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Supreme Court Decision on Medical Causation

Fulcher Hagler Wins Important Georgia Supreme Court Case Clarifying When Plaintiffs Must Present Expert Evidence To Prove Causation in Simple Negligence Cases

In Cowart v. Widener, 287 Ga. 622 (2010), Fulcher Hagler partners Art Davison and Amy Snell prevailed on behalf of a trucking company client in an unusual case that had been winding its way through Georgia courts since 2004. Resolving apparently conflicting and unclear precedent, the Supreme Court ruled that a plaintiff in a simple negligence case is required to present expert evidence to prove causation when a “specialized medical question” is presented. This case is noteworthy not only for its clarification of Georgia negligence law but also for its resolution of the highly unusual facts of the case.

Death by Inaction?

In 2003, truck driver Nathan Lee Widener hauled a load of freight from Georgia to Ohio for United Transportation, Inc. (UTI) and took his brother-in-law Roby E. Cowart (Cowart), Sr. along for the ride. Cowart suffered from a number of medical problems, most seriously erosive esophagitis and esophageal stricture from acid reflux disease. As a result, he spit up small amounts of blood several times a day. He complained about throat pain the morning they left for Ohio but said he felt well enough to make the trip. His condition did not appear to be life-threatening. During the trip, Cowart’s medical condition deteriorated, and he died of natural causes in the sleeper berth of the truck. His body was discovered only after Widener was involved in a minor fender bender at a truck stop and the Ohio State Patrol performed a routine post-accident investigation. Amusingly, the police allegedly joked with Widener that the search was necessary “to make sure he didn’t have any dead bodies” back there. Widener responded, “Well, my brother-in-law is back there, but I don’t think he is dead.” The presumed cause of death was exsanguination from internal bleeding. The only visible blood in the truck was on some tissues found in the trash can and a little dried blood in the corner of Cowart’s mouth. Widener gave several inconsistent accounts about whether he understood the severity of Cowart’s condition or if he did, why he did not stop and get medical care.

Cowart’s children filed a wrongful death lawsuit against Widener and UTI, claiming that Widener indirectly caused Cowart’s death by failing to get aid for him. UTI allegedly was liable based on, inter alia, respondeat superior as Widener’s alleged employer. The defendants sought summary judgment, arguing that the plaintiffs lacked an expert who could testify that Cowart would not have bled to death had Widener gotten aid for him when his condition first appeared life-threatening. They cited in support Gilbert v. R.J. Taylor Mem. Hosp., 265 Ga. 580, 581 & n.4, 458 S.E.2d 341 (1995) (finding expert evidence required in that simple negligence case because “medical questions are raised.”). The plaintiffs countered with Self v. Exec. Comm. of the Ga. Baptist Convention of Ga., Inc., 245 Ga. 548, 549, 266 S.E.2d 168 (1980), which ruled that expert evidence is not required to prove causation in a simple negligence case. The trial court found Gilbert more persuasive and ruled in favor of defendants. The Court of Appeals affirmed in Cowart v. Widener, 296 Ga. App. 712, 675 S.E.2d 591 (2009).

The Supreme Court settled the apparent conflict presented by Gilbert and Self, ruling that: “even in simple negligence cases, plaintiffs must come forward with expert evidence to survive a defense motion for summary judgment, where ‘medical questions’ relating to causation are involved.” In this case, because the heirs’ death-by-inaction claim was not one that could be resolved based on common knowledge or experience, the high court agreed that expert testimony was required for a jury to conclude that Cowart would have survived had Widener taken him for immediate emergency care when his condition first appeared to be life-threatening.

When is a “Medical Question” not a “Medical Question”?

The other question resolved by the Court was how to determine whether a “medical question” is presented requiring a plaintiff to present expert evidence to establish a causal link between his/her injuries and the defendant’s actions or inactions. Some “medical questions” can be answered by a jury easily without expert assistance, including whether a stab wound in the gut can cause death or whether a gunshot wound to the head of an otherwise healthy person who died shortly thereafter was the proximate cause of death. In other cases, however, the link between action/inaction and injury is not so clear. In a toxic tort case, for example, it is not easy for a jury to determine whether exposure to the substance caused or worsened respiratory ailments. In Gilbert, a nurse lost a cancer biopsy specimen on the way to the lab, and a jury would need the assistance of an expert to determine whether this loss caused the plaintiff to have unnecessary cancer treatment.

To distinguish those “medical questions” requiring expert assistance from those that do not, the Court modified the law by stating that “we will now refer to ‘specialized medical questions’ as those that can be answered only by witnesses with specialized expert knowledge. In Cowart, a “specialized medical question” was presented because without expert evidence, a jury could not find that Widener’s failure to render aid to Cowart could have made a difference in preventing his death by internal bleeding. The plaintiffs offered no expert to testify on this question, so the trial court properly granted summary judgment in favor of the defendants.


The Supreme Court’s opinion is a necessary and logical extension of Georgia negligence law. Plaintiffs bear the burden of proving all elements of a simple negligence claim, including causation. This burden includes introducing evidence that affords a reasonable basis for a jury to conclude more likely than not that the defendant’s action or inaction was the cause of the plaintiff’s injury. When causation involves a “specialized medical question,” a verdict returned without the benefit of expert evidence is nothing but conjecture and speculation. Such a verdict is ripe for reversal on appeal.

This case demonstrates the value of articulate appellate advocacy and persistence in fending off an arduous, ongoing trial and appellate battle. Thanks to the Supreme Court, defendants and defense attorneys now have one more weapon in their arsenal for a successful attack on the element of causation in a simple negligence case.