                                 [J-12-2016]
                   IN THE SUPREME COURT OF PENNSYLVANIA
                              EASTERN DISTRICT

       SAYLOR, C.J., BAER, TODD, DONOHUE, DOUGHERTY, WECHT, JJ.


RICHARD M. ROST, EXECUTOR OF                 :   No. 56 EAP 2014
THE ESTATE OF RICHARD J. ROST &              :
ERIN SIPLEY, EXECUTRIX OF THE                :   Appeal from the Judgment of Superior
ESTATE OF JOYCE ROST,                        :   Court entered on May 19, 2014 at No.
                                             :   404 EDA 2012 affirming the Judgment
                    Appellees                :   entered on December 28, 2011 in the
                                             :   Court of Common Pleas, Civil Division,
                                             :   Philadelphia County at No. 1978
             v.                              :   September Term, 2010
                                             :
                                             :   ARGUED: May 6, 2015
FORD MOTOR COMPANY,                          :   REARGUED: April 6, 2016
                                             :
                    Appellant                :


                                       OPINION


JUSTICE DONOHUE                                        DECIDED: November 22, 2016


      We address again the proper application of the “frequency, regularity, and

proximity” criteria in asbestos product liability litigation, seeking to provide further

illumination on the principles set forth in our decisions in this area, Gregg v. V-J Auto

Parts, Co., 943 A.2d 216 (Pa. 2007), and Betz v. Pneumo Abex. LLC, 44 A.3d 27 (Pa.

2012). For the reasons that follow, we conclude that the trial court and the Superior

Court properly applied those principles in this case, and thus affirm the judgment

entered in favor of Appellees.
      In October 2009, Appellees Richard and Joyce Rost1 filed suit against multiple

manufacturers of asbestos, averring that exposure to the defendants’ asbestos-

containing products caused Richard Rost (“Rost”) to contract mesothelioma. Before

trial, the Rosts settled their claims against all defendants except for Appellant Ford

Motor Company (“Ford”). Over Ford’s objections, the trial court consolidated the case

for trial with two other mesothelioma cases. Trial commenced in September 2011, at

which time the trial court reminded the parties of a pre-trial ruling, in accordance with

Gregg, precluding any expert from offering testimony that “each and every breath” of

asbestos may constitute an evidentiary basis for the jury to find that the defendant’s

product was a substantial cause of mesothelioma.2 N.T., 9/12/2011 (AM), at 37.

      At trial, Rost testified that upon graduation from high school in 1950, he took a

job at Smith Motors in Washington, New Jersey, for three to four months, working full

time Monday through Friday and half a day on Saturday. N.T., 9/14/2011 (AM), at 101,

114. While Smith Motors was a full service garage, it serviced approximately eighty-five

to ninety percent Ford vehicles. Id. at 151. The parties stipulated that all model year

Ford vehicles, from 1945 until 1950, used asbestos brakes and asbestos clutches, and

that Ford’s brakes and clutches were forty to sixty percent chrysotile asbestos by


1
  Richard and Joyce Rost both passed away during the pendency of this action, and his
executor and her executrix have been substituted as parties. For ease of identification,
herein Appellees will be referred to as the “Rosts.”
2
   In a products liability action, Pennsylvania law requires that a plaintiff prove two
elements: “that the product was defective, and that the defect was the substantial factor
in causing the injury.” Spino v. John S. Tilley Ladder Co., 696 A.2d 1169, 1172
(Pa. 1997). In a pre-trial ruling, the trial court concluded that the Rosts were not
required to prove that asbestos brakes manufactured by Ford were a defective product.
Trial Court Opinion, 12/28/2011, at 6-7. The Superior Court affirmed. Rost v. Ford
Motor Company, 2014 WL 2178528, at *11-12 (Pa. Super. May 19, 2014). Despite
Ford’s request, this Court declined to grant allocatur on the issue.



                                     [J-12-2016] - 2
weight. Stipulation, Rost Exhibit 5. Rost described his job as being a “gofer,” which

involved basic maintenance tasks (changing oil, lubrication, and undercoating). Id. at

103. It was also his job to keep the garage area clean. Id. Approximately three to five

times per week, when the mechanics removed brake shoes before performing a brake

job, Rost had to pop off the asbestos lining from each shoe and throw it away. Id. at

103-05.   There were two linings on each brake shoe, so this necessitated that he

remove eight linings in connection with each brake job. Id. Asbestos dust was released

as each lining was popped off, and Rost testified that he would breathe this dust in on

every occasion. Id. at 105. Once a day, the mechanics would use an air compressor to

blow out the dirt and debris inside the brake drums, and this would result in a significant

amount of asbestos dust circulating throughout the garage.            Id. at 106.   Rost was

typically within thirty to forty feet of these blowouts. Id. at 149-50.

       Rost was also exposed to asbestos based upon his proximity to mechanics

sanding brakes, replacing clutches, and performing engine work (head gaskets

containing asbestos). Id. at 105, 129-31. At the end of each day, Rost testified that he

cleaned up all of the asbestos dust and debris generated from the brake jobs, blow

outs, and clutch and engine work. Id. at 113-14. He used a push broom to gather the

waste from the mechanics’ work areas, and typically deposited three coal shovelfuls of

waste into the garbage at the end of each day. Id. at 114. Smith Motors did not have

an exhaust system, with only a single fan in the window for ventilation, and Rost

testified that “there was a smell in the garage from the dust in the air the whole time we

were working in there.” Id. at 111. Smith Motors also had no shower facilities, and so

Rost wore his dirty dust-covered clothes home at the end of each day on the job. Id. at

131.




                                       [J-12-2016] - 3
       Rost also testified regarding his subsequent occupational history and exposures

to asbestos in connection therewith. After Smith Motors, he worked for Washington

Woodcraft and Griffith & Williams (a construction company), but was not exposed to

asbestos in those jobs.      Id. at 159-61.   He then went to work for Tung-Sol, a

manufacturer of television vacuum tubes, from 1952-53 and, after a term in the Army,

from 1955-60. Id. at 115, 166. Rost did not believe that he was exposed to asbestos at

Tung-Sol, although he did perform maintenance work on the boiler once a week and

worked on the turbines “twice a year for a couple of hours” during seasonal annual

maintenance. Id. at 115-16, 165-67. In 1960, he went to work for Metropolitan Edison

at its power plant near Portland, Pennsylvania, where he remained until his retirement in

1994. Id. at 116. He began as a janitor and served as a coal handler, boiler attendant,

pump operator, instrument operator, and finally as the chief of instrumentation and

controls. Id. at 118. During his time with Metropolitan Edison, he was exposed to

asbestos in its boilers, turbines and generators.      Id. at 131.   Rost agreed that his

asbestos exposure, especially in connection with his proximity to the turbines, was at

“pretty high levels.”   N.T., 9/14/2011 (PM), at 62.     He also testified, however, that

Metropolitan Edison became aware of the dangers of asbestos in or around 1970, and

that by 1972 or 1973 he wore a face mask over his nose and mouth in high asbestos

areas. N.T., 9/14/2011 (AM), at 122-23; N.T., 9/14/2011 (PM), at 62. Over a ten-year

period, the company also incrementally replaced its asbestos-containing equipment. Id.

       The Rosts called expert witnesses on medical and causation issues, including

Dr. Arnold Brody, Ph.D., and Dr. Arthur Frank, M.D. Dr. Brody is an experimental

pathologist and a professor at North Carolina State University. N.T., 9/20/2011 (AM), at

7-8. Dr. Frank is a physician and a professor at Drexel University School of Public

Health and the Drexel University College of Medicine. N.T., 9/19/2011 (AM), at 8.




                                     [J-12-2016] - 4
       Dr. Brody did not testify regarding the specific cause of Rost’s medical condition,

and instead offered more general testimony about how asbestos causes mesothelioma.

He explained that there are two types or “families” of asbestos fibers, amphibole and

chrysotile. N.T., 9/20/2016 (AM), at 82. About ninety-five percent of the asbestos-

containing products used in the United States contained chrysotile fibers, including all of

the Ford products at issue in this case. Id. at 86. Dr. Brody testified that on a fiber-per-

fiber basis, amphibole fibers are more potent than chrysotile fibers, but that both types

cause mesothelioma. Id. at 83-119. Given their smaller size, chrysotile fibers are more

likely to get into the lymphatic flow and reach the pleura (the membrane on the outside

lining of the lungs), and when investigators examine the target site of mesothelioma on

the lung, they typically find a predominance of chrysotile fibers. Id. at 117.

       Dr. Brody described for the jury precisely how asbestos causes mesothelioma.

Mesothelioma is a cancer of the mesothelial cells of the pleura. Id. at 27, 52. When

asbestos fibers reach the mesothelial cells of the pleura, either through the blood

stream or the lymphatic system, they act as a “complete carcinogen,” as they can lead

to cancer without any other contributing agent. Id. at 50, 56. Asbestos fibers damage

the DNA in the mesothelial cells that control cell reproduction. Id. Some damaged cells

die and tumor suppressor genes stop others from reproducing. Id. at 64-65. Where

suppressor genes do not stop the reproduction process, however, the damaged cells

divide, replicating the damage in the sister cells. Id. at 68. As the division continues

over decades, a tumor is formed.         Id.   This explains why mesothelioma has an

extremely long latency period,3 as mesothelial cells have a very slow growth rate. Id. at

55.

3
  Dr. Frank testified that the average latency period for mesothelioma, from exposure to
diagnosis, is approximately thirty-five years. N.T., 9/19/2011 (AM), at 85-87.



                                      [J-12-2016] - 5
        The Rosts called Dr. Frank as an expert in “asbestos-related diseases and their

causes, the ability of asbestos, including chrysotile asbestos, to cause mesothelioma in

humans, the risk imposed from inhalation of chrysotile asbestos from brakes, the

epidemiology of asbestos disease, asbestos industrial hygiene, asbestos toxicology and

public health.” N.T., 9/19/2011 (AM), at 40. In his testimony, Dr. Frank referenced

epidemiological studies, animal studies, and case reports, and indicated that he had

himself performed epidemiological, animal, and cell and organ culture studies on

individuals exposed to asbestos; he also participated in a study on the development of

asbestos-related disease in brake mechanics, and has published many peer reviewed

articles and book chapters on asbestos-related disease. Id. at 15-40. He stated that in

his practice and research studies, he has seen “hundreds, if not thousands” of people

exposed to asbestos. Id. at 25.

        Dr. Frank testified that mesothelioma is a dose-response disease, by which “as

the dose increases, the likelihood of developing the disease increases”: “small amounts

carry small risks; larger amounts cause larger risks.” Id. at 82-83. According to Dr.

Frank, it is not scientifically possible to identify the particular exposure or exposures that

caused a patient’s mesothelioma, and instead the causative agent is “the series of

exposures.” Id. at 71. All exposures to asbestos contribute to the cumulative dose of

asbestos, and the cumulative dose causes mesothelioma.              Accordingly, Dr. Frank

testified that “[a]ll of the exposures that can be documented should all be considered as

contributory to [Rost’s] developing his disease.” 4 Id. at 122. It is also not scientifically

4
    Dr. Brody concurred with this opinion, testifying as follows:
        [I]t is the series of exposures. You can’t just pick out one and say, “This
        exposure caused this set of errors.” You can’t do that. It’s just not
        possible. So the answer is that all of the exposures that are in the history
        of that individual have contributed to the development of the disease.
(continued…)

                                        [J-12-2016] - 6
possible to quantify how much asbestos is required to initiate the disease process, id. at

83, and varying individual susceptibility also plays a role. Id. at 72 (“Asbestos will cause

disease in people who work, in people who don’t work.”); see also N.T., 9/19/2011 (PM),

at 13 (“It creates a risk. … They don’t all develop [disease].”).

       Moreover, Dr. Frank testified that while precise exposure threshold levels for the

contraction of mesothelioma cannot be quantified, different asbestos-related diseases

require different exposure levels. Contraction of asbestosis, the non-cancerous scarring

of lung tissue, requires a “significant amount” of asbestos exposure before the condition

will appear. N.T., 9/19/2011 (AM), at 83. Mesothelioma, in significant contrast, requires

far less exposure. Dr. Frank testified that both case reports and animal studies reflect

that there is evidence that both animals and humans may contract mesothelioma after a

single day of exposure to asbestos. Id. at 84-85 (“very low levels will still produce the

disease mesothelioma”). Even more, there is evidence that a single month of exposure

to asbestos may double an individual’s risk of contracting mesothelioma. Id. In this

case, Rost was exposed to asbestos at Smith Motors for more than three months, in

potentially high amounts on a daily basis. Based upon studies by a mineralogist, Dr.

Frank testified that when a mechanic used an air compressor to blow out the inside of a

brake drum, the resulting dust contained approximately seventeen fibers of chrysotile

asbestos per cubic centimeter of air, and that even if Rost was as far as sixty feet away

(he testified was typically within thirty to forty feet), the dust in the air would have been

at elevated levels. Id. at 100. Dr. Frank also found it significant that Rost wore his dust-

covered clothes home each day after work, as it brought asbestos fibers into the home,




(…continued)
N.T., 9/20/2011 (AM), at 71.



                                       [J-12-2016] - 7
which extended his exposure well beyond the three months he worked at Smith Motors.

Id. at 118-19.

       In response to a hypothetical question that detailed Rost’s exposure to asbestos

while at Smith Motors, Dr. Frank testified that it was his opinion, within a reasonable

degree of medical certainty, that Rost’s exposure to Ford products was a “significant

contributing cause to developing mesothelioma.” Id. at 111-17. He then offered the

following testimony:

       Q.        Now, Dr. Frank, I’ve asked you to assume that these
                 exposures in 1950 for the three months approximately were
                 at the Ford dealership. Now, if those were -- now, you know
                 in this case, that there are other exposures after 1950,
                 correct?

       A.        Yes, sir.

       Q.        Now, if the only exposures that Mr. Rost had were those in
                 1950, would those have been enough alone without any of
                 the ones he had later for you to say that was a significant
                 contributing factor to his mesothelioma?

       A.        Yes.

                                     *       *     *

       Q.        Okay. Now, we do know that in this case that there are
                 other asbestos exposures. Given the fact that there were
                 other asbestos exposures in this case, Doctor, is there any
                 way for you to say that the early 1950s exposures didn’t
                 contribute and the ones afterwards did?

       A.        There’s no scientifically plausible way to do that. They all
                 contributed, his early exposures and his later exposures.

       Q.        Now, Doctor, is there any doubt in your mind that chrysotile
                 asbestos from brakes contributed to Mr. Rost’s
                 mesothelioma?

                                     *       *     *

       A.        None whatsoever. No doubt.


                                         [J-12-2016] - 8
       Q.        Is there any doubt in your mind that his exposures to
                 insulation contributed to his mesothelioma?

       A.        No doubt whatsoever.

       Q.        Are all the exposures that he experienced to asbestos that
                 can be demonstrated the causes of his mesothelioma?

       A.        All of the exposures that can be documented should all be
                 considered as contributing to his developing the disease.

       Q.        Is there any doubt in your mind, Dr. Frank, that just working
                 with those brakes or around those brakes in 1950 at the
                 Ford dealership could have caused his mesothelioma?

                                     *       *     *

       A.        If that would have been his only exposure, I would be sitting
                 here saying that that was the cause of his disease. Given
                 that he had other exposures, it was all contributory.

Id. at 120-23.

       When the Rosts rested their case-in-chief, Ford moved for a nonsuit, contending

that Dr. Frank had offered “each and every breath” opinion testimony prohibited as

evidence of substantial causation by this Court in Gregg. N.T., 9/26/2011 (AM), at 98-

99. Concluding that Dr. Frank had not done so and that the Rosts had presented

sufficient evidence to send the case to the jury, the trial court denied the motion. Id. at

99. At the close of the evidence, the jury awarded the Rosts $994,800 ($844,800 to

Rost and $150,000 to Joyce Rost). N.T., 10/7/2011, at 8-11. The jury also found that

the products of three companies with asbestos-containing equipment at Metropolitan

Edison (General Electric, Ingersoll-Rand, and Westinghouse) were also substantial

causes of Rost’s mesothelioma. Id. The trial court molded the verdict by dividing it into

four equal parts, thus entering judgment against Ford in the amount of $248,700. Id. at




                                         [J-12-2016] - 9
17. Ford filed post-trial motions for judgment notwithstanding the verdict and/or a new

trial, arguing, inter alia, that the trial court had erred in (1) failing to rule that Dr. Frank’s

alleged “each and every breath” testimony was legally insufficient to establish

substantial causation as a matter of law, and (2) failing to grant Ford’s motion in

opposition to consolidation of its case with two other mesothelioma cases. By order

dated December 28, 2011, the trial court denied Ford’s post-trial motions and entered

judgment in favor of the Rosts.

       Ford raised these same two issues on appeal to the Superior Court.                  In an

unpublished memorandum decision, the court affirmed. On the first issue, the Superior

Court concluded that Drs. Brody and Frank “provided detailed testimony about the

nature of mesothelioma and its causes, backed up by published research on the

subject. Their testimony was internally consistent and by the admission of Ford’s own

experts, supported by at least 50 asbestos scientists around the world.” Rost v. Ford

Motor Company, 2014 WL 2178528, at *10 (Pa. Super. May 19, 2014) (unpublished

memorandum). The Superior Court further indicated that “while it is true that the ‘every

exposure’ theory does not, by itself, meet the standard for substantial causation in a

legal sense, this record is more than sufficient to establish its general scientific

legitimacy.” Id. With respect to consolidation, the Superior Court noted that this Court

had previously instructed the Philadelphia courts of common pleas to implement

procedural measures to handle the volume of mesothelioma litigation, Pittsburgh

Corning Corp. v. Bradley, 453 A.2d 314, 317 (Pa. 1982), and that, as such, it did not

have any authority to address procedural issues in this instance “absent a claim of

violation of constitutional rights.” Rost, 2014 WL 2178528, at *12.




                                        [J-12-2016] - 10
       This Court granted Ford’s petition for allowance of appeal to consider the

following two issues, as stated by Ford:

       1.     Whether--contrary to Howard, Betz, and Gregg--a plaintiff in
              an asbestos action may satisfy the burden of establishing
              substantial-factor causation by an expert’s “cumulative
              exposure” theory that the expert concedes is simply an “any
              exposure” theory by a different name[?]

       2.     Whether the Philadelphia Court of Common Pleas’
              mandatory practice of consolidating unrelated asbestos
              cases--even where the defendants suffer severe prejudice
              as a result--is consistent with the Pennsylvania Rules of Civil
              Procedure and Due Process; whether consolidation in this
              case was proper; and whether the Superior Court has the
              authority to review a trial court’s case-consolidation
              decisions in asbestos cases[?]

Allocatur Order, 11/6/2014, at 1.

       With respect to the first issue, Ford presents two arguments.             For its first

argument, Ford contends that this Court has established a bright line rule in

mesothelioma products liability cases: namely, that a causation expert may not, when

opining on substantial causation, rely on the theory that every exposure to asbestos is

substantially causative of the disease. Ford’s Brief at 17. Ford argues that Dr. Frank’s

testimony5 regarding cumulative exposures, including that all of Rost’s exposures to

asbestos contributed to his disease and that “any exposure … would … be causative in

the development of Mr. Rost’s disease,” N.T., 9/19/2011 (AM), at 82-83, 120, was “each

and every breath” testimony even if he did not use those precise words or place the

word “substantial” before the word “causative.” Ford’s Reply Brief at 5. According to

5
  In its post-trial motions, Ford argued that the trial court erred in permitting Dr. Brody to
offer “each and every breath” testimony, although it did so on competency grounds (i.e.,
that Dr. Brody is a cell biologist and not a medical doctor). Post-trial Motions,
10/17/2011, ¶¶ 78-79. Ford has not raised this issue on appeal.



                                      [J-12-2016] - 11
Ford, the context surrounding Dr. Frank’s statements shows that his intention was to

convey to the jury that every exposure to asbestos was a substantial cause of Rost’s

mesothelioma. Id. at 6.

      The Rosts argue, conversely, that Pennsylvania law requires that a plaintiff in a

mesothelioma products liability action demonstrate that his or her exposure to asbestos

was frequent, proximate and regular, and that a causation expert cannot rely merely on

the proposition that every exposure to asbestos is a substantial cause of the disease.

Rosts’ Brief at 26-27. The Rosts posit that Dr. Frank testified in accordance with these

basic principles.   According to the Rosts, Ford is simply confusing, or intentionally

conflating, the basic scientific axiom that “every exposure contributes” into the

impermissible “every exposure is a substantial cause.” Id.

      Ford asks this Court to enter judgment notwithstanding the verdict in its favor or,

alternatively, grant it a new trial. We will reverse a trial court's grant or denial of a

request for judgment notwithstanding the verdict only when we find an abuse of

discretion or an error of law. Reott v. Asia Trend, Inc., 55 A.3d 1088, 1093 (Pa. 2012);

Dooner v. DiDonato, 971 A.2d 1187, 1193 (Pa. 2009).             An award of judgment

notwithstanding the verdict is appropriate only if, reading the record in the light most

favorable to the appellees as the verdict winners, and affording them the benefit of all

reasonable inferences, we would conclude that there is insufficient competent evidence

to sustain the verdict. Pennsylvania Dep't of Gen. Servs. v. U.S. Mineral Products Co.,

898 A.2d 590, 604 (Pa. 2006). The appellate court must reject all evidence which does

not support the verdict.    Fitzpatrick v. Natter, 961 A.2d 1229, 1244 (Pa. 2008).

Regarding Ford’s contention that the prejudice resulting from Dr. Frank’s “any exposure”




                                    [J-12-2016] - 12
testimony entitles it to a new trial, our standard of review is one of abuse of discretion.

Bruckshaw v. Frankford Hosp. of City of Philadelphia, 58 A.3d 102, 106 (Pa. 2012);

Harman v. Borah, 756 A.2d 1116, 1122 (Pa. 2000).

       We begin with a review of our decisions in Gregg and Betz. In Gregg, the estate

of John Gregg, Jr. (“Gregg”), a mesothelioma victim, sought to recover against a

manufacturer and a supplier of brake products, contending that Gregg had installed and

removed brake linings during his lifetime. Gregg, 943 A.2d at 219. The trial court,

relying on the Superior Court’s decision in Eckenrod v. GAF Corp., 544 A.2d 50 (Pa.

Super. 1988), granted summary judgment, concluding that the record at most supported

Gregg’s use of asbestos-containing products sold by the defendants on two or three

occasions. Id. at 52 (“Whether a plaintiff could successfully get to the jury or defeat a

motion for summary judgment by showing circumstantial evidence depends upon the

frequency of the use of the product and the regularity of plaintiff's employment in

proximity thereto.”). A panel of the Superior Court reversed, holding that Eckenrod did

not apply when a plaintiff could offer direct testimony concerning exposure to a

defendant’s products. Gregg, 943 A.2d at 220-21.

       This Court granted review to consider whether the trial court erred in its

application of the Eckenrod “frequency, regularity, and proximity” test on motions for

summary judgment in mesothelioma cases. Id. at 221. In so doing, we recognized “the

difficulties facing plaintiffs in this and similar settings, where they have unquestionably

suffered harm on account of a disease having a long latency period and must prove

specific causation under prevailing Pennsylvania law which may be insurmountable.”

Id. at 226.   Nevertheless, we concluded that these difficulties did not warrant the




                                     [J-12-2016] - 13
indulgence “in a fiction that each and every exposure to asbestos, no matter how

minimal in relation to other exposures, implicates a fact issue concerning substantial-

factor causation in every ‘direct evidence’ case.” Id. at 226-27. As such, we held that

an “every exposure” generalized opinion does “not suffice to create a jury question in a

case where exposure to the defendant’s product is de minimis… .” Id. at 226.

      Instead, to permit trial courts to make a reasoned determination at the summary

judgment stage as to whether the plaintiff has proffered sufficient evidence to permit a

jury to make the “necessary inference of a sufficient causal connection between the

defendant’s product and the asserted injury,” id. at 227, we adopted the “frequency,

regularity, and proximity” test, as refined and applied by the United States Court of

Appeals for the Seventh Circuit in Tragarz v. Keene Corp., 980 F.2d 411 (7th Cir. 1992):

             Tragarz explains that these criteria do not establish a rigid
             standard with an absolute threshold necessary to support
             liability. Rather, they are to be applied in an evaluative
             fashion as an aid in distinguishing cases in which the plaintiff
             can adduce evidence that there is a sufficiently significant
             likelihood that the defendant's product caused his harm, from
             those in which such likelihood is absent on account of only
             casual or minimal exposure to the defendant's product.
             Further, Tragarz suggests that the application of the test
             should be tailored to the facts and circumstances of the
             case, such that, for example, its application should become
             “somewhat less critical” where the plaintiff puts forth specific
             evidence of exposure to a defendant's product. Similarly,
             under Tragarz, the frequency and regularity prongs become
             “somewhat less cumbersome” in cases involving diseases
             that the plaintiff's competent medical evidence indicates can
             develop after only minor exposures to asbestos fibers.

Gregg, 943 A.2d at 225 (citing Tragarz, 980 F.2d at 421) (citations omitted).

      In Betz, this Court addressed a trial court’s decision to exclude “each and every

breath” expert testimony under principles derived from Frye v. United States, 293 F.




                                    [J-12-2016] - 14
1013 (D.C. Cir. 1923). The expert witness in Betz (Dr. John C. Maddox, M.D.) testified

at the Frye hearing that he did not need to know the exposure histories of mesothelioma

plaintiffs to offer an opinion on causation “so long as they could establish exposure to a

single fiber from each defendant’s product.” Betz, 44 A.3d at 55. We held that the trial

court did not abuse its discretion in excluding this expert testimony, as it was “right to be

circumspect about the scientific methodology underlying the any-exposure opinion”

because it presented no “coherent methodology supporting the notion that every single

fiber from among, potentially, millions is substantially causative of disease.” Id. at 53.

“Simply put, one cannot simultaneously maintain that a single fiber among millions is

substantially causative, while also conceding that a disease is dose responsive.”6 Id.

       Together, Gregg and Betz establish two basic precepts important to resolution of

the issues presented here. First, expert testimony based upon the notion that “each

6
   Ford also relies upon this Court’s decision in Howard v. A.W. Chesterton Co., 78 A.3d
605 (Pa. 2013). We do not, for the reasons set forth in Justice Todd’s concurring
statement in that case. In Howard, the appeal before this Court was decided by mutual
consent among the parties, as the plaintiffs conceded that they could not satisfy the
“frequency, regularity, and proximity” test as adopted in Gregg. Howard, 78 A.3d at
607. In a per curiam decision, however, a majority of the members of this Court
nevertheless decided to summarize the “governing principles” in Gregg and Betz.
As Justice Todd properly concluded, the evidentiary concession and subsequent
agreement between the parties regarding the entry of a final order in accordance
therewith ended the matter. Howard, 78 A.3d at 609-10 (Todd, J., concurring). No
issues remained for determination and thus the entirety of the per curiam opinion is non-
precedential obiter dicta. Id. (Todd, J., concurring). Justice Todd further indicated that
the majority’s decision violated “the axiom that judicial decisions are to be read against
their facts, so as to prevent “the wooden application of abstract principles to
circumstances in which different considerations may pertain.” Id. (Todd, J., concurring)
(citing Maloney v. Valley Med. Facilities, Inc., 984 A.2d 478, 485–86 (Pa. 2009)).
Finally, we note that the majority itself recognized that its decision lacked any
precedential value. Howard, 78 A.3d at 609 (“[W]e do not suggest that a per curiam
order has any effect beyond that represented in Justice Todd's responsive opinion.”).



                                      [J-12-2016] - 15
and every breath” of asbestos is substantially causative of mesothelioma will not suffice

to create a jury question on the issue of substantial factor causation. Second, to create

a jury question, a plaintiff must adduce evidence that exposure to defendant’s asbestos-

containing product was sufficiently “frequent, regular, and proximate” to support a jury’s

finding that defendant’s product was substantially causative of the disease.7

       Ford contends that Dr. Frank’s testimony regarding the cause of Rost’s

mesothelioma violates the first precept because it rested upon an “each and every

breath” theory of causation. Ford argues that Dr. Frank revealed the true nature of his

testimony when he told the jury that “[w]hatever exposures you can show [Rost] had

would have been contributory” and that “[t]he cumulative exposures contributed to his

disease.” N.T., 9/19/2011 (PM), at 22. Ford further relies upon Dr. Frank’s indication

7
   It is important to recognize that this Court settled on these principles based on a
policy concern: that it is fundamentally unfair to hold a defendant jointly and severally
liable for a mesothelioma plaintiff’s injuries for a de minimis contribution to the plaintiff’s
overall exposure. Gregg, 943 A.2d at 227 (“The result, in our view, is to subject
defendants to full joint and several liability for injuries and fatalities in the absence of
any reasonably developed scientific reasoning that would support the conclusion that
the product sold by the defendant was a substantial factor in causing the harm.”); Betz,
44 A.3d at 57 (same). Pennsylvania has now eliminated joint and several liability in
most cases through amendment of the Fair Share Act, 42 Pa.C.S.A. § 7102. The
Rosts’ claims accrued prior to the effective date of the amendment to the Fair Share Act
(June 28, 2011).
When the Rosts’ claims accrued, joint tortfeasors in Pennsylvania, including those in
products liability actions, remained jointly and severally liable for the plaintiff’s damages.
Baker v. ACandS, 755 A.2d 664, 669 (Pa. 2000). Accordingly, this Court did not
consider any potential countervailing policy implications to adoption of the “frequency,
regularity, and proximity” test. See Gregg, 943 A.2d at 226 (citing Comment, The
Threshold Level of Proof of Asbestos Causation: The “Frequency, Regularity and
Proximity Test” and a Modified Summers v. Tice Theory of Burden-Shifting, 24 Capital
U. L. Rev. 735, 750 (1995) (explaining that the “‘frequency, regularity and proximity’ test
imposes an inappropriately high burden of proof upon many asbestos victims,” as it
“distort[s] the medically proven fact that significant injury can result without ‘frequent’ or
‘regular’ exposure”)).



                                      [J-12-2016] - 16
that he could not separate the causative effects of Rost’s exposure to Ford products

from those associated with other asbestos products. N.T., 9/19/2011 (AM), at 82-83.

         In offering this testimony, however, Dr. Frank never indicated that a single

exposure was a substantial cause of Rost’s mesothelioma. Dr. Frank explained to the

jury, in some detail, about the dose response relationship between exposure to

asbestos and the possibility of contracting mesothelioma. Id. at 82 (“As the amount of

asbestos, as the dose increases, the likelihood of developing a disease increases.”).

Dr. Brody offered the same opinion. N.T., 9/20/2011 (AM), at 71. In an amicus brief,

fifty-eight physicians and scientists describe the fundamental notion that each exposure

to asbestos contributes to the total dose and increases the person’s probability of

developing mesothelioma or other cancers as an “irrefutable scientific fact.” Amicus

Brief of Fifty-Eight Physicians/Scientists at 2.     According to these physicians and

scientists, cumulative exposure is “merely an extension of the ancient concept of dose-

response, which is the “oldest maxim in the field.” Id. at 12 (citing Bernard D. Goldstein,

Toxic Torts: The Devil is in the Dose, 16(2) J.L. & Pol’y. 551 (2008)). At the same time,

while the threshold level of asbestos exposure for developing mesothelioma is unknown

(and unquestionably varies by individual susceptibility), it is well-established that

mesothelioma can occur in cases with relatively low exposure levels. N.T., 9/19/2011,

at 83.

         Similarly, Dr. Frank’s testimony regarding the inability to separate the causative

effects of different exposures to asbestos was an effort to convey certain scientific

limitations to the jury. Dr. Brody concurred, testifying, “You can’t just pick out one and




                                      [J-12-2016] - 17
say, ‘This exposure caused this set of errors.’ You can’t do that. It’s just not possible.”

N.T., 9/20/2011 (AM), at 71.

       We must agree with the Rosts that Ford has confused or conflated the

“irrefutable scientific fact” that every exposure cumulatively contributes to the total dose

(which in turn increases the likelihood of disease), with the legal question under

Pennsylvania law as to whether particular exposures to asbestos are “substantial

factors” in causing the disease. It was certainly not this Court’s intention, in either

Gregg or Betz, to preclude expert witnesses from informing juries about certain

fundamental scientific facts necessary to a clear understanding of the causation process

for mesothelioma, even if those facts do not themselves establish legal (substantial

factor) causation. In this case, while Dr. Frank clearly testified that every exposure to

asbestos cumulatively contributed to Rost’s development of mesothelioma, he never

testified that every exposure to asbestos was a “substantial factor” in contracting the

disease.

       Instead, by way of, inter alia, the lengthy hypothetical that detailed the entirety of

Rost’s exposure to asbestos-containing Ford products while at Smith Motors, Dr. Frank

testified that Rost’s actual exposures to asbestos at Smith Motors over three months

was substantially causative of his mesothelioma. N.T., 9/19/2011 (AM), at 121. In other

words, Dr. Frank did not testify that a single breath of asbestos while at Smith Motors

caused Rost’s mesothelioma, but rather that the entirety of his exposures during the

three months he worked there caused his disease. In this regard, Dr. Frank stressed

that, unlike with some other asbestos-related diseases (e.g., asbestosis), mesothelioma

may develop after only relatively small exposures. Id. at 83. Moreover, in offering his




                                     [J-12-2016] - 18
testimony on the issue of legal (substantial factor) causation, Dr. Frank testified strictly

in accordance with this Court’s dictates in Gregg and Betz -- namely, that Rost’s

exposures to asbestos at Smith Motors were sufficiently frequent, regular, and

proximate to permit the inference that these exposures were substantially causative.

Id. at 111-17. Dr. Frank reviewed the nature of the multiple exposures to asbestos at

Smith Motors (e.g., removing brake shoe linings, his proximity to mechanics blowing out

brake drums, sanding brakes, replacing clutches, replacing head gaskets, and

sweeping up the dust and debris at the end of each day8), id., and the length of time the

exposure continued (in excess of three months, while noting studies showing that a

single month of regular exposure to asbestos can double one’s likelihood of developing

mesothelioma).    Id. at 84.    He also reviewed Rost’s exposure history elsewhere,

acknowledging that his exposures at Metropolitan Edison were also causative of his

disease. Id. at 122. Given all of this information, Dr. Frank testified that the totality of

Rost’s exposure to asbestos at Smith Motors, standing alone, was sufficient to have

caused his mesothelioma, even if there had been no other exposures (at Metropolitan

Edison or elsewhere).




8
   As previously indicated, Dr. Frank also found it significant that Rost wore his dust
covered clothes home each day, which may have resulted in the deposit of asbestos
fibers in the Rost home, thus extending the length of his exposure. N.T., 9/19/2011
(AM), at 118-19. In one case, Dixon v. Ford Motor Company, 70 A.3d 328 (Md. 2013),
the Court of Appeals of Maryland found no abuse of discretion in a trial court’s finding
that a wife’s exposure to, inter alia, asbestos fibers on her husband’s work clothes was
sufficiently “frequent, regular, and proximate” to submit the issue of causation to the
jury. Id. at 355 (holding that “because the asbestos fibers brought in on each occasion
remained in the home for a considerable period of time, the exposure was continuous
and cumulative in effect”).



                                     [J-12-2016] - 19
        Unlike the expert witness in Betz, who unabashedly offered “each and every

breath” testimony, in this case Dr. Frank relied upon a generally accepted methodology,

taking into consideration exposure history, individual susceptibility, biological plausibility,

and relevant scientific evidence (including epidemiological studies).9 Brief of Fifty-Eight

Physicians/Scientists at 6. Moreover, per Gregg, his testimony regarding the frequency,

regularity and proximity of Rost’s exposures to asbestos while at Smith Motors provided

a sufficient basis to create a jury question regarding the existence of a causal

connection between his exposure to asbestos-containing Ford products and the

subsequent development of mesothelioma.               In Gregg, this Court adopted the

“frequency, regularity, and proximity” test as a refinement to the substantial factor

requirement for proving causation in mesothelioma cases.            In the context of expert

testimony on substantial factor causation, Gregg provides the legal test, not an

additional legal test, for proving substantial factor causation in cases involving disease

resulting from asbestos exposure.

        For its second argument in support of its first issue on appeal, Ford contends that

this Court in Betz established another test, in addition to “frequency, regularity, and


9
    Indeed, we agree with the Superior Court’s observation that
        this record is nearly the mirror image of that described in Betz. The
        Rosts’[] experts provided detailed testimony about the nature of
        mesothelioma and its causes, backed up by published research on the
        subject. Their testimony was internally consistent, and by the admission
        of Ford’s own experts, supported by at least 50 asbestos scientists around
        the world. In contrast, Ford’s expert’s critiques were at times internally
        inconsistent and generally consisted of subjective beliefs that had not
        been subjected to peer-review by the appropriate scientific community.
Rost, 2014 WL 2178528, at *10.



                                      [J-12-2016] - 20
proximity,” that plaintiffs in mesothelioma cases must meet to establish substantial

factor causation. In Betz, this Court noted that the expert in that case (Dr. Maddox)

indicated that individual exposures differ “in the potency of the fiber to which an

individual is exposed, to the concentration or intensity of the fibers to which one is

exposed, and to the duration of the exposure to that particular material.” Betz, 44 A.3d

at 56. These considerations, according to Dr. Maddox, go into “trying to estimate the

relative effects of different exposures” and are “required for causal attrition as a matter

of science.” Id. at 56, 58. Based upon this language in Betz, Ford argues that a

causation expert in a mesothelioma case must compare all of the plaintiff’s exposures to

asbestos over his or her lifetime to “determine which among a plaintiff’s exposures

substantially caused mesothelioma.” Ford’s Reply Brief at 11-12. According to Ford,

the “question for an expert is not whether plaintiff’s exposure to a given product is

‘substantial’ standing alone, but whether exposure to that product is a substantial cause

in light of other exposures.” Id. at 12. Because Dr. Frank did not compare Rost’s

exposures at Smith Motors with his exposures at Metropolitan Edison (including fiber

type, intensity and duration), Ford insists that his testimony failed to satisfy this second

test. Id. at 12.

       Ford misconstrues our decision in Betz for several reasons. First, Betz did not

involve any consideration of multiple asbestos exposures or any attempts to parse

causally significant exposures from de minimis exposures.            Instead, in Betz we

addressed a trial court’s exclusion of “each and every breath” expert testimony after a

Frye hearing. In so doing, we expressly disregarded the appellant’s contention that we

should take into consideration that his four-decade history as an auto mechanic was




                                     [J-12-2016] - 21
“not a case of a de minimis occupational exposure.” Betz, 44 A.3d at 55. We indicated

that because the expert (Dr. Maddox) testified that his opinion on causation did not

depend upon any knowledge of a plaintiff’s exposure history, our consideration of the

issue presented would proceed without regard to the appellant’s actual exposure to

asbestos. Id. Since no issues associated with multiple exposures were before the

Court, Betz could not and did not add a significant new requirement for plaintiffs to

establish substantial factor causation in cases involving multiple asbestos exposures.

Because the issue was not presented, any attempt to create such an additional legal

hurdle would have been mere obiter dicta. See generally Rendell v. Pennsylvania State

Ethics Comm'n, 983 A.2d 708, 714 (Pa. 2009) (holding that statements which were

“unnecessary to the resolution of the controversy” were non-binding dicta).

       Second, Ford takes the relevant language in Betz, specifically that a

“comparative assessment of impact among differing exposures … is required for causal

attrition … under Pennsylvania law,” Betz, 44 A.3d at 58, out of context. This language

in Betz was intended to disabuse the Superior Court from any further reliance upon a

statement in Tragarz that where “there is competent evidence that one or a de minimis

number of asbestos fibers can cause injury, a jury may conclude the fibers were a

substantial factor in causing a plaintiff’s injury.” Id. (quoting Tragarz, 980 F.2d at 421).

Of course, in Betz we merely reaffirmed our holding in Gregg that, contrary to the

quoted statement in Tragarz, causation experts may not testify that a single exposure

(i.e., “one or a de minimis number of asbestos fibers”) is substantially causative. Id. at

56-57; Gregg, 943 A.2d at 226-27.        Rather than offering “each and every breath”

theoretical constructs, causation experts must provide concrete testimony of causal




                                     [J-12-2016] - 22
attribution by assessing the frequency, regularity, and proximity of the plaintiff’s

exposure to the defendant’s product. Gregg, 943 A.2d at 226-27. This assessment, in

turn, requires a focus on the precise nature of the plaintiff’s exposure to the

defendant’s product, not on other asbestos-containing products. As we advised in

Gregg, the Tragarz “frequency, regularity, and proximity” factors should be applied “in

an evaluative fashion as an aid in distinguishing cases in which the plaintiff can adduce

evidence that there is a sufficiently significant likelihood that the defendant’s product

caused his harm.” Id. at 225; see also Lindstrom v. A-C Prod. Liab. Trust, 424 F.3d

488, 493 (6th Cir. 2005) (“The requirement … is that the plaintiff make a showing with

respect to each defendant that the defendant's product was a substantial factor in

plaintiff's injury.”). Moreover, we indicated that, consistent with Tragarz, application of

the factors becomes “somewhat less critical” where the plaintiff puts forth specific

evidence of exposure to a defendant's product, and that the frequency and regularity

prongs become “somewhat less cumbersome” in cases involving diseases that the

plaintiff's competent medical evidence establishes can develop after only minor

exposures to asbestos fibers. Gregg, 943 A.2d at 225.10

      In this case, Rost’s testimony confirmed his frequent, regular and proximate

exposures to asbestos from Ford products while at Smith Motors, and Dr. Frank, in part

through the hypothetical question incorporating this exposure history, opined within a

reasonable degree of medical certainty that the exposures at Smith Motors were

10
    As applied to this case, all three factors are “somewhat less critical” because Rost
put forth specific evidence of direct exposure to Ford’s product, and the frequency and
regularity prongs become “somewhat less cumbersome” because Rost’s competent
medical evidence established that mesothelioma can develop after only minor exposure
to asbestos fibers.



                                     [J-12-2016] - 23
sufficient, in and of themselves, to cause Rost’s mesothelioma.11 Comparison of Rost’s

other occupational exposures to asbestos was unnecessary. We are unaware of any

state or federal court that requires such a comparison. While some states continue to

permit “each and every breath” testimony, e.g., Morin v. AutoZone Ne., Inc., 943 N.E.2d

495, 500 (Mass. App. 2011); Weakley v. Burnham Corp., 871 A.2d 1167, 1177 (D.C. Ct.

App. 2005); Purcell v. Asbestos Corp. Ltd., 959 P.2d 89, 94 (Or. App. 1998); Sheffield v.

Owens–Corning Fiberglass Corp., 595 So.2d 443, 456 (Ala. 1992), the majority of state

and federal courts have adopted the “frequency, regularity, and proximity” test. 12 See

Holcombe v. Georgia Pacific, LLC, 289 P.3d 188, 195 (Nev. 2012) (“The majority of the

federal circuits and state courts addressing this question have chosen to apply” the

“frequency, regularity, and proximity” test to “determine whether the plaintiff has

satisfied his burden of showing that a specific defendant’s products caused his

disease.”) (citing Charles T. Greene, Determining Liability in Asbestos Cases:        The


11
    While not required to do so, Dr. Frank included in his assessment the three factors
that Dr. Maddox referenced in Betz. See Betz, 44 A.3d at 56, and discussion supra at
21. He considered the potency of chrysotile asbestos fibers, testifying that while
amphibole fibers are more potent, “there really should be no question that chrysotile
fibers can cause mesothelioma,” in part based upon their superior ability to reach the
pleura more quickly and in greater quantities. N.T., 9/19/2011, at 90-95. He considered
the intensity of Rost’s exposures, including the potential for blowouts of brake drums to
generate seventeen chrysotile asbestos fibers per cubic centimeter of air, with elevated
levels up to sixty feet away (well within the range where Rost was typically situated). Id.
at 100. And he testified regarding the duration of Rost’s exposure while at Smith Motors
(in excess of three months), referencing case reports revealing that consistent exposure
to asbestos for even one month could double a person’s risk of developing
mesothelioma. Id. at 82-84.
12
   Virginia appears to have developed its own test, requiring proof that the illness would
not have occurred without exposure to the defendant's asbestos or that exposure to the
defendant's asbestos was independently sufficient to cause the illness.” Ford Motor Co.
v. Boomer, 736 S.E.2d 724, 732 (Va. 2013).



                                     [J-12-2016] - 24
Battle to Assign Liability Decades After Exposure, 31 Am. J. Trial Advoc. 571, 572

(2008)). Not even Texas, which employs the most stringent test of any state, requiring

detailed expert testimony to establish the precise extent and intensity of the plaintiff’s

exposure to the defendant’s product (including the approximate quantum of fibers

actually inhaled), insists upon a similarly detailed analysis of the plaintiff’s lifetime

exposure to other asbestos-containing products. See Bostic v. Georgia-Pacific Corp.,

439 S.W.3d 332, 338 (Tex. 2014).           Our decisions in Gregg and Betz aligned

Pennsylvania with the majority of other courts adopting the “frequency, regularity, and

proximity” test.

       The focus on Rost’s exposures to Ford’s products at Smith Motors, rather than

on other lifetime exposures, is also consistent with Pennsylvania law on substantial

factor causation. To establish proximate causation, a plaintiff must adduce evidence to

show that the defendant’s act was a substantial factor in bringing about the plaintiff’s

harm. Jones v. Montefiore Hospital, 431 A.2d 920, 923 (Pa. 1981); Ford v. Jeffries, 379

A.2d 111, 114 (Pa. 1977) (“[T]he issue is whether the defendant's conduct was, on the

one hand, a ‘substantial factor’ or a ‘substantial cause’ or, on the other hand, whether

the defendant's conduct was an ‘insignificant cause’ or a ‘negligible cause.’”). This

Court has consistently and without exception held that issues of causation are matters

of fact for the jury to decide:

               Whether in a particular case that standard [plaintiff’s burden
               of proof with the preponderance of the evidence] has been
               met with respect to the element of causation is normally a
               question of fact for the jury; the question is to be removed
               from the jury’s consideration only where it is clear that
               reasonable minds could not differ on the issue. … [I]t is
               enough that reasonable minds are able to conclude that the
               preponderance of the evidence shows defendant's conduct



                                     [J-12-2016] - 25
              to have been a substantial cause of the harm to plaintiff.

Hamil v. Bashline, 392 A.2d 1280, 1284–85 (Pa. 1978); see also Vattimo v. Lower

Bucks Hosp., Inc., 465 A.2d 1231, 1234 (Pa. 1983) (holding that where reasonable

minds may differ, questions of causation are for the jury); Topelski v. Universal South

Side Autos, Inc., 180 A.2d 414, 419 (Pa. 1962) (holding that where “reasonable

difference of opinion as to whether the defendant's act was the, or a proximate cause of,

the injury, the matter is for the jury to decide”).

       Indeed, in Summers v. Certainteed Corp., 997 A.2d 1152 (Pa. 2010), this Court

held that if a plaintiff presents an expert opinion, within a reasonable degree of medical

certainty, that his or her debilitating injuries were caused, at least in part, by

occupational exposure to asbestos, the issue of substantial causation is for the jury to

decide, even if the evidence also presented other causative forces of lung disease (e.g.,

a history of cigarette smoking). Id. at 1164-65. In ruling that our law regarding proof of

substantial causation is the same for exposure to asbestos as it is in other tort contexts,

we held that “under this Commonwealth’s jurisprudence, where it is clear that

reasonable minds could differ on the issue of causation, precluding asbestos litigants

from pursuing causes of action, supported by competent medical evidence, merely

because of the existence of competing health conditions, is unsustainable.” Id. at 1165.

We further noted that this Court has issued a “plethora of decisions … that require juries

to resolve competing theories of causation,” id. at 1165 n.19, and “we now instruct juries

on the very idea of competing issues of factual causation.” Id. at 1165 n.19 (citing

Pa.SSJI (Civ) §§ 3.15 (“The defendant’s conduct need not be the only factual cause.

The fact that some other causes concur ... does not relieve the defendant of




                                       [J-12-2016] - 26
liability ... .”); 8.04B (instructing that, in a strict products liability action, when a

defendant manufacturer proffers a different factual cause of the sustained injury, “the

manufacturer has the burden of proving by a fair preponderance ... that the plaintiff's

injuries are divisible and [the defective product] did not contribute to this particular

injury.”)).

        In Gregg, this Court held that in asbestos products liability cases, evidence of

“frequent, regular, and proximate” exposures to the defendant’s product creates a

question of fact for the jury to decide.13 Gregg, 943 A.2d at 226-27. This Court has

never insisted that a plaintiff must exclude every other possible cause for his or her

13
    Contrary to the dissenting opinion of Justice Baer, this Court in Gregg did not
promote the necessity of a comparative assessment for purposes of substantial
causation, or otherwise suggest that the “frequency, regularity, and proximity” test was
part of a comparative assessment of differing exposures. Dissenting Op. at 4 (Baer, J.,
dissenting). To the contrary, as explained hereinabove, in Gregg we adopted the three-
pronged test for substantial causation as it was set forth and described in the Seventh
Circuit’s decision in Tragarz. Gregg, 943 A.2d at 226-27 (“We agree with the Tragarz
court's approach and adopt it here.”). In Tragarz, the Seventh Circuit specifically
rejected any notion that its test requires a comparative analysis of different exposures to
asbestos, and instead made clear that the focus must be on the level of exposure to the
defendant’s product:
        Suppose a plaintiff shows that the amount of exposure that it received
        from defendant A’s asbestos product was alone sufficient to cause
        mesothelioma. If such a plaintiff was not exposed to any other products,
        the plaintiff would have sufficient evidence to support a finding that but for
        exposure to the defendant A's product the plaintiff would not have gotten
        ill. On the other hand, under [a comparative approach], if the plaintiff was
        exposed to numerous other asbestos products, the plaintiff might not be
        able to prove cause in fact in a suit against defendant A because the
        same exposure to defendant A's product might not be substantial in
        comparison to the exposure to the other products. Such a result does
        not promote the purposes of the substantial factor test, which is
        aimed at alleviating the inequities that result when applying the but-
        for test in a multi-defendant case, not at creating such inequities.
Tragarz, 980 F.2d at 425 (emphasis added).



                                      [J-12-2016] - 27
injury, and in fact, we have consistently held that multiple substantial causes may

combine and cooperate to produce the resulting harm to the plaintiff. See, e.g., Harsh

v. Petroll, 887 A.2d 209, 218 (Pa. 2006); Powell v. Drumheller, 653 A.2d 619, 622 (Pa.

1995); Hamil, 392 A.2d at 1284–85 (“In establishing a [p]rima facie case [of substantial

causation], the plaintiff need not exclude every possible explanation ... .”). Rost’s expert

testified unequivocally that exposures to Ford’s products were a substantial factor in

causing Rost’s mesothelioma. Given the further scientifically irrefutable testimony of

Drs. Frank and Brody that the threshold level of exposure to asbestos for developing

mesothelioma is very low and that the disease may be caused by a series of exposures

over a short period of time, N.T., 9/19/2011 (AM), at 84-85; N.T., 9/20/2011 (AM), at 71,

it is hardly surprising that exposure to multiple asbestos-containing products will lead a

fact-finder to decide that there were multiple substantial factors causative of a plaintiff’s

mesothelioma. In this case, the jury found that Rost’s exposures to four asbestos-

containing products were substantially causative of Rost’s disease, including Ford’s

products at Smith Motors and three other products used at Metropolitan Edison.

       The learned dissenting justices are of the view that our jurisprudence in

asbestos-related cases has created exceptions to substantial factor causation principles

beneficial to plaintiffs. Dissenting Op. at 3-4 (Saylor, C.J., dissenting). Having excluded

the proffered expert scientific testimony on substantial factor causation in Gregg in favor

of the “frequency, regularity and proximity” approach in Tragarz, the dissenting justices

now recommend that, based upon obiter dicta in Betz, we retreat from the “frequency,

regularity and proximity” standard for substantial causation and instead erect even more

onerous obstacles to recovery.      Minimizing “frequency, regularity and proximity” as




                                      [J-12-2016] - 28
mere risk assessment (or, even worse, as nothing more than a guideline for establishing

product identification), and contrary to the holding in Gregg that the Tragarz approach

provides the jury with “the necessary inference of a sufficient causal connection

between the defendant’s product and the asserted injury,” Gregg, 943 A.2d at 227, the

dissenting justices now insist that the Tragarz approach is insufficient to protect

defendants in asbestos cases from liability.         Dissenting Op. at 14 (Saylor, C.J.,

dissenting) (“After all, the [Tragarz] test is undeveloped in terms of metrics or degree-

based standards of any kind and, in cases involving mesothelioma, tends to devolve

into the any-exposure theory.”). Rather than the “frequency, regularity and proximity”

test adopted in Gregg, the dissenting justices contend that experts in all asbestos-

related disease cases should be required, at a minimum, to quantify the plaintiff’s dose

from the defendant’s product as well as the cumulative dose from all exposures (which

would in turn require a detailed quantification of all of the plaintiff’s lifetime exposures),

and the jury must then compare these quantifications when considering substantial

causation . Id. at 6-15 (Saylor, C.J., dissenting); see also id. at 7 n.6 (“Dr. Frank made

no attempt to even roughly quantify either the dose experienced by Mr. Rost at Smith

Motors or his cumulative exposure or dose.”).

       There are several overarching problems with this proposal. First, on this record,

there is substantial doubt whether such quantification is possible. According to the brief

of the amicus physicians and scientists, “[t]o require quantification where it is almost

always impossible and unnecessary to do so, would be a public health travesty. That is,

this would have the effect of creating an impossible burden of proof, and no claim would

be able to meet this impossible standard … .”                 Amicus Brief of Fifty-Eight




                                      [J-12-2016] - 29
Physicians/Scientists at 9.    Moreover, Dr. Frank testified that it is not scientifically

possible to quantify the precise quantity of asbestos inhalation that is required to initiate

the disease process or to identify the particular exposure or exposures that caused the

disease. N.T., 9/19/2011 (AM), at 83, 121-22; see also N.T., 9/20/2011 (AM), at 71 (Dr.

Brody).

        Second, the goal in a comparison of lifetime exposures could only be to

determine which exposure to asbestos was the most causative of plaintiff’s

mesothelioma.     At bottom, the contention of the dissenting justices is that Rost’s

exposure to asbestos at Metropolitan Edison, given its longer duration, was more

causative than was his shorter exposure at Smith Motors, thereby precluding recovery

against Ford.     As explained hereinabove, however, multiple asbestos-containing

products may be substantial factors causative of a plaintiff’s mesothelioma. It is for the

finder of fact, and not the courts, to make these determinations regarding substantial

causation.

        Third, given Dr. Frank’s testimony in this case, such a comparison is entirely

unnecessary. As reviewed hereinabove, Dr. Frank testified that the totality of Rost’s

exposures to asbestos at Smith Motors, standing alone, was sufficient to have caused

his mesothelioma, even if there had been no other exposures. N.T., 9/19/2011 (AM),

at 121. As a result, Rost’s other exposures to asbestos (at Metropolitan Edison and

elsewhere) were irrelevant to the jury’s consideration of substantial causation in this

case.     The dissenting justices’ concern about whether the jury could understand

whether the bucket of water was placed in a bathtub or an ocean, Dissenting Op. at 10




                                      [J-12-2016] - 30
(Saylor, C.J., dissenting), misses the mark entirely, since Dr. Frank testified that Rost’s

exposures at Smith Motors, without more, were sufficient to cause his cancer.

       Pursuant to Gregg and Betz, for all exposures to asbestos that satisfy the

“frequency, regularity, and proximity” test, when coupled with competent medical

testimony establishing substantial factor causation, it is for the jury to decide the

question of substantial causation. The dissenting justices implicitly concede that the

Rosts satisfied these requirements, but simply cannot square Dr. Frank’s expert opinion

on the low quantum of asbestos exposure sufficient to cause mesothelioma with

opposing views on how mesothelioma is caused. See Gregg, 943 A.2d at 228 (Cappy,

C.J., dissenting). To bridge this apparent gap, the dissenting justices seek to place on

plaintiffs in asbestos disease cases an evidentiary burden not borne by plaintiffs in other

tort actions. Plaintiffs in other tort actions have no obligation to eliminate every other

potential cause of the development of disease through a ranking of different exposures

by type and duration. See, e.g., Jones, 431 A.2d at 923 (“A plaintiff need not exclude

every possible explanation … .”).         Instead, in other cases it is for a defendant

challenging a plaintiff’s evidence of substantial causation to bring to the jury’s attention

other potential causes, both through cross-examination and contrary expert testimony,

and in so doing attempt to convince the jury that the defendant’s product was not

substantially causative of the plaintiff’s disease.

       The record in the present case reflects that Ford did precisely this, through its

lengthy cross-examination of Dr. Frank focusing on, inter alia, Rost’s other exposures to

asbestos (including at Metropolitan Edison) and a detailed review of published studies

regarding the incidence of asbestos-related disease related to exposure to chrysotile




                                      [J-12-2016] - 31
asbestos in brakes. N.T., 9/19/2011 (P.M.), at 16-55. Ford also called two expert

witnesses in efforts to discredit and contradict Dr. Frank’s testimony, including Dr.

Michael Graham, M.D., a professor of pathology at St. Louis University, and Dr. Herman

Gibb, Ph.D., who worked at the United States Environmental Protection Agency for

more than thirty years.     Drs. Graham and Gibb both opined at length that Rost’s

exposure to chrysotile asbestos from Ford products was not causative of his

mesothelioma and that instead his occupational exposure to asbestos while at

Metropolitan Edison (which included exposure to amphibole asbestos) was responsible

for his contraction of the disease. N.T., 9/20/2011 (P.M.), at 62-114); N.T., 9/27/2011,

at 100-146.

       As reflected by its verdict, the jury credited the testimony of Dr. Frank rather than

that of Drs. Graham and Gibb. Because we conclude, based upon our review of the

record, that the Rosts presented sufficient evidence to satisfy the “frequency, regularity,

and proximity” test and Dr. Frank provided competent medical testimony establishing

substantial factor causation, we conclude that the trial court did not err in submitting the

issue of substantial causation to the jury and in denying Ford’s motions for non-suit,

judgment notwithstanding the verdict, and for a new trial.

       With respect to its second issue on appeal, Ford objects to the trial court’s

decision to consolidate its case for trial with two other mesothelioma cases, Estate of

Wasekanes v. Sears, in which the plaintiff alleged that exposure to asbestos while

changing brakes sold by Sears caused his mesothelioma, and Graver v. Foster Wheeler

Corporation, in which the plaintiff alleged that occupational exposure to a boiler built by

Foster Wheeler caused his mesothelioma. Ford contends that the local practice of




                                     [J-12-2016] - 32
mandatory consolidation of asbestos cases was contrary to statewide consolidation

practices under Rule 213(a) of the Pennsylvania Rules of Civil procedure, which

requires a discretionary analysis based upon, inter alia, commonality of fact or law.14

Ford’s Brief at 43-45. Ford further claims that the trial court’s refusal to sever its case

for trial violated its constitutional rights to due process, as the introduction of evidence

and argument in the other cases contrary to Ford’s defense in the present case resulted

in prejudice. Id. at 58-63. Finally, Ford argues that the Superior Court erred in refusing

to review Ford’s challenge to consolidation on appeal. Id. at 53.

       At the time of trial in this case (September 2011), the Philadelphia Court of

Common Pleas followed an apparently unwritten policy15 of mandatory consolidation of

mass tort and asbestos cases based (apparently) solely upon the type of disease at

issue. When, at the outset of trial, Ford reasserted its prior requests to sever its case,


14
    Ford also claims that the mandatory consolidation policy is inconsistent with Rule
213(a) of the Pennsylvania Rules of Civil Procedure and, as such, the trial court
encroached on this Court’s exclusive powers under Article V, Section 10(c) of the
Pennsylvania Constitution governing practice in our state courts. Ford did not raise this
issue in its post-trial motions or before the Superior Court, however, and thus has not
been preserved it for appeal. Pa.R.A.P. 302(a). Even if this issue had been preserved
for appeal, this Court did not grant allocatur to consider it. Commonwealth v. Hacker,
15 A.3d 333, 336 n.6 (Pa. 2011).
15
    As of 2011, the policy had not been promulgated into a local rule or included in the
court’s published regulations. The common pleas court first adopted a formal
consolidation policy in 2012, with the issuance of General Court Regulation 2012-01,
which was amended a year later in General Court Regulation 2013-01. Pursuant to
2013-01, asbestos cases may be consolidated for trial only after consideration of, inter
alia, the law (by state) to be applied, the identical nature of the disease (mesotheliomas,
lung cancers, other cancers, non-malignancy cases), counsel in the same law firm, and
Fair Share Act applicability. The court may also consider “other factors as determined
appropriate in weighing whether all parties to the litigation receive a prompt and just
trial.” The court’s backlog of asbestos cases “shall not be an overriding factor in the
consolidation determination.”



                                     [J-12-2016] - 33
the trial court again denied the request, stating that “[w]e have all been doing it for

years.” N.T., 9/12/2011 (AM), at 21. When Ford reasserted its request to sever again

on the fifth day of trial, the trial court responded, “We don’t sever cases.”          N.T.,

9/16/2011 (AM), at 81. In its written opinion pursuant to Rule 1925 of the Pennsylvania

Rules of Appellate Procedure, the trial court defended its ruling by noting that “in

Philadelphia, we have been doing so for years.” Trial Court Opinion, 12/28/2011, at 5.

       We agree with Ford that this was error. Rule 213(a) provides that cases may be

consolidated only if they “involve a common question of law or fact or which arise from

the same transaction or occurrence.” Pa.R.C.P. 213(a). This Court has long held that

Rule 213 only permits (rather than requires) the consolidation of cases, and that “the

matter of consolidation rests in the sound discretion of the court … .” Ragano v. Socony

Vacuum Oil Co., 101 A.2d 686, 687 (Pa. 1954). The record in this case does not reflect

that the trial court exercised any discretion with respect to either the consolidation of the

three cases at issue, or in connection with Ford’s requests to sever the Rost case from

the Wasekanes and Graver cases.

       We likewise agree with Ford that the Superior Court’s refusal to review the trial

court’s consolidation rulings was error. The Superior Court based its decision upon

Pittsburgh Corning Corp. v. Bradley, 453 A.2d 314 (Pa. 1982). In Bradley, this Court

denied a request for a writ of prohibition challenging a 1982 local regulation establishing

a program of non-jury trials for asbestos-related claims, with a separate right to a de

novo jury trial thereafter. Id. at 315. Given the heavy backload of such cases, this

Court did not reach the issue of whether the court of common pleas had the authority to

promulgate the regulation, and instead permitted the policy to remain in effect, subject




                                      [J-12-2016] - 34
to our close supervision, as it promoted “the efficient disposition of asbestos cases

without unfairly depriving any litigant of an opportunity to obtain a full and fair

adjudication of his rights.” Id. at 318.

       Based upon our decision in Bradley, the Superior Court determined that it had no

authority “to address procedural issues such as this absent a claim of violation of

constitutional rights.”   Rost, 2014 WL 2178528, at *12.        Our decision in Bradley,

however, did not preclude appellate review of abuse-of-discretion determinations

relating to consolidation of cases for trial. To the contrary, it merely permitted the

continuation of a particular procedure (not the one at issue here) designed to expedite

the resolution of asbestos-related cases. Bradley, 453 A.2d at 318. We plainly did not

hold that the trial court was free to adopt any other such procedures (even if

inconsistent with statewide consolidation rules), and we neither said nor suggested that

we intended to eliminate intermediate appellate court review of consolidation decisions.

       Whether Ford is entitled to relief in the form of a new trial for these errors, or on

its claim of a violation of its constitutional rights to due process, depends upon whether

Ford was prejudiced by the consolidation. Com., Dep’t of Gen. Servs. v. U.S. Mineral

Products Co., 956 A.2d 967, 970 (Pa. 2008) (“The governing review principles require

the award of a new trial only where a trial court has committed an error of law or abuse

of discretion which may have affected the verdict.”); Boyle v. Independent Life Truck,

Inc., 6 A.3d 492, 494-95 (Pa. 2010); Harman ex rel. Harman v. Borah, 562 455, 467,

756 A.2d 1116, 1122 (Pa. 2000). Ford claims that it was prejudiced in three ways.

First, consolidation “stripped away Ford’s ability to cross-examine adverse witnesses,”

including in particular Dr. James Millette, a plaintiffs’ expert in the Wasekanes case who




                                       [J-12-2016] - 35
used tests of Ford brakes to explain his research into asbestos release from brakes.

Ford’s Brief at 38. Second, Ford contends that the defendants in the three cases all

pursued different defense theories at trial. In the Graver case, for example, Foster

Wheeler attempted to prove that the plaintiff’s exposure to its boiler did not cause the

plaintiff’s mesothelioma, which Ford argues was inconsistent with its attempt to

demonstrate that Rost’s exposure to the boilers at Metropolitan Edison was the cause of

his mesothelioma. Id. at 40-41. Ford similarly complains that an expert witness called

by Sears (Dr. Andrew Sporn) testified that epidemiological research might be different

for professionals (as opposed to amateurs) who work on brakes, which the jury could

have understood as an indirect reference to Rost’s work at Smith Motors.               Id.   In

addition, Ford complains that in closing arguments, counsel for Sears attempted to

distinguish itself as a mere retailer of brakes, in contrast to a manufacturer of such

products. Id. at 41-42. Third, Ford insists that consolidation of three cases without any

significant factual overlap confused the jury. Id. at 42-43.

       Based upon our review of the record, we find little support for these arguments.

With respect to Dr. Millette, contrary to Ford’s contentions, the trial court offered Ford

the opportunity to cross-examine him, but Ford declined to do so. N.T., 9/16/2011 (AM),

at 84. In addition, the trial court instructed the jury that Dr. Millette’s testimony could “in

no way” be “attributed to Ford in the Rost case.”16 Id. at 133.



16
    The dissenting justices reference a short segment of testimony from the closing
argument of counsel for Sears in the Wasekanes case as the “tipping point” for
prejudice against Ford. Dissenting Op. at 16 (Saylor, C.J., dissenting). Viewed in
context, however, counsel’s reference to a “grand conspiracy” was, if anything, more
favorable to Ford than it was prejudicial. Sears’ counsel referred to the alleged “grand
conspiracy” sarcastically, as part of an effort to discredit Dr. Millette’s credibility with
(continued…)

                                      [J-12-2016] - 36
       While it is true that Foster Wheeler contended that the boiler it constructed in the

1950s was not a cause of the mesothelioma in the Graver case, its argument was

based principally upon the timing of the plaintiff’s exposure -- well after the asbestos in

the boiler would have been replaced. N.T., 10/5/2011, at 221-23. Foster Wheeler did

not argue that asbestos in boilers could not cause mesothelioma, and thus, there was

no inconsistent defense prejudicial to Ford’s efforts to show that asbestos-containing

boilers at Metropolitan Edison were substantially causative of Rost’s mesothelioma.

Likewise, Dr. Sporn’s testimony was not, as a whole, prejudicial to Ford, as he testified,

consistently with Ford’s own experts, that chrysotile asbestos fibers from brakes do not

cause mesothelioma. N.T., 9/26/2011 (PM), at 32. In any event, Ford did not object to

any portion of Dr. Sporn’s testimony, or to the relevant portions of closing arguments by

counsel for Sears.

       With regard to its final claim of prejudice, that consolidation of the three cases led

to jury confusion, Ford cites to academic research indicating that consolidation generally

favors plaintiffs, as results suggest that where two or three cases are consolidated for

trial, plaintiffs are fifteen percent more likely to prevail than in individual trials. Ford’s

Brief at 42. Moreover, Ford contends that the jury was clearly confused in this case, as

during deliberations it asked the trial court to be advised of Rost’s last annual income,

even though no claim for lost wages had been asserted. Id. at 43. Based upon our

(…continued)
regard to a contention that studies showing no increase in risk of contracting asbestos-
related disease from exposure to chrysotile asbestos in friction brake products had been
industry financed. Counsel immediately followed his “grand conspiracy” remark (to
which Ford did not object) by reminding the jury that Dr. Millette had himself performed
studies (referenced in his testimony against Sears) that had been financed by plaintiffs’
attorneys. N.T., 10/5/2011, at 156-58.



                                      [J-12-2016] - 37
review of the record, however, we find no evidence of any significant jury confusion.

The trial court repeatedly instructed the jury to treat each of the cases individually and to

apply the evidence in each case separately to decide it on its own merits. See, e.g.,

N.T., 8/12/2011, at 13417; N.T., 10/6/2011 (AM), at 12. The question regarding Rost’s

last annual income is not any clear indication of jury confusion. During deliberations,

the jury asked a number of questions in connection with each of the three cases, all

reasonably related to the issues in the case at issue. Moreover, there is no indication

that the jury included lost wages in its award to the Rosts. Ford did not propound jury

interrogatories.

       In the absence of any demonstrable prejudice to Ford resulting from

consolidation, no basis exists to conclude that the trial court erred in denying Ford a

new trial. As a result, no relief is due on Ford’s second issue on appeal.18


17
     Immediately upon the swearing of the jury, the trial court advised its members as
follows:
       Now, keep in mind, I’m going to be emphasizing this from the beginning,
       you’re sitting on three separate cases. So what you do in one case
       doesn’t follow you are going to do the same thing in the other case.
       You’ve got to analyze all three cases separately, and that’s what your
       function will be in the trial or trials, if you want to use it that way.
N.T., 8/12/2011, at 134.
18
    The Rosts filed an “Application to Supplement the Record on Appeal,” seeking to
supplement the original record with non-privileged documents that Ford allegedly failed
to produce during discovery that are supportive of Dr. Frank’s testimony. We will deny
the application, as these documents were not before the trial court at the time of its
decisions relating to Dr. Frank’s testimony, and were not a part of the record on appeal
when the Superior Court rendered its decision. Rule 1921 of the Pennsylvania Rules of
Civil Procedure generally limits the contents of the original record to items before the
lower courts at the time of decision. Pa.R.A.P. 1921 (describing the record on appeal
as containing “original papers and exhibits filed in the lower court, … the transcript of
proceedings, if any, … and a certified copy of the docket entries… .”). Also, while
(continued…)

                                      [J-12-2016] - 38
      Judgment affirmed.

      Justices Todd, Dougherty and Wecht join the opinion.

      Chief Justice Saylor and Justice Baer file dissenting opinions.




(…continued)
Pa.R.A.P. 1926 permits appellate courts to correct omissions in the original record, such
corrections must be directed to ensuring that “the record truly discloses what occurred
in the trial court.” See generally Fotta v. Workmen’s Compensation Appeal Board, 626
A.2d 1144, 1147 n.2 (Pa. 1993) (refusing to consider a revised medical report not
considered by the tribunals below).



                                    [J-12-2016] - 39
