                                             Filed:   July 26, 2000

                   UNITED STATES COURT OF APPEALS

                       FOR THE FOURTH CIRCUIT


                              No. 99-1622
                             (CA-98-41-4)



Loretta Jones Murray, etc.,

                                                 Plaintiff - Appellee,

          versus


United States of America,

                                                Defendant - Appellant.



                              O R D E R



     The court amends its opinion filed June 21, 2000, as follows:

     On page 10, second full paragraph, line 13 -- the words

“rejected the defendant’s argument” are corrected to read “rejected

the plaintiff’s argument.”

                                          For the Court - By Direction



                                          /s/ Patricia S. Connor
                                                   Clerk
PUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

LORETTA JONES MURRAY, Executrix
and Personal Representative of the
Estate of Weston Murray, Deceased,
Plaintiff-Appellee,

v.
                                                                      No. 99-1622
UNITED STATES OF AMERICA,
Defendant-Appellant,

MARY IMMACULATE HOSPITAL,
Movant.

Appeal from the United States District Court
for the Eastern District of Virginia, at Newport News.
Henry C. Morgan, Jr., District Judge.
(CA-98-41-4)

Argued: April 6, 2000

Decided: June 21, 2000

Before NIEMEYER, Circuit Judge, Roger J. MINER,
Senior Circuit Judge of the United States Court of Appeals
for the Second Circuit, sitting by designation and
Joseph R. GOODWIN, United States District Judge for the
Southern District of West Virginia, sitting by designation.

_________________________________________________________________

Reversed and remanded by published opinion. Judge Goodwin wrote
the opinion, in which Judge Niemeyer and Senior Judge Miner joined.

_________________________________________________________________
COUNSEL

ARGUED: Anita Kay Henry, Assistant United States Attorney,
UNITED STATES ATTORNEY'S OFFICE, Norfolk, Virginia, for
Appellant. Larry W. Shelton, SHELTON & MALONE, P.C., Norfolk,
Virginia, for Appellee. ON BRIEF: Helen F. Fahey, United States
Attorney, UNITED STATES ATTORNEY'S OFFICE, Norfolk, Vir-
ginia, for Appellant.

_________________________________________________________________

OPINION

GOODWIN, District Judge:

This wrongful death action arises from the negligent medical ser-
vices provided by Dr. James Hendricks, an agent of the McDonald
Army Community Hospital, to Weston Murray, the plaintiff's
deceased husband. The issue on appeal is whether the district court,
in reaching a verdict for the plaintiff, Loretta Murray, correctly
applied the concept of "substantial possibility of survival" to the ele-
ment of proximate cause. We conclude that the district court erred in
interpreting the Virginia Supreme Court's use of the"substantial pos-
sibility of survival" language as relaxing the standard of proof
required to establish causation. Accordingly, we reverse and remand
with instructions that judgment be entered in favor of the defendant.

I.

At approximately 1:03 a.m. on November 26, 1996, Weston Mur-
ray presented himself at the Urgent Care Center, an affiliate of the
McDonald Army Community Hospital in Fort Eustis, Virginia. Dr.
James Hendricks, the on-duty physician, examined Mr. Murray. Dur-
ing the examination, Mr. Murray informed Dr. Hendricks that he was
suffering from abdominal pain that felt "like a hernia, like something
[was] popping in [his] stomach." After reviewing the results of sev-
eral diagnostic tests, Dr. Hendricks informed Mr. Murray that he had
a urinary tract infection.

The Urgent Care Center released Mr. Murray at approximately
2:45 a.m., and Mr. Murray asked his wife to bring the car around

                     2
because he still was not feeling well. Mr. Murray collapsed as he was
approaching the car, and the Urgent Care Center readmitted him. Mr.
Murray collapsed a second time at approximately 3:40 a.m., and he
lost his pulse at 3:55 a.m. Attempts to resuscitate him were unsuc-
cessful, and he was pronounced dead at 4:33 a.m. The medical staff
informed Ms. Murray that her husband died of a heart irregularity. An
autopsy of Mr. Murray's body determined, however, that the actual
cause of death was a relatively large ruptured right common iliac
artery aneurysm (abdominal aneurysm).

On September 17, 1997, the plaintiff, on behalf of her husband's
estate, filed an administrative claim for $1 million with the Depart-
ment of the Army pursuant to 28 U.S.C. § 2675. The plaintiff subse-
quently filed suit in the Eastern District of Virginia under the Federal
Tort Claims Act, 28 U.S.C. § 2671 et seq., alleging that the govern-
ment's failure to diagnose and surgically repair her husband's abdom-
inal aneurysm was the proximate cause of his death. The plaintiff
requested funeral expenses, lost income, damages for sorrow and
solace, and other damages permitted by the Virginia Wrongful Death
Act, Va. Code § 8.01-50 et seq.

After a three day bench trial, the district court granted judgment in
favor of the plaintiff in the amount of $267,282.23, including taxable
court costs. The district court subsequently issued an opinion explain-
ing its decision. See generally Murray v. United States, 36 F. Supp.
2d 713 (E.D. Va. 1999). In support of its entry of judgment for the
plaintiff, the district court stated that the defendant, through its agent
Dr. Hendricks, was negligent in its diagnosis and treatment of Mr.
Murray and that the plaintiff had proven that such negligence was a
proximate cause of Mr. Murray's death.

The district court based its finding of negligence on testimony that
Dr. Hendricks's medical record and physical exam of Mr. Murray
were incomplete and that the laboratory results did not support Dr.
Hendricks's diagnosis of a urinary tract infection. Id. at 723. The dis-
trict court discussed expert testimony that Dr. Hendricks should have
referred Mr. Murray to another hospital, where he could have
received a CT-Scan and life saving surgery. Id. at 716. The defen-
dant's own expert described Dr. Hendricks's misdiagnosis as "inde-

                     3
fensible." Id. at 723. The parties do not dispute the district court's
finding of negligence.

The issue on appeal concerns the district court's finding of proxi-
mate cause. The district court stated in its opinion that to establish
that Dr. Hendricks's negligence proximately caused Mr. Murray's
death, the plaintiff must establish that the negligence destroyed a sub-
stantial possibility that Mr. Murray would have survived the abdomi-
nal aneurysm. Id. The district court then found by a preponderance of
the evidence that Mr. Murray would have survived if, prior to losing
his pulse at 3:55 a.m., he had arrived in an operating room at the sec-
ond hospital ready for surgery. Id. The district court then determined
that neither side had proven by a preponderance of the evidence
whether or not Mr. Murray could have arrived at the second hospital
in time to receive life saving surgery by 3:55 a.m. Id. Accordingly,
the court concluded that the plaintiff had not proven that it is more
probable than not that Mr. Murray would have survived. Id.

The district court then proceeded to discount this conclusion, stat-
ing that Virginia law does not require the plaintiff to prove that it is
more probable than not that Mr. Murray would have survived the
aneurysm. Id. The court found that Mr. Murray "possibly could have
obtained life saving surgery, and his possibility of survival in these
circumstances was between thirty and sixty percent." Id. The court
reached these percentages by "combining the percentage survival rate
with the possibility of obtaining surgery in the available time frame."
Id. The court then found that "thirty to sixty percent constitutes a sub-
stantial possibility that Mr. Murray could have obtained life saving
surgery." Id. Based on this finding, the court concluded that the plain-
tiff had proven that the defendant's negligence was a proximate cause
of Mr. Murray's death.

II.

The central issue on appeal concerns the application of the concept
of "substantial possibility of survival" to the proximate cause element
of medical malpractice cases. The defendant appeals the district
court's finding of proximate cause, arguing that Virginia adheres to
the traditional elements of proof and causation. The defendant there-
fore does not believe that Virginia courts intended their use of the

                     4
"substantial possibility of survival" concept to relax proof of causa-
tion requirements.

The plaintiff argues in response that the appropriate test for proxi-
mate cause is whether the defendant's negligence destroyed a sub-
stantial possibility of the decedent's survival. She further maintains
that the district court correctly found that the Virginia Supreme Court
does not define "substantial possibility of survival" as meaning that
it is "more probable than not" that the decedent would have survived.
The plaintiff therefore contends that the district court's finding that
Mr. Murray could have obtained life saving surgery but for Dr. Hen-
dricks's negligence is sufficient to establish proximate cause.

On appeal, we review de novo the district court's legal conclusions
regarding the correct standard of proof for proximate cause. See Wil-
liams v. Sandman, 187 F.3d 379, 381 (4th Cir. 1999) (stating that on
appeal from a bench trial, the court reviews the district court's conclu-
sions of law de novo). Having conducted a de novo review and for the
reasons set forth below, we find that Virginia law applies the tradi-
tional standard of proximate cause and that requiring a plaintiff to
prove destruction of a "substantial possibility of survival" is equiva-
lent to requiring the plaintiff to prove that it is"more likely than not"
that the decedent would have survived in the absence of the defen-
dant's negligence. Accordingly, we conclude that the district court
erred in interpreting the "substantial possibility of survival" language
as relaxing the standard of proof required to establish causation.

III.

In traditional negligence cases, the plaintiff must satisfy the follow-
ing four basic elements by a preponderance of the evidence: 1) duty;
2) breach; 3) causation; and 4) harm. W. Page Keeton et al., Prosser
and Keeton on Torts § 30, at 164-65 (5th ed. 1984). The causation
element requires the plaintiff to prove that there is a reasonable con-
nection between the defendant's negligence and the plaintiff's dam-
ages. See id. § 41, at 263. In essence, the plaintiff must prove that the
"defendant's breach of duty was more likely than not (i.e., probably)
the cause of injury." Hurley v. United States , 923 F.2d 1091, 1094
(4th Cir. 1991).

                     5
A.

Applying the causation element to medical malpractice cases has
been a confusing task for many courts since the Fourth Circuit's deci-
sion in Hicks v. United States, 368 F.2d 626 (4th Cir. 1966). Hicks
was a wrongful death medical malpractice action in which the plain-
tiff, administrator of the decedent's estate, alleged that the decedent's
death was due to the defendant's failure to diagnose and treat her ill-
ness. Id. at 628. In finding that the defendant's negligence proxi-
mately caused the decedent's death, the Fourth Circuit stated:

          When a defendant's negligent action or inaction has effec-
          tively terminated a person's chance of survival, it does not
          lie in the defendant's mouth to raise conjectures as to the
          measure of the chances that he has put beyond the possibil-
          ity of realization. If there was any substantial possibility of
          survival and the defendant has destroyed it, he is answer-
          able. Rarely is it possible to demonstrate to an absolute cer-
          tainty what would have happened in circumstances that the
          wrongdoer did not allow to come to pass. The law does not
          in the existing circumstances require the plaintiff to show to
          a certainty that the patient would have lived had she been
          hospitalized and operated on promptly.

Id. at 632 (citing Harvey v. Silber, 2 N.W.2d 483 (1942)). This lan-
guage introducing the concept of "substantial possibility of survival"
within the context of proximate cause has become the source of con-
fusion for the parties in this action and has "precipitated misunder-
standing throughout the courts." See Hurley, 923 F.2d at 1093.

Courts have adopted conflicting interpretations of the Hicks lan-
guage. Some courts have determined that Hicks has no effect on neg-
ligence law, leaving traditional causation principles unaltered. See id.
at 1097-98 (citing Maryland case that does not recognize Hicks as
affecting the law of negligence). Other courts, including the district
court below, have interpreted the concept of "substantial possibility
of survival" as relaxing the proof of causation requirement. See id. at
1098 (citing Maryland case that indicates that Hicks relaxes proof of
causation requirement). Further, other courts have concluded that
Hicks created an entirely new cause of action for deprivation of a sub-

                     6
stantial possibility of survival.1 See Lisa Perrochet et al., Lost Chance
Recovery and the Folly of Expanding Medical Malpractice Liability,
27 Tort & Ins. L.J. 615, 617-18 (1992) (stating that courts recognizing
the loss of a less than even chance of recovery as an actionable injury
frequently refer to Hicks).

This court has adopted the first approach and determined that Hicks
does not alter traditional causation principles. See Hurley, 923 F.2d
at 1093-95; Lisa Perrochet et al., supra at 618 (stating that "the Fourth
Circuit recently clarified that its decision in Hicks did not represent
a departure from the traditional rule that medical malpractice plain-
tiffs must prove causation in accordance with the reasonable medical
probability standard"). In Hurley v. United States, we found that the
second sentence in the Hicks passage is the one that courts have seri-
ously misconstrued: "If there was any substantial possibility of sur-
vival and the defendant has destroyed it, he is answerable." Hurley,
923 F.2d at 1094 (quoting Hicks, 368 F.2d at 632). We then noted that
"the third and fourth sentences in the passage shed light on the proper
interpretation of `substantial possibility.'" Hurley, 923 F.2d at 1094.
We stated that

        [the third and fourth sentences] say in essence that it is
        rarely possible for a plaintiff to show to an absolute cer-
        tainty what would have happened had the defendant not
        been negligent. Thus, the plaintiff need not prove to a cer-
        tainty that the plaintiff would have lived had she been
        treated in compliance with the standard of care. For support,
        Judge Sobeloff cited Harvey v. Silber, which held that evi-
        dence showing that there is a probability, rather than a cer-
        tainty, that an operation would have saved a patient's life is
        sufficient to prove that a negligent diagnosis was the proxi-
        mate cause of death. Evidently, the message in the passage
        is that a plaintiff need not show to a certainty that surgery
        would have saved the patient's life. A probability of success
        is sufficient.
_________________________________________________________________

1 Such a cause of action is not available in Virginia. See Dolwick v.
Leech, 800 F. Supp. 321, 327 (E.D. Va. 1992).

                    7
Id. We further provided:

          The law of negligence requires the plaintiff to prove by a
          preponderance of the evidence that defendant's breach of
          duty caused the plaintiff's injury. In other words, the plain-
          tiff must prove the defendant's breach of duty was more
          likely than not (i.e., probably) the cause of injury. Therefore,
          the point made in the passage that causation must be proved
          to a probability, but not to a certainty, does not make any
          change in the law of causation.

Id. Accordingly, we interpreted "a `substantial possibility' to be tanta-
mount to a `probability'" and concluded that"Hicks made no change
to the law that requires the plaintiff to establish proximate cause by
a preponderance of the evidence in order to prove medical malprac-
tice negligence." Id. at 1095.

This court therefore views a "substantial possibility of survival" as
equivalent to a "probability" of survival. A probability is a "condition
or state created when there is more evidence in favor of the existence
of a given proposition than there is against it." Black's Law Dictio-
nary 1201 (6th ed. 1990). It implies something that "is more likely
than not, or that is greater than 50%."2 Hurley, 923 F.2d at 1095 n.26.
Thus, applying the "substantial possibility of survival" concept to the
causation element of medical malpractice cases does nothing more
than require a plaintiff to prove that it is more likely than not that the
decedent would have survived in the absence of the defendant's negli-
gence.

B.

We believe that this view is consistent with that adopted by the
Virginia Supreme Court. See Lisa Perrochet et al., supra at 623 (list-
ing Virginia as one of the American jurisdictions that continues "to
_________________________________________________________________

2 The phrases "more likely than not" and "more probable than not" have
the same meaning. See Black's Law Dictionary, supra at 1201 (equating
"probable" with "likely"). The court therefore uses the term "probability"
and the phrases "more likely than not" and"more probable than not"
interchangeably.

                     8
adhere to the traditional reasonable medical probability standard of
causation"). The Virginia Supreme Court first discussed the concept
of "substantial possibility of survival" in Whitfield v. Whittaker
Memorial Hospital, 169 S.E.2d 563 (Va. 1969). Whitfield was a medi-
cal malpractice action in which the trial court granted the physician
defendant's motions to strike the plaintiff's evidence and to enter
judgment in his favor. Id. at 564. The defendant argued on appeal that
evidence that an operation probably would have saved the patient's
life was "mere speculation." Id. at 568. The Virginia Supreme Court
disagreed, citing Hicks for the principle that "[i]f there was any sub-
stantial possibility of survival and the defendant has destroyed it, he
is answerable" and that "[r]arely is it possible to demonstrate to an
absolute certainty what would have happened if certain actions had
been taken." Id. at 568-69 (citing Hicks, 368 F.2d at 632). The Vir-
ginia Supreme Court therefore simply reiterated the message behind
the Hicks passage: It is not necessary to prove to a certainty that a
patient would have survived; a probability is sufficient.

Since Whitfield, the Virginia Supreme Court has continued to apply
the "substantial possibility of survival" concept in evaluating the suf-
ficiency of a plaintiff's evidence of proximate cause. See Bryan v.
Burt, 486 S.E.2d 536, 539-40 (Va. 1997); Poliquin v. Daniels, 486
S.E.2d 530, 534 (Va. 1997); Griffett v. Ryan, 443 S.E.2d 149, 152
(Va. 1994); Hadeed v. Medic-24, Ltd., 377 S.E.2d 589, 594 (Va.
1989); Brown v. Koulizakis, 331 S.E.2d 440, 446 (Va. 1985). In these
cases, as in Whitfield, evidence existed to demonstrate that in the
absence of the defendant's negligence, the decedent more likely than
not would have survived. See Poliquin, 486 S.E.2d at 534 (discussing
expert's opinion "to a reasonable degree of medical probability that,
had the Defendants known what they should have known about [the
decedent's] condition prior to surgery and, thereafter, employed the
appropriate procedures during surgery, [the decedent] would have
survived the surgery" (emphasis added)); Griffett, 443 S.E.2d at 152
(considering testimony that "within a reasonable degree of medical
certainty there `would have been a high likelihood that [an] operation
. . . would have resulted in the patient being saved'" (emphasis
added)); Hadeed, 377 S.E.2d at 594 (finding that jury could reason-
ably determine that with bypass surgery, the decedent would have had
an 85-90% chance of living to age 70 (emphasis added)); Brown, 331
S.E.2d at 446 (discussing evidence that 95-98% of patients in the

                    9
decedent's condition survive when properly treated (emphasis
added)). Given such evidence, the Virginia Supreme Court concluded
in each case that the plaintiff had demonstrated that the defendant's
negligence destroyed a substantial possibility of the decedent's sur-
vival and that the plaintiff therefore had sufficient evidence of proxi-
mate cause. See Poliquin, 486 S.E.2d at 534; Griffett, 443 S.E.2d at
152; Hadeed, 377 S.E.2d at 594; Brown , 331 S.E.2d at 446.

The Virginia Supreme Court, in its use of the "substantial possibil-
ity of survival" concept in these cases, did not relax the standard of
proof to be applied to proximate causation. In none of these cases did
the Virginia Supreme Court deem as sufficient evidence that does not
demonstrate to a probability that the decedent would have survived.
Rather, these cases simply rejected the certainty standard of proof.
The Virginia cases are therefore consistent with the view that requir-
ing a plaintiff to prove that the defendant destroyed a "substantial pos-
sibility of survival" is equivalent to requiring a plaintiff to prove that
in the absence of the defendant's negligence, the decedent more likely
than not would have survived.

This conclusion is further supported by the Virginia Supreme
Court's decision in Blondel v. Hays, 403 S.E.2d 340 (Va. 1991).
Blondel involved an appeal from a trial court's denial of the plaintiff's
requested jury instruction on the "substantial possibility of survival"
standard. The plaintiff argued that he was entitled to an instruction
informing the jury of the principle of Virginia law that "a defendant
physician's destruction of `any substantial possibility of the patient's
survival' is `a proximate cause of the patient's death.'" Id. at 343. The
plaintiff further argued that the traditional proximate cause instructions3
given by the court were improper because they "require him to prove
that the patient would have recovered perfect health, or survived
indefinitely in the absence of the negligence." Id. at 344. The Virginia
Supreme Court rejected the plaintiff's argument, stating: "The plain-
_________________________________________________________________

3 The court gave the following instructions on proximate cause: 1) "If
Dr. Hays was negligent, was her negligence a proximate cause of Ms.
Sheehan's death?" and 2) "A proximate cause of an injury or death is a
cause which in natural and continuous sequence produces the injury or
death. It is a cause without which the injury or death would not have
occurred." Blondel, 403 S.E.2d at 343.

                     10
tiff's burden . . . was simply to prove that the particular time and man-
ner of the patient's death resulted from the defendant's negligence. In
that respect, his burden is no different from that attendant upon any
other actions for personal injuries or wrongful death." Id. The court
further stated:

          The jury's function in a medical malpractice-wrongful death
          case remains the same as in any other tort action: to decide
          the issues of negligence, proximate cause, and damages. The
          well-settled law on the subject of proximate cause was cor-
          rectly expressed by [the instructions given]. Under those tra-
          ditional instructions, the plaintiff's theory of the case could
          have been readily established by proof that the defendant
          physician's negligence was a proximate cause of the
          patient's death because, in the absence of that negligence,
          her death would not have occurred when it did.

Id. This language demonstrates that the Virginia Supreme Court, in
equating destruction of a "substantial possibility of survival" with
proximate cause, has not altered the traditional principles of causa-
tion.

The Virginia Supreme Court further stated that it has only
employed the "substantial possibility of survival" language to provide
trial courts with a decisional standard in evaluating the sufficiency of
a plaintiff's evidence of proximate cause. See id. We do not believe
that the Virginia Supreme Court, in making this statement, intended
for courts to apply a standard in evaluating a plaintiff's evidence of
proximate cause that is different than that employed by the fact finder
in determining whether the plaintiff has proven causation by a pre-
ponderance of the evidence. As previously explained, the "substantial
possibility of survival" standard is identical to the traditional standard
of proximate causation. In emphasizing that the"substantial possibil-
ity of survival" language is not appropriate for a jury instruction, the
Blondel court was simply expressing its concern about the "indiscrim-
inate use of language from appellate opinions in a jury instruction"
and about leaving a jury to speculate as to what may be considered
"substantial." Id. at 344-45.

                     11
IV.

Having determined that the Virginia Supreme Court's use of the
"substantial possibility of survival" language does not deviate from
traditional principles of proximate cause, we find that the district
court erred in relaxing the standard of proof that the plaintiff must
meet in establishing causation. The district court correctly stated in its
opinion that "the applicable test for proximate cause is whether th[e
defendant's] negligence destroyed a substantial possibility of the
decedent's survival from the condition misdiagnosed or mistreated."
Murray, 36 F. Supp. 2d at 721 (citing Whitfield, Bryan, and Poliquin).
In its findings of fact, the district court evaluated the plaintiff's evi-
dence of proximate cause and found that "neither side has proven by
a preponderance of the evidence whether or not the decedent could
have secured life saving surgery by 3:55 a.m." Id. at 723. Accord-
ingly, the court found that the plaintiff did not prove "that it is more
probable than not that Mr. Murray would have survived." Id.

This finding leads to the conclusion, under Virginia law, that the
plaintiff did not prove that the defendant destroyed a substantial pos-
sibility of Mr. Murray's survival. Accordingly, the plaintiff failed to
prove causation by a preponderance of the evidence. Rather than enter
judgment in favor of the defendant, however, the district court pro-
ceeded to reach an erroneous conclusion of law. The district court
stated that "Virginia law does not require that the Plaintiff prove it is
more probable than not that he would have survived the aneurysm."
Id. The district court then found that there was a substantial possibil-
ity that the decedent could have obtained life saving surgery. Id.
Believing that the "substantial possibility of survival" language
relaxes the plaintiff's burden of proof, the court concluded, despite its
previous finding, that "the Plaintiff had proven that the Defendant's
negligence was a proximate cause of the decedent's death." Id. Under
the traditional principles of proximate cause that are accepted by Vir-
ginia law, this conclusion is in direct conflict with the district court's
finding that the plaintiff did not meet the "more probable than not"
standard.

For these reasons, we reverse the judgment entered in the plain-
tiff's favor and remand with instructions that judgment be entered for
the defendant consistent with the district court's finding that the plain-

                     12
tiff failed to prove that it is more probable than not that the decedent
would have survived in the absence of the defendant's negligence.

REVERSED AND REMANDED WITH INSTRUCTIONS

                     13
