B. Proximate Cause

            In the cases presented in this section, either the plaintiff has made out the elements previously discussed—duty, violation of duty, and cause in fact—or else they are sufficiently in dispute that the defendant cannot establish the absence of any of them as a matter of law. Instead, the defendant will argue that even a negligent defendant who actually caused the harm in question should not be liable for the plaintiff’s harm. The legal formulation of the claim is that the defendant’s admitted or assumed negligence was not the proximate cause (or “legal cause”) of the plaintiff’s harm. The cases in which this claim is given serious consideration tend to have one feature in common—something quite unexpected has contributed either to the occurrence of the harm or to its severity.

1. Unexpected Harm


Supreme Court of Iowa, 1994.

512 N.W.2d 537.

            Considered by McGIVERIN, C.J., and HARRIS, LARSON, SNELL, and ANDREASEN, JJ.

            McGIVERIN, Chief Justice.

            The main question here is whether the trial court erred in refusing to instruct the jury on the “eggshell plaintiff” rule in view of the fact that plaintiff’s decedent, who had a history of coronary disease, died of a heart attack six days after suffering a bruised chest and fractured ankle in a motor vehicle accident caused by defendant’s negligence. The court of appeals concluded that the trial court’s refusal constituted reversible error. We agree with the court of appeals and reverse the judgment of the trial court and remand for a new trial.

            [Benn’s executor sued defendant for Loras Benn’s injuries and his death after defendant’s vehicle rear-ended the van in which decedent was a passenger.]

            At trial, the estate’s medical expert, Dr. James E. Davia, testified that Loras had a history of coronary disease and insulin‑dependent diabetes. Loras had a heart attack in 1985 and was at risk of having another. Dr. Davia testified that he viewed “the accident that [Loras] was in and the attendant problems that it cause[d] in the body as the straw that broke the camel’s back” and the cause of Loras’s death. Other medical evidence indicated the accident did not cause his death.

            Based on Dr. Davia’s testimony, the estate requested an instruction to the jury based on the “eggshell plaintiff” rule, which requires the defendant to take his plaintiff as he finds him, even if that means that the defendant must compensate the plaintiff for harm an ordinary person would not have suffered. [Plaintiff requested the following charge:

If Loras Benn had a prior heart condition making him more susceptible to injury than a person in normal health, then the Defendant is responsible for all injuries and damages which are experienced by Loras Benn, proximately caused by the Defendant’s actions, even though the injuries claimed produced a greater injury than those which might have been experienced by a normal person under the same circumstances.

The trial judge denied that request and instead gave the following general charge:

The conduct of a party is a proximate cause of damage when it is a substantial factor in producing damage and when the damage would not have happened except for the conduct. “Substantial” means the party’s conduct has such an effect in producing damage as to lead a reasonable person to regard it as a cause.

            Special Verdict Number 4 asked the jury: “Was the negligence of Leland Thomas a proximate cause of Loras Benn’s death?” The jury answered this question, “No.” The jury returned a verdict for $17,000 for Loras’s injuries but nothing for his death. In its special verdict, the jury determined the defendant’s negligence in connection with the accident did not proximately cause Loras’s death. The court of appeals reversed the trial court’s judgment for $17,000 and remanded the case because the charge given to the jury failed to convey the applicable law.]

            A tortfeasor whose act, superimposed upon a prior latent condition, results in an injury may be liable in damages for the full disability. [ ] This rule deems the injury, and not the dormant condition, the proximate cause of the plaintiff’s harm.

[ ] This precept is often referred to as the “eggshell plaintiff” rule, which has its roots in cases such as Dulieu v. White & Sons, [1901] 2 K.B. 669, 679, where the court observed:

If a man is negligently run over or otherwise negligently injured in his body, it is no answer to the sufferer’s claim for damages that he would have suffered less injury, or no injury at all, if he had not had an unusually thin skull or an unusually weak heart.[ ]

            . . .

            Defendant contends that plaintiff’s proposed instruction was inappropriate because it concerned damages, not proximate cause. Although the eggshell plaintiff rule has been incorporated into the Damages section of the Iowa Uniform Civil Jury Instructions, we believe it is equally a rule of proximate cause. See Christianson v. Chicago, St. Paul, Minneapolis & Omaha Ry. Co., 69 N.W. 640, 641 (Minn.1896) (“Consequences which follow in unbroken sequence, without an intervening efficient cause, from the original negligent act, are natural and proximate; and for such consequences the original wrongdoer is responsible, even though he could not have foreseen the particular results which did follow.”).

            Defendant further claims that the instructions that the court gave sufficiently conveyed the applicable law. . . .

            We agree that the jury might have found the defendant liable for Loras’s death as well as his injuries under the instructions as given. But the proximate cause instruction failed to adequately convey the existing law that the jury should have applied to this case. The eggshell plaintiff rule rejects the limit of foreseeability that courts ordinarily require in the determination of proximate cause. [ ] Once the plaintiff establishes that the defendant caused some injury to the plaintiff, the rule imposes liability for the full extent of those injuries, not merely those that were foreseeable to the defendant. Restatement (Second) of Torts § 461 (1965) (“The negligent actor is subject to liability for harm to another although a physical condition of the other ... makes the injury greater than that which the actor as a reasonable man should have foreseen as a probable result of his conduct.”).

            The instruction given by the court was appropriate as to the question of whether defendant caused Loras’s initial personal injuries, namely, the fractured ankle and the bruised chest. This instruction alone, however, failed to adequately convey to the jury the eggshell plaintiff rule, which the jury reasonably could have applied to the cause of Loras’s death.

            Defendant maintains “[t]he fact there was extensive heart disease and that Loras Benn was at risk any time is not sufficient” for an instruction on the eggshell plaintiff rule. Yet the plaintiff introduced substantial medical testimony that the stresses of the accident and subsequent treatment were responsible for his heart attack and death. Although the evidence was conflicting, we believe that it was sufficient for the jury to determine whether Loras’s heart attack and death were the direct result of the injury fairly chargeable to defendant Thomas’s negligence.[ ]

            Defendant nevertheless maintains that an eggshell plaintiff instruction would draw undue emphasis and attention to Loras’s prior infirm condition. We have, however, explicitly approved such an instruction in two prior cases. [ ]

            Moreover, the other jurisdictions that have addressed the issue have concluded that a court’s refusal to instruct on the eggshell plaintiff rule constitutes a failure to convey the applicable law. [ ]

            To deprive the plaintiff estate of the requested instruction under this record would fail to convey to the jury a central principle of tort liability.

            . . .

            The record in this case warranted an instruction on the eggshell plaintiff rule. We therefore affirm the decision of the court of appeals. We reverse the judgment of the district court and remand the cause to the district court for a new trial consistent with this opinion.

Notes and Questions

            1. What questions of actual causation exist in this case?

            2. The Restatement suggests that this “rule” is an exception to the normal rule that negligent parties are not liable for more than they could reasonably “have foreseen as a probable result of his conduct.” Why should that be the general proposition in any event?

            Is that Restatement approach consistent with the passage the court quotes from the Christianson case to the effect that the defendant is liable for “consequences which follow in unbroken sequence . . . even though he could not have foreseen the particular results which did follow”?

            3. In the famous case of Dillon v. Twin State Gas & Electric Co., 163 Atl. 111 (N.H. 1932), a boy lost his balance while sitting on the girder of a bridge. In an effort to avoid falling, he grabbed hold of a negligently exposed wire and was electrocuted. The court concluded that if it were found that the boy would have been killed by the fall without regard to the wire, any award against the defendant utility for the exposed wire should be reduced drastically. Is that sound? Would the same analysis apply in Benn?

            4. In Steinhauser v. Hertz Corp., 421 F.2d 1169 (2d Cir. 1970), although the 14-year-old plaintiff sustained no bodily injury in a minor automobile accident, she began, within minutes, to behave in “an unusual way.” In the following days “things went steadily worse.” She was institutionalized for a period and diagnosed with a “chronic schizophrenic reaction,” where “chronic” was defined to mean that the patient did not come to the psychiatrist because of a sudden onset of symptoms. The court cited a variety of events in plaintiff’s life that occurred shortly before the accident and might have given her “a predisposition to schizophrenia which, however, requires a ‘precipitating factor’ to produce an outbreak.” The court held that the trial judge had committed prejudicial error by failing to charge that plaintiff was entitled to recover for the schizophrenia if the jury concluded that it had been “precipitated” by the accident. At the same time the court observed that the existence of the prior tendencies might greatly affect damages. Defendants were entitled to explore the possibility that plaintiff would have developed schizophrenia in any event. On this point the court concluded that although this kind of prediction may be “taxing” for those “who have devoted their lives to psychiatry, it is one for which a jury is ideally suited.”

            5. In discussing claims based on emotional distress, courts often say that to be actionable the harm must be such that it would cause distress in the ordinarily sensitive person or the reasonably constituted person. If that standard is met in a case, should the plaintiff’s recovery be limited by such a standard or should plaintiff recover the harm that plaintiff actually sustained even if it is greater than what an “ordinarily sensitive person” would have suffered?

            6. In Bartolone v. Jeckovich, 481 N.Y.S.2d 545 (App.Div. 1984), plaintiff was slightly injured in a four‑car chain reaction collision suffering primarily from whiplash, and back strain for which he was treated with muscle relaxants and physical therapy.  He was a single 48-year-old man who worked as a carpenter.  He was "very proud of his physique and his strength, spending an average of four hours daily . . . engaged in body building."  On weekends, he painted, sang, and played music.  Since the accident plaintiff had been withdrawn, hostile, delusional, heard voices, refused to cut his hair, shave or bathe, and no longer participated in any of his former interests.

            It appeared at the trial that plaintiff's mother and sister had died of cancer at early ages and that plaintiff had probably acquired a fear and dislike of physicians.  His body building was being done to avoid doctors and ward off illness.  After the accident, he perceived that his "bodily integrity was impaired and that he was physically deteriorating."  This led to psychological and social deterioration as well.  The consensus of the plaintiff's experts was that plaintiff had "suffered from a pre‑existing schizophrenic illness which had been exacerbated by the accident [and] was now in a chronic paranoid schizophrenic state which is irreversible."

            The trial judge cut plaintiff's award of $500,000 to $30,000.  The appellate court, relying on Steinhauser, reinstated the verdict.  A defendant "must take a plaintiff as he finds him and hence may be liable in damages for aggravation of a preexisting illness." See also Aflague v. Luger, 589 N.W.2d 177 (Neb.App. 1999), in which plaintiff, who had been badly hurt seven years earlier and returned to fine health, was hurt again in what appeared to be a minor way. Her earlier injury had rendered her more vulnerable, and the defendant was liable for entire amount of harm to which she was “predisposed.”

            7. Suicide.  Courts have shown an increasing willingness to allow recoveries where the defendant's negligence has severely injured a person who later commits suicide.  In Fuller v. Preis, 322 N.E.2d 263 (N.Y.1974), the victim was a 43-year-old surgeon who sustained injuries in an automobile accident that left him subject to seizures and caused a physical deterioration.  Meanwhile, his wife, who had been partially paralyzed by polio, suffered "nervous exhaustion."  Seven months after the crash he learned that his mother had cancer.  One of his suicide notes warned his family to destroy it because "it would alter the outcome of the 'case'--i.e., it's worth a million dollars to you all."  Chief Judge Breitel declared that an "irresistible impulse" does not necessarily mean a "sudden impulse."  The jury could find that the irresistible impulse that "caused decedent to take his life also impelled the acquisition of the gun and the writing of the suicide notes."

            See also Zygmaniak v. Kawasaki Motors Corp., 330 A.2d 56 (App. 1974)(defendant liable for the death of a victim who was shot and killed at his own request by his brother after defendant's negligence had rendered the victim a quadriplegic);  Stafford v. Neurological Medicine, Inc., 811 F.2d 470 (8th Cir.1987)(defendant liable for suicide after negligently permitting patient to receive mail indicating incorrectly that she was suffering from a brain tumor).  But recall the reluctance of courts to hold negligent attorneys liable for the suicides of disappointed clients, p. ___, supra.

            8. Secondary harm.  In Stoleson v. United States, 708 F.2d 1217 (7th Cir.1983), plaintiff worked in a munitions plant and was found to have suffered heart problems from negligently being exposed to nitroglycerine.  Although the harm was temporary and should have stopped when plaintiff ceased working at the factory, she developed hypochondria after the episode and was unable to function normally.  The court adverted to the possibility that the plaintiff's condition was brought about by medical advice given her after the exposure to nitroglycerine had ended:

            If a pedestrian who has been run down by a car is taken to a hospital and because of the hospital's negligence incurs greater medical expenses or suffers more pain and suffering than he would have if the hospital had not been negligent, he can collect his incremental as well as his original damages from the person who ran him down, since they would have been avoided if that person had used due care.

Is the original wrongdoer liable if the hospital staff reasonably chooses a course of treatment that does not work--if it later appears that another reasonable choice would in fact have done the job?  What if the staff surgeon is drunk and operates on the wrong leg?

            9. Several cases have involved secondary harm during transportation to the hospital for needed attention. In Pridham v. Cash & Carry Bldg. Center, Inc., 359 A.2d 193 (N.H. 1976), plaintiff, who had been seriously injured by defendant's negligence, died when the ambulance driver transporting him to a hospital suffered a heart attack and the ambulance swerved into a tree.  The trial judge charged that the defendant was liable for further injuries resulting from "normal efforts of third persons in rendering aid . . . which the other's injury reasonably requires irrespective of whether such acts are done in a proper or in a negligent manner."  The charge was upheld on appeal from a plaintiff's judgment. If medical services "are rendered negligently, the rule based on questions of policy makes the negligence of the original tortfeasor a proximate cause of the subsequent injuries suffered by the victim." The ambulance trip was a "necessary step in securing medical services required by the accident at Cash & Carry.”  See also Atherton v. Devine, 602 P.2d 634 (Okla. 1979), in which the aggravation occurred when the ambulance was in an accident with another vehicle. In holding that proximate cause was a jury question, the court did not mention which driver was negligent. Should that matter?

            In Anaya v. Superior Court, 93 Cal.Rptr.2d 228 (App. 2000), plaintiff’s child was injured in an accident with a city garbage truck. As she was being airlifted to a hospital, the helicopter crashed and she was killed. The cases that imposed liability on the original tortfeasor for malpractice, were authority for imposing liability for aggravation incurred during transportation to the hospital. There were also allegations against other defendants that the helicopter was negligently maintained and that it was defectively manufactured. Should either of these affect the liability of the original tortfeasor?

            Consider also transportation that occurs during recuperation. P, who has been badly hurt by D's negligence, has been recuperating in the hospital for 18 days. The doctors order a transfer to a hospital that has better physical therapy facilities.  As P is being transferred by ambulance the driver has an epileptic seizure and the ambulance crashes.  Lucas v. City of Juneau, 127 F.Supp. 730 (D.Alaska 1955) (imposing liability).


            10. In Wagner v. Mittendorf, 134 N.E. 539 (N.Y. 1922), the defendant negligently broke plaintiff's leg. While plaintiff was recovering, through no fault of his own his crutch slipped and the leg was rebroken. The court held the defendant liable for that aggravation.  Why?