporal dimension of the causal inquiry. When we ask whether the claimant’s damage would have occurred but for a defendant’s breach, this can only meaningfully be understood as meaning ‘But for a defendant’s breach, would the claimant’s dam- age have occurred when it did ?’^44 Unless it is understood in this way, a But For inquiry is either impossible to answer, or legally meaningless, or both. Consider, as an example, a claim in which death forms the gist of the damage. Clearly, here, but for the defendant’s breach, the claimant would definitely have died. At some stage.^45 The point of legal relevance is of course whether the claimant would have died when she did but for the defendant’s breach.^46 Where death is concerned,
(^40) Weir, ‘The Maddening Effect’, above n 24 at 238. (^41) And Smith LJ reiterates extra-judicially in Smith, ‘Causation’, above n 12 at 103. (^42) The correct approach was taken in Fitzgerald v Lane [1989] AC 328 (HL), in which two defendants, acting independently, were found to have been equally responsible for the ultimate indivisible injury (partial tetraplegia), alongside a substantial contribution from the claimant himself. After reducing the total damages by 50% for contributory negligence, the defendants were held jointly and severally liable for the remaining 50%. (^43) L Caun, ‘Multiple Causes of Injury’ [2003] Journal of Personal Injury Law 96, 107–08. (^44) As already apparently recognised in academic literature, but rarely translated into express practi- cal applications – see R Wright, ‘The NESS Account: Response to Criticisms’ in R Goldberg (ed), Perspectives on Causation (Oxford, Hart Publishing, 2011) n 48 and J Stapleton, ‘Choosing What We Mean by “Causation” in the Law’ (2003) 73 Missouri Law Review 433, 452–53. (^45) See D Lewis, ‘Causation as Influence’ in J Collins, N Hall and LA Paul (eds), Causation and Counterfactuals (Cambridge, MA, The MIT Press, 2004) 86. The significance of this point becomes even more acute in cases involving epidemiological evidence; see below, text to n 50. (^46) Although it is sometimes obvious that this is really what the But For inquiry is asking, this is by no means universally the case (nor is it universally accepted as being appropriate).
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therefore, a non-temporally specific But For inquiry will always be easy to answer, but it will tell us nothing of value to the causal inquiry.^47 Where, on the other hand, the gist of the claim is damage of some other type, such as a broken leg, it will be impossible to predict whether a claimant would ever have suffered such an injury at any point in their life, were it not for the defendant’s breach. An inquiry such as this one is therefore both impossible to conduct and lacks any legal purchase. Facile examples these may be, but they illustrate clearly how important it is that any But For inquiry is imbued with temporal specificity. Without this, as we have seen, no such test will be able to distinguish between overdetermined and pre- empted causal inquiries.^48 It is difficult to discern a reason, therefore, for omitting this crucial qualification from the express formulation of the test.^49 In addition to this conceptual argument, there are practical justifications for why the causal inquiry should have as its focus the stage at which a claimant incurred the damage of which she ultimately complains. First, the specific ques- tion of whether an individual would have incurred damage when she did is an established part of epidemiological causal theory:
One definition of the cause of a specific disease occurrence is an antecedent event, con- dition or characteristic that was necessary for the occurrence of the disease at the moment it occurred, given that other conditions are fixed. In other words, a cause of a disease occurrence is an event, condition or characteristic that preceded the disease onset and that, had the event, condition or characteristic been different in a specified way, the disease either would not have occurred at all or would not have occurred until some later time.^50
It is easy to identify several significant reasons why claimants should want to remain undamaged for as long as possible. Clearly, most of us would want to die later rather than sooner, and this applies not only to our emotional and physiolog- ical perspectives, but also to the material effect that a longer life will often have on our estate. Where illness is concerned, similar arguments apply, in that people generally will want to have as much of their life as possible unaffected by pain, suffering and infirmity. In the context of property damage, particularly where that property is fungible and replaceable, the significance of timing is not necessarily so striking from the subjective viewpoint of the claimant. Nevertheless, it remains legally pertinent because, as with personal injury, determining the point at which a defendant’s breach affected the claimant allows a court either to divide damage up amongst several factors (where this is possible) or, in any event, to determine
(^47) See text to n 124 below. (^48) Wright, ‘The NESS Account’, above n 44 at n 125. (^49) Which is what Richard Wright has long argued for in relation to the US Restatement : American Law Institute, 82nd Annual Meeting, Proceedings 2005 (Philadelphia, PA, American Law Institute, 2006) 81–84 (thus far in vain – see American Law Institute, Restatement of the Law, Third, Torts: Liability for Physical and Emotional Harm (St Paul, MN, American Law Institute, 2010) § 26). (^50) K Rothman, S Greenland, T Lash, Modern Epidemiology 3rd edn (Philadelphia, PA, Wolters Kluwer, 2008) 6. The statistical implications of this for the legal test are explored further below.
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circumstances, be open to a court to reduce the damages payable accordingly.^60 This has been referred to as the ‘crumbling skull doctrine’:
The so-called ‘crumbling skull rule’ simply recognizes that the pre-existing condition was inherent in the plaintiff’s ‘original position’. The defendant need not put the plaintiff in a position better than his or her original position. The defendant is liable for the injuries caused, even if they are extreme, but need not compensate the plaintiff for any debilitat- ing effects of the pre-existing condition which the plaintiff would have experienced any- way. The defendant is liable for the additional damage but not the pre-existing damage
... if there is a measurable risk that the pre-existing condition would have detrimentally affected the plaintiff in the future, regardless of the defendant’s negligence, then this can be taken into account in reducing the overall award... This is consistent with the general rule that a plaintiff must be returned to the position he would have been in, with all of its attendant risks and shortcomings, and not a better position.^61
In the case from which this excerpt is taken, Athey v Leonati ,^62 the Supreme Court of Canada dealt meticulously with the particularities of the material contribution to injury means of analysis. In that case, the claimant, who had a history of back problems, had been injured in two successive car accidents, each resulting from the defendants’ breach of duty.^63 Subsequently, whilst performing a routine stretch, he suffered a disc herniation for which he required surgery. As a result, he was forced to take lower-paid employment so that he could avoid heavy manual work. The trial judge awarded the claimant 25 per cent of the global damages fig- ure on the basis that the two accidents were not the sole cause of the herniation, (because of the pre-existing back problems) but that they played a causative role, estimated to be in the region of 25 per cent. The Court of Appeal agreed with this assessment, but the Supreme Court rectified this mistake conclusively and con- structively in awarding full damages against the defendants. It did so primarily on the basis that the trial judge had concluded that ‘the plaintiff has proven, on a balance of probabilities, that the injuries suffered in the two earlier accidents con- tributed to some degree to the subsequent disc herniation’.^64 Major J, in giving the judgment of the Court, went on to say:
Had the trial judge concluded (which she did not) that there was some realistic chance that the disc herniation would have occurred at some point in the future without the accident, then a reduction of the overall damage award may have been considered. This is because the plaintiff is to be returned to his ‘original position’, which might have included a risk of spontaneous disc herniation in the future. However, in the absence of such a finding, it remains ‘speculative’ and need not be taken into consideration.^65
(^60) [2008] EWCA Civ 1144, [2009] IRLR 58 at [47] 64. See also A Dugdale and M Jones, Clerk & Lindsell on Torts , 20th edn (London, Sweet & Maxwell, 2010) 2-161. (^61) Athey v Leonati [1996] 3 SCR 458 (SCC) at [35]. (^62) Athey v Leonati [1996] 3 SCR 458 (SCC). (^63) Although there were two defendants in fact, both were represented as one at the trial. (^64) [1996] 3 SCR 458 (SCC) at [44]. (^65) [[1996] 3 SCR 458 (SCC) at [48]. See also Graham v Rourke (1990) 75 OR (2d) 622 (Ont CA), Malec v JC Hutton Proprietary Ltd [1990] HCA 20, (1990) 169 CLR 638 and Schrump v Koot (1977) 18 OR (2d) 337 (Ont CA).
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Even more helpfully, the Supreme Court explicitly summarised the principles on which it reached its decision:
If the injuries sustained in the motor vehicle accidents caused or contributed to the disc herniation, then the defendants are fully liable for the damages flowing from the her- niation. The plaintiff must prove causation by meeting the ‘but for’ or material contribu- tion test.^66 Future or hypothetical events can be factored into the calculation of damages according to degrees of probability, but causation of the injury must be determined to be proven or not proven. This has the following ramifications:
- If the disc herniation would likely have occurred at the same time, without the injuries sustained in the accident, then causation is not proven.
- If it was necessary to have both the accidents and the pre-existing back condition for the herniation to occur, then causation is proven, since the herniation would not have occurred but for the accidents. Even if the accidents played a minor role, the defendant would be fully liable because the accidents were still a necessary contribut- ing cause.
- If the accidents alone could have been a sufficient cause, and the pre-existing back condition alone could have been a sufficient cause, then it is unclear which was the cause-in-fact of the disc herniation. The trial judge must determine, on the bal- ance of probabilities, whether the defendant’s negligence materially contributed to the injury.^67
This last paragraph is slightly ambiguous. If it means that, because the judge in such a situation is unable to make such a determination on the balance of proba- bilities there can be no liability, it is correct. Otherwise, it is difficult to follow. Nonetheless, the Athey judgment as a whole is to be welcomed for its generally concise (at only 53 short paragraphs), straightforward and accurate exposition of how to analyse a situation in which there have been material contributions to an injury. At the other end of the spectrum, a judgment apt to cause much confusion is that of the English Court of Appeal in Bailey v Ministry of Defence.^68 The claimant in this case suffered from severe brain damage, resulting from a cardiac arrest brought on by her aspirating her own vomit. She had attended a hospital managed by the defendants in order that she might undergo a procedure, known as an ERCP, to examine and treat a suspected gall stone in her bile duct. It was in rela- tion to the claimant’s post-operative care that the defendant breached its duty of care, since there was a failure to resuscitate the claimant during the night following the procedure, leading to her being very unwell by the following morning. At the same time, and unrelated to the defendant’s breach of duty, the claimant also developed pancreatitis, an illness which is known to occur in some patients follow- ing an ERCP. More than a fortnight after her initial operation, the claimant
(^66) Emphasis added – these italics highlight an unfortunate flaw in the Court’s otherwise coherent reasoning: as should now be apparent, the But For and material contribution to injury analyses are not mutually exclusive. Rather, the latter is a specialised application of the former. (^67) [1996] 3 SCR 458 (SCC) at [41]. (^68) Bailey v Ministry of Defence [2008] EWCA Civ 883, [2009] 1 WLR 1052.
Medical Negligence 109
of part of a (theoretically) divisible injury. The first stage of the NBA must be satis- fied in order for there to be liability on the grounds of a material contribution to injury.
1 – Is it more likely than not that a defendant’s breach of duty changed the claimant’s normal course of events so that damage (including constituent parts of larger damage) occurred which would not otherwise have happened when it did?
In his proposition, Waller LJ appears to conflate But For with de minimis non curat lex , by seeing them as mutually exclusive, or at least as alternatives. Since both are necessary, this may well be the source of his confusion. Where indivisible injury, such as that suffered in Bailey , is concerned, a claimant must establish, on the bal- ance of probabilities, that the defendant’s breach was a part-cause of that damage. In other words, she must prove that, but for the defendant’s breach, her injury would not have occurred when it did. It may well be the case that, even where a claimant has established that a defendant’s breach was, in But For terms, a part- cause of her injury, a court may decide that that contribution was so small as to absolve the defendant from liability on the basis of the de minimis principle, but the two principles are complementary and not alternative. The facts in Bailey should have led to a conclusion of no liability because the experts therein were unable to say that, on the balance of probabilities, but for the negligent care, Ms Bailey would have avoided having the cardiac arrest (which led to the brain damage) when she did.^73 The medical evidence did, however, suggest that the defendant’s breach had a more than negligible chance of being a cause of the claim- ant’s ultimate damage and this is what, erroneously, Waller LJ regarded as being sufficient to find liability on a material contribution to injury basis. As a result, Bailey is a confused, confusing, and ultimately unhelpful decision.
Medical Negligence
The performance of a material contribution to injury analysis requires particular care in situations involving medical negligence. The medical context provides, in any event, a special kind of challenge for the causal inquiry because, almost by definition, medical practitioners deal with individuals who are already injured or damaged in some way. Often, it is the task of extricating the breach from the non- breach factors which makes this area of the law so difficult. An added dimension to this problem is the fact that human physiology is unpredictable, imperfectly understood and often makes it very hard to determine where the effect of one fac- tor ends and another begins.
(^73) For an Australian perspective, see Tubemakers of Australia Ltd v Fernandez (1976) 50 AJLR 720 (HCA) at 724.
110 Material Contribution to Injury
Wright v Cambridge Medical Group provides an example of these difficulties.^74 In this case, the claimant’s GP, who worked for the defendant partnership, was consulted by the claimant’s mother by telephone, and subsequently failed to see the claimant or to refer her to hospital as (the defendants conceded) he should have done. The claimant, who was 11 months old, was actually suffering from a bacterial super-infection contracted during an earlier visit to hospital for chicken pox treatment. She was finally referred to hospital two days later. Once there, however, she received inadequate medical care, which would doubtless have been deemed to be in breach of duty had the hospital been joined as a defendant to the action which, inexplicably, it was not. The causal question for the court, therefore, was whether the GP’s breach of duty was causative of the claimant’s ultimate injury (a permanently unstable hip, restricted movement range, leg length dis- crepancy and restricted mobility). It had to consider whether the hospital’s inad- equate treatment broke the chain of causation between the defendant’s breach and the claimant’s injury, and whether it would be reasonable to hold, as the trial judge had done, that even a timely referral would have made no difference to the claim- ant’s position, since the hospital would have treated her inadequately, leading to her injuries occurring in any event. Ultimately, the Court of Appeal (Elias LJ dissenting) allowed the claimant’s appeal and found the defendants liable in full for the claimant’s permanent dam- age.^75 The essential basis of this decision can be found in the judgment of Lord Neuberger of Abbotsbury MR:
In the present case, I consider that the defendants’ negligence was a causative factor of the claimant’s permanent injury. In other words, as in Rahman’s case [2001] QB 351, para 34, I have concluded that the negligence of the defendants and the failings of the hospital had a ‘synergistic interaction, in that each tends to make the other worse’, and accordingly it seems appropriate to proceed on the basis that both were causative of the damage suffered by the claimant. I do not consider the hospital’s failure to treat the claimant properly once she was admitted... was of such significance that it justifies a finding that the defendant’s neg- ligence was not causative of the claimant’s injury – or indeed a finding that it broke the chain of causation between the defendant’s negligence and the claimant’s injury. It was not such an egregious event, in terms of the degree or unusualness of the negligence, or the period of time for which it lasted, to defeat or destroy the causative link between the defendant’s negligence and the claimant’s injury.^76
Although there was no mention in any of the majority judgments^77 of a material contribution to injury analysis, the facts of the case meant that this would have
(^74) Wright v Cambridge Medical Group [2011] EWCA Civ 669, [2013] QB 312. (^75) Although it also made the point that the pain and suffering endured by the claimant after the time of the negligence but before her eventual admission to hospital did not form part of the ultimate per- manent damage, and the defendants should not therefore be liable for it. See [2011] EWCA Civ 669, [2013] QB 312 at [52]–[53] 328 and [92] 336–37. (^76) [2011] EWCA Civ 669, [2013] QB 312 at [36]–[37] 325 (per Lord Neuberger). (^77) Elias LJ refers to it implicitly, see [2011] EWCA Civ 669, [2013] QB 312 at [92] 336–37 and explic- itly at [96] 337–38.
112 Material Contribution to Injury
establish, at the lowest, that it is more likely than not that any permanent damage the claimant would have suffered due to the inept treatment, which the judge found that she would have received if she had been referred on 15 April [the Wednesday], would have been significantly less than that which she did suffer. Indeed, I think that this evidence established that there is a reasonable chance that she would have suffered relatively little long-term damage if she had been referred in the late afternoon or early evening of 15 April.^80
When the claimant’s damage became permanent, the risk created by the defend- ant’s breach was still operative.^81 It is clear, therefore, why Lord Neuberger consid- ered the effects of the two factors to have been operating synergistically. As a factor which partially contributed thereby to an indivisible injury, the breach of duty was rightly held to be a legally relevant cause and the defendant liable for full damages. Had the hospital been joined as a defendant, it would have been appropriate for the Court to have held both parties jointly and severally liable, since both would have materially contributed to the claimant’s injury. It is worth re-emphasising a point already made in Chapter 4 on Duplicative Causation. Like the case of Elayoubi^82 mentioned there,^83 Wright is a case properly categorised as one involving a material contribution to injury because the multiple factors therein were not independent from one another. If, however, the GP’s fail- ure to refer in Wright had in no way affected the treatment provided by the hospi- tal, and if the delay had made no difference to the ultimate outcome, the factors would have been independent, which would have made the case one of pre-empted cause. Had this been the case, the defendants would not have been liable because the second stage of the NBA would not have been satisfied in relation to it: the effects of its breach would not ever have affected the claimant, since they would have been pre-empted by the effects of the hospital’s sub-standard treatment. It is easy to see, therefore, how significant interaction between factors (or lack of it) can affect the outcome of the causal inquiry. A material contribution to injury analysis is also appropriate to the harrowing facts of Paroline v United States et al.^84 Although a case principally about criminal restitution in the US,^85 the judgment makes significant reference to causation in tort law. The claimant in that case had as a young girl been the victim of sexual abuse, which had been filmed and distributed extensively online. Her hurt and humiliation were therefore set to continue into the future, as more and more individuals witnessed the material on the Internet. The defendant, whilst not the individual who produced the material or first put it into circulation, was charged with possessing child pornography, including images of the claimant, and the US Supreme Court was asked to consider
(^80) [2011] EWCA Civ 669, [2013] QB 312 at [73] 332 (per Lord Neuberger). (^81) [2011] EWCA Civ 669, [2013] QB 312 at [65]–[79] 330–34 (per Lord Neuberger). (^82) Elayoubi v Zipser [2008] NSWCA 335. (^83) See Ch 4, text to n 134. (^84) Paroline v United States et al No 12-8561, April 23, 2014 (USA). (^85) Under the Violence against Women Act 1994.
The ‘Doubling of the Risk’ Test 113
the theory of ‘aggregate causation,’ one formulation of which finds factual causation satisfied where a wrongdoer’s conduct, though alone ‘insufficient... to cause the plain- tiff’s harm,’ is, ‘when combined with conduct by other persons,’ ‘more than sufficient to cause the harm.’ 1 Restatement (Third) of Torts: Liability for Physical and Emotional Harm §27, Comment f. 86
Since the claimant’s mental distress, as well as her need for ongoing counselling and lost income, amounted to indivisible damage, and since the act of each indi- vidual viewing the material contributed to that damage in an interdependent way, this was a case in which the defendant had materially contributed to the claimant’s injury.^87
The ‘Doubling of the Risk’ Test^88
Cases classified as those in which a defendant has materially contributed to a claimant’s injury are just one of the instances in which an application of the ‘dou- bling of the risk’ (DTR) test has been mooted. This test, conceived as an epide- miological device, performs a very specific function, and has unfortunately been misapplied in a forensic context several times. The following excerpt from Novartis Grimsby Ltd v Cookson^89 exemplifies a factual phenomenon which is particularly common in cases in which the claimant’s damage takes the form of a disease.
Besides the occupational exposure to aromatic amines in the dyestuffs industry, which has been recognised as a cause of bladder cancer for many years, it is also known that cigarette smoking can be a cause, as can the ingestion of certain drugs. More than one potential cause was present in this case. As well as working for the Appellant for many years, Mr Cookson had been a moderate cigarette smoker (10 to 20 a day) for about 20 years. He had given up the habit in about 1980. He had also taken potentially harmful drugs for a time but it was not suggested by either side that those drugs had had any significant effect on the causation of his bladder cancer. Cigarette smoke contains amines and the amines from both sources act on the body in the same way. It was accepted by both sides that the two forms of exposure would have had at least an additive, if not multiplicative, effect. The argument between the parties was about the relative potency of the effects of smoking and occupational exposure. In essence, the argument was whether the occupational exposure was sufficient to have caused or mate- rially contributed to the development of the cancer.^90
(^86) No 12-8561, April 23, 2014 (USA) at B. (^87) The defendant in that case was not held liable for all of the restitution claimed by the defendant. Instead, the Court attempted to establish what was the defendant’s relative causal contribution – see No 12-8561, April 23, 2014 (USA) at B. (^88) With thanks to Mark Ingham for checking the statistical accuracy of what follows. (^89) Novartis Grimsby Ltd v Cookson [2007] EWCA Civ 1261, [2007] All ER (D) 465 (Nov). (^90) [2007] EWCA Civ 1261, [2007] All ER (D) 465 (Nov) at [44] (per Smith LJ).
