                                                                                Michigan Supreme Court
                                                                                      Lansing, Michigan
                                                          Chief Justice:          Justices:



Opinion                                                   Marilyn Kelly           Michael F. Cavanagh
                                                                                  Elizabeth A. Weaver
                                                                                  Maura D. Corrigan
                                                                                  Robert P. Young, Jr.
                                                                                  Stephen J. Markman
                                                                                  Diane M. Hathaway



                                                                           FILED JULY 31, 2010

                              STATE OF MICHIGAN

                                      SUPREME COURT


 RAYMOND O’NEAL,

               Plaintiff-Appellant,

 v                                                               No. 138180

 ST. JOHN HOSPITAL & MEDICAL
 CENTER, RALPH DiLISIO M.D. and
 EFSTATHIOS TAPAZOGLOU, M.D.,

               Defendant-Appellees.


 BEFORE THE ENTIRE BENCH

 HATHAWAY, J.

        This case addresses the burden of proof necessary to establish proximate causation

 in a traditional medical malpractice action. At issue is whether the Court of Appeals

 properly reversed the trial court’s denial of summary disposition. The trial court ruled

 that plaintiff had established a question of fact on the issue of proximate causation

 sufficient to withstand a motion for summary disposition.                 The Court of Appeals

 reversed. It treated plaintiff’s claim as a loss-of-opportunity claim instead of a traditional

 medical malpractice claim and held that plaintiff did not raise a genuine issue of fact, as
required by Fulton v William Beaumont Hosp, 253 Mich App 70; 655 NW2d 569 (2002),

because plaintiff could not prove that receiving the alleged appropriate treatment would

have decreased his risk of stroke by greater than 50 percentage points. We disagree with

the Court of Appeals’ analysis and conclusion.

         We hold that the Court of Appeals erred by relying on Fulton and determining that

this is a loss-of-opportunity case controlled by both the first and second sentences

of MCL 600.2912a(2), and instead hold that this case presents a claim for traditional

medical malpractice controlled only by the first sentence of § 2912a(2). Further, we

conclude that plaintiff established a question of fact on the issue of proximate causation

because plaintiff’s experts opined that defendants’ negligence more probably than not

was the proximate cause of plaintiff’s injuries. Finally, we hold that Fulton did not

correctly set forth the burden of proof necessary to establish proximate causation for

traditional medical malpractice cases as set forth in § 2912a(2). Therefore, we overrule

Fulton to the extent that it has led courts to improperly designate what should be

traditional medical malpractice claims as loss-of-opportunity claims and has improperly

transformed the burden of proof in a traditional malpractice case from a proximate cause

to the proximate cause.

         Accordingly, we reverse the judgment of the Court of Appeals and remand this

matter to the Court of Appeals for consideration of the issue not decided on appeal in that

court.




                                             2
                             I. FACTS AND PROCEEDINGS

       This case involves allegations of negligence in medical care. Plaintiff had an

illness known as sickle cell anemia. Plaintiff developed acute chest syndrome (ACS),

which is a known complication of sickle cell anemia. Plaintiff claims that his ACS was

misdiagnosed as pneumonia and as a consequence he did not receive the correct

treatment. Plaintiff’s experts opined that ACS requires treatment with an aggressive

blood transfusion or an exchange transfusion, either of which needs to be given on a

timely basis. While plaintiff ultimately received a transfusion, his experts opined that it

was given too late and as a consequence, plaintiff suffered a disabling stroke. Plaintiff

alleged that defendants’ failure to provide a timely transfusion violated the standard of

care and that defendants’ negligence was a proximate cause of his disabling stroke.

Plaintiff’s complaint pled a traditional malpractice claim and did not plead a claim for

lost opportunity.

       In support of his position, plaintiff offered two expert hematologists who testified

that defendants’ violations of the standard of care more probably than not caused

plaintiff’s injuries. Plaintiff’s third hematology expert explained his opinion in statistical

terms and testified that a patient with ACS has a 10 to 20 percent chance of developing a

stroke. He further testified that with a timely exchange transfusion, the risk of stroke is

reduced to less than 5 to 10 percent.

       Defendants brought a motion for summary disposition challenging the sufficiency

of plaintiff’s expert testimony on the issue of proximate causation.            Even though

plaintiff’s complaint pled only traditional malpractice, defendants’ motion made no


                                              3
distinction between the proof required for proximate causation in a traditional

malpractice claim and the burden required for a claim based on loss of opportunity.

Instead, defendants argued that plaintiff’s case was controlled by both the first and

second sentences of MCL 600.2912a(2), which requires that the plaintiff prove “that he

or she suffered an injury that more probably than not was proximately caused by the

negligence of the defendant or defendants” and that “the plaintiff cannot recover for loss

of an opportunity to survive or an opportunity to achieve a better result unless the

opportunity was greater than 50%.”

       Defendants argued that a reduction in the risk of stroke from 10 to 20 percent to

less than 5 to 10 percent amounted to at best a 20 percentage point differential,1 which

would be insufficient to meet the burden of proof on proximate causation. Defendants

relied on Fulton to support their position that plaintiff must comply with this percentage

point differential theory. Plaintiff countered that defendants’ statistical portrayal of these

numbers was mathematically inaccurate because his experts’ testimony supported a

finding that his injuries were more probably than not proximately caused by defendants’

negligence. The trial court agreed with plaintiff. The trial court denied defendants’




       1
         The Court of Appeals reasoned: “This number is the difference between the
highest chance plaintiff had of developing a stroke without proper treatment (i.e., 20
percent) and the lowest chance of developing a stroke with proper treatment (i.e., less
than five percent, or in the light most favorable to plaintiff, zero percent)”. O’Neal v St
John Hosp & Med Ctr, unpublished opinion per curiam of the Court of Appeals, issued
November 4, 2008 (Docket Nos. 277317 and 277318), p 5 n 7.



                                              4
motion, ruling that plaintiff had presented sufficient testimony to establish a question of

fact on proximate causation.

       The Court of Appeals based its decision entirely on Fulton and reversed the trial

court in an unpublished opinion per curiam, holding that this case presented a claim for a

loss of opportunity and that plaintiff had not met his burden of proof under MCL

600.2912a(2).2 The Court of Appeals reasoned that plaintiff was bound by the Fulton

analysis and that a percentage point differential applied to this case.3 The Court opined:

               In asserting that defendants’ negligence resulted in a stroke, plaintiff
       essentially argues that had defendants ordered a transfusion sooner, plaintiff
       would have avoided a stroke. Thus, to say defendants’ failure to apply
       proper treatment caused the stroke is to say that this failure deprived
       plaintiff a greater opportunity to avoid the stroke. Consequently, plaintiff’s
       claim amounts to one of lost opportunity to achieve a better result, and §
       2912a(2) is applicable.

             In Fulton, this Court set forth the formula by which to calculate
       whether the opportunity to achieve a better result was greater than 50
       percent – specifically, the Court must “subtract[] the plaintiff's opportunity
       to survive after the defendant’s alleged malpractice from the initial
       opportunity to survive without the malpractice.” Ensink [v Mecosta Co Gen
       Hosp, 262 Mich App 518, 531; 687 NW2d 143 (2004)], supra at 531.[4]

       We granted leave to review this matter, asking the parties to brief:

              (1) whether the requirements set forth in the second sentence of
       MCL 600.2912a(2) apply in this case; (2) if not, whether the plaintiff
       presented sufficient evidence to create a genuine issue of fact with regard to
       whether the defendants’ conduct proximately caused his injury or (3) if so,
       whether Fulton v William Beaumont Hosp, 253 Mich App 70 (2002), was
       2
           Id. at 4.
       3
           Id. at 4-5.
       4
           Id. at 4.



                                              5
      correctly decided, or whether a different approach is required to correctly
      implement the second sentence of § 2912a(2).[5]

                             II. STANDARD OF REVIEW

      This case involves review of a trial court’s decision on a motion for summary

disposition which this Court reviews de novo.6 The issue also involves questions of

statutory interpretation. Statutory interpretation is a question of law, which this Court

also reviews de novo.7

                                    III. ANALYSIS

      At issue is whether the Court of Appeals properly reversed the trial court’s denial

of summary disposition on the issue of proximate causation. In order to answer this

question we must review MCL 600.2912a.

      MCL 600.2912a provides:


              (1) Subject to subsection (2), in an action alleging malpractice, the
      plaintiff has the burden of proving that in light of the state of the art
      existing at the time of the alleged malpractice:

              (a) The defendant, if a general practitioner, failed to provide the
      plaintiff the recognized standard of acceptable professional practice or care
      in the community in which the defendant practices or in a similar
      community, and that as a proximate result of the defendant failing to
      provide that standard, the plaintiff suffered an injury.



      5
          O’Neal v St John Hosp & Med Ctr, 485 Mich 901 (2009).
      6
          Herald Co v Bay City, 463 Mich 111, 117; 614 NW2d 873 (2000).
      7
      In re Investigation of March 1999 Riots in East Lansing), 463 Mich 378, 383;
617 NW2d 310 (2000).



                                           6
              (b) The defendant, if a specialist, failed to provide the recognized
      standard of practice or care within that specialty as reasonably applied in
      light of the facilities available in the community or other facilities
      reasonably available under the circumstances, and as a proximate result of
      the defendant failing to provide that standard, the plaintiff suffered an
      injury.

              (2) In an action alleging medical malpractice, the plaintiff has the
      burden of proving that he or she suffered an injury that more probably than
      not was proximately caused by the negligence of the defendant or
      defendants. In an action alleging medical malpractice, the plaintiff cannot
      recover for loss of an opportunity to survive or an opportunity to achieve a
      better result unless the opportunity was greater than 50%.

      This statute, which governs the burden of proof in medical malpractice cases, was

originally added to the Revised Judicature Act in 1977. It has been amended on several

occasions, with the most recent amendment in 1993 adding subsection (2), which is at

issue in this case. Subsection (2) contains two sentences. It is undisputed that the first

sentence, which repeats the burden of proof as articulated in subsections (1)(a) and (b),

merely reiterates the longstanding rule requiring a plaintiff to prove “that he or she

suffered an injury that more probably than not was proximately caused by the negligence

of the defendant or defendants.” MCL 600.2912a(2).

      The second sentence of § 2912a(2) addresses a subcategory of injuries in medical

malpractice litigation governed by the loss-of-opportunity doctrine. The Legislature did

not define the phrase “loss of an opportunity to survive or an opportunity to achieve a

better result.” However, while not defined in the statute, the doctrine was initially




                                            7
recognized and defined in Michigan in Falcon v Mem Hosp, 436 Mich 443; 462 NW2d

44 (1990).8

       It is generally accepted that the 1993 amendment to § 2912a was adopted in a

direct reaction to Falcon, meaning that it repudiated Falcon’s reduced proximate

causation theory.9 Thus, it is generally accepted that in adopting this amendment, the

Legislature intended to limit medical malpractice claims to the pre-Falcon state of the

law: if it was more probable than not that the plaintiff would have died even with the best

of treatment, a claim for medical malpractice is precluded.10

       We next turn to the correct interpretation of both sentences of § 2912a(2) and their

applicability to the case before us. In examining the first line of § 2912a(2), we are

guided by the principle that nothing in § 2912a(2) has changed the burden of proof for

traditional medical malpractice claims. The language of the first line of subsection (2) is

clear: “in an action alleging medical malpractice, the plaintiff has the burden of proving

that he or she suffered an injury that more probably than not was proximately caused by

       8
         Falcon held that in a wrongful death case a plaintiff could bring a claim for a
decedent’s loss of opportunity to survive even if he or she did not meet the traditional
proximate causation standard. Falcon reasoned that when the decedent suffered a
substantial reduction in the loss of opportunity to survive—in that case 37.5 percent—
even though the plaintiff could not maintain a traditional malpractice claim for the death
itself because the plaintiff could not establish causation, she could bring a claim for loss
of opportunity to survive. Falcon also stated that the doctrine applied to wrongful death
claims and left the question of whether the doctrine applied to lesser injuries to another
day. 436 Mich at 460-462, 469-470 (opinion by LEVIN, J.).
       9
           Stone v Willaimson, 482 Mich 144, 169; 753 NW2d 106 (2008).
       10
            Nothing in our opinion today alters or changes that premise.



                                               8
the negligence of the defendant or defendants.” This language reiterates the language of

the previous subsections and merely restates the well-accepted, well-established historical

rule for proximate causation.11 As the meaning of this sentence is well-established, no

further statutory construction is necessary.

       The proper interpretation of proximate causation in a negligence action is well-

settled in Michigan. In order to be a proximate cause, the negligent conduct must have

been a cause of the plaintiff’s injury and the plaintiff’s injury must have been a natural

and probable result of the negligent conduct.        These two prongs are respectively

described as “cause-in-fact” and “legal causation.” See Skinner v Square D Co, 445

Mich 153, 162-163; 516 NW2d 475 (1994); Sutter v Biggs, 377 Mich 80; 139 NW2d 684

(1966); Glinski v Szylling, 358 Mich 182; 99 NW2d 637 (1959). While legal causation

relates to the foreseeability of the consequences of the defendant’s conduct, the cause-in-

fact prong “generally requires showing that ‘but for’ the defendant’s actions, the

plaintiff’s injury would not have occurred.” Skinner, 455 Mich at 163. It is equally well-

settled that proximate causation in a malpractice claim is treated no differently than in an

ordinary negligence claim, and it is well-established that there can be more than one

proximate cause contributing to an injury. Brisboy v Fibreboard Corp, 429 Mich 540;

418 NW2d 650 (1988); Barringer v Arnold, 358 Mich 594; 101 NW2d 365 (1960);

Gleason v Hanafin, 308 Mich 31; 13 NW2d 196 (1944). Finally, it is well-established


       11
       Kirby v Larson, 400 Mich 585, 600-607; 256 NW2d 400 (1977)(opinion by
WILLIAMS, J.).



                                               9
that the proper standard for proximate causation in a negligence action is that the

negligence must be “a proximate cause” not “the proximate cause.” Kirby v Larson, 400

Mich 585; 256 NW2d 400 (1977). Thus, the burden of proof for proximate causation in

traditional medical malpractice cases is analyzed according to its historical common law

definitions and the analysis is the same as in any other ordinary negligence claim.

Nothing in this opinion changes or alters these well-settled principles.12

       We next consider whether the Court of Appeals erred by relying on Fulton and

applying the second sentence of § 2912a(2) to the present case. The second sentence of

§ 2912a(2) provides “In an action alleging medical malpractice, the plaintiff cannot

recover for loss of an opportunity to survive or an opportunity to achieve a better result

unless the opportunity was greater than 50%.” Since the statute was amended in 1993,

litigants and the courts have debated the meaning of this second sentence.13 While the

       12
          This is true despite the contrary statements in Justice YOUNG’s dissent. The
comments of the dissent amount to nothing more than another intemperate outburst of
inappropriate accusations and illogical assertions. While the dissent decries confusion,
the only apparent confusion in this matter lies in the dissent itself, which lacks sound
analytical reasoning and even a basic understanding of the law of proximate causation.
The dissent, if followed to its logical conclusion, would allow recourse for the negligent
actions of medical providers only in those instances in which one provider’s conduct is at
issue and only when no pre-existing medical condition exists. Such an interpretation is
not supported by any case law or the statute itself.
       13
          The opinions in Stone illustrate this point. The debate has centered on such
questions as whether the Legislature intended this sentence to restore the law to its pre-
Falcon state, meaning that loss-of-opportunity claims are not recognized at all, or
whether the Legislature’s choice of language reflected intent to recognize such claims but
limit their availability. Questions have also arisen about whether the last sentence of
§ 2912a(2) applies to all medical malpractice cases, including traditional ones, or only
those that are presented as loss-of-opportunity claims.



                                             10
debate over the meaning of the second sentence demonstrates that significant questions

surround loss-of-opportunity cases, it is clear from the plain language of the statute that

the second sentence is intended to apply to loss-of-opportunity cases. Today we address

whether the second sentence of § 2912a(2) also applies to traditional malpractice cases

and we unequivocally hold that it does not. Because the Court of Appeals in this case

relied on Fulton, which erroneously applied the second sentence to a traditional

malpractice case, we review Fulton and determine what, if any, continuing validity it has.

       Fulton involved a claim for the failure to timely diagnose cervical cancer. The

plaintiff, the personal representative of the decedent’s estate, alleged that if decedent’s

cancer had been diagnosed during her pregnancy, she would have had treatment options

available that could have saved her life. The theory was that the decedent was not

diagnosed until her cancer was untreatable and, as a consequence, she died.            The

plaintiff’s expert’s testimony on proximate causation was described by the Court of

Appeals as follows:

              Defendants moved for summary disposition under MCR
       2.116(C)(10), arguing that plaintiff could not show that their negligence
       was the cause of Fulton's death. In response, plaintiff submitted an
       affidavit from Dr. Taylor, opining that if Fulton's cancer had been
       diagnosed while she was pregnant and if she had been treated after her child
       was delivered, she would have had an eighty-five percent chance to survive.
       Dr. Taylor opined that when Fulton was actually diagnosed with cancer, her
       opportunity to survive had decreased to sixty to sixty-five percent.
       Therefore, according to Dr. Taylor, Fulton's opportunity to survive the
       cancer decreased by twenty to twenty-five percent because of defendants'
       malpractice. In reply, defendants argued that Dr. Taylor's affidavit was
       improper because it contradicted his deposition testimony and that, in any




                                            11
       event, this affidavit was not enough to create a question of fact under MCL
       600.2912a(2).[14]

       Fulton opined that because the decedent went from an 85 percent pre-malpractice

chance of survival to a 60-65 percent post-malpractice chance of survival, she “suffered a

loss of a twenty to twenty-five percent chance of survival.”15 Fulton determined that a

percentage point differential subtraction analysis was required by the statute.          As

demonstrated by the Fulton analysis, the conclusion is reached by a simplistic subtraction

formula.      Fulton subtracted the statistical likelihood of a better outcome without

treatment from the statistical likelihood of a better outcome with treatment to determine if

the resulting number is greater than 50.

       Fulton’s simplistic subtraction formula is not an accurate way to determine

whether a defendant’s malpractice is a proximate cause of the injury. Fulton’s analysis

was erroneous because it misconstrued proximate causation as it applies to a traditional

malpractice case. Under the Fulton subtraction formula it is mathematically impossible

for there to be more than one proximate cause.        Thus, in creating and applying this

simplistic formula, Fulton fundamentally altered plaintiff’s burden of proof. Fulton

transformed the burden of proof in traditional malpractice cases from a proximate cause

to the proximate cause because it allows for only one proximate cause in any case. This

proposition is in error because it has no basis in statute or common law and it is

inconsistent with the clear and unambiguous language of the first sentence of § 2912a(2).
       14
            Fulton, 253 Mich App at 74-75.
       15
            Id. at 82.



                                             12
Moreover, as the Court of Appeals’ decision in this case illustrates, Fulton’s analysis is

being applied to all malpractice cases, even when they are pled only as traditional

malpractice cases.

       The Court of Appeals analysis in the present case perpetuates the Fulton doctrine

and the confusion surrounding proximate causation in medical malpractice claims. Much

of the confusion stems from the inherent nature of medical malpractice: the plaintiff is

generally seeking treatment for a preexisting medical condition that is causing a problem

of some sort on its own, whereas in an ordinary negligence claim the plaintiff is generally

an otherwise uninjured person who is claiming that the entire injury was caused by the

incident.

       In the present case, plaintiff was prepared to offer three expert witnesses to testify

on his behalf on the issue of proximate causation at the time of trial. Two of plaintiff’s

experts unequivocally opined, in a discovery deposition, that had the necessary treatment

been given, it was more probable than not that plaintiff would not have had a stroke.

       Plaintiff’s first expert, Dr. Richard Stein, opined:

              Q. I just have one question. Doctor, based on the extrapolation of
       the peds data that you’ve described for us, within a reasonable degree of
       medical certainty, and by that I mean with a greater than 50 percent
       likelihood, if Dr Tapazoglou had met the standard of care as you defined it
       today, would the stroke have been avoided?

              A. To a reasonable degree of medical certainty, my opinion is yes,
       and I have already stated the basis for that opinion.




                                             13
      After opining that an exchange transfusion was necessary to reduce plaintiff’s

hemoglobin S concentration to less than 30 percent, Dr. Luce, plaintiff’s second expert,

opined:

            Q. With respect to Mr. O’Neal, if the hemoglobin S had been
      reduced to less than 30 percent, do you have an opinion as to whether or not
      he would have had the stroke anyhow?

             A. I think it is probable that he would not have.

             Q. When you say “probable,” are you prepared to say more
      probably than not had Mr. O’Neal had his hemoglobin S reduced to less
      than 30 percent he would not have had a stroke?

             A. Correct.

      The testimony of the third expert, Dr. Griffin Rodgers, was more specific in

expressing the statistics. The trial court summarized his testimony:

             Dr. Griffin Rodgers, a hematologist, testified that a patient in sickle
      cell crisis of acute chest syndrome has in the order of 10 or 20 percent
      chance of developing a stroke. With a timely exchange transfusion, it
      reduces the risk of stroke to less than 5 or 10 percent. Dr. Griffin’s
      testimony demonstrates that Plaintiff had more than a 50 percent chance to
      avoid a stroke.

      As this case demonstrates, the way causation is analyzed is important, especially

when reviewing statistical data. In this instance, do these facts represent at best a 20

percent chance to avoid an injury, as the Court of Appeals concluded, or do they establish

proximate causation as found by the trial court? To answer this question we must

determine whether we use a percentage point differential subtraction analysis (as used by

the Court of Appeals in applying the Fulton formula) or whether we follow the approach

taken by the trial court. In doing so we must follow the analysis that is most consistent

with our historical rules governing proximate causation and the plain language of


                                            14
§ 2912a(2), which requires that a plaintiff prove that he or she suffered an injury that

more probably than not was proximately caused by the negligence of the defendant or

defendants, in the context of this case. While the use of mathematical statistics is not

required by the statute, and we do not impose such a requirement, we conclude that the

analysis used by plaintiff’s experts and the trial court represents the correct approach in

this instance because it accurately represents the historical view of proximate causation

as expressed in the first sentence of § 2912a(2) based on its application to these facts.

       In this case, it is undisputed that with or without treatment plaintiff was more

probably than not going to avoid the stroke. In other words, even without treatment it

was more probable that plaintiff would not have a stroke. However, plaintiff did have a

stroke. If the Fulton 50 percentage point differential subtraction analysis is used, plaintiff

cannot proceed with a traditional claim because the failure to provide treatment was not

the cause of the injury expressed in percentage point differential terms. As previously

indicated, however, the problem is that a 50 percentage point differential subtraction

analysis necessarily means that there can only be one cause of an injury. This analysis is

not consistent with the historical test for proximate causation, which has always been that

the malpractice be a proximate cause rather than the proximate cause.

       Applying a 50 percentage point differential subtraction analysis requires that we

change the traditional analysis of causation in medical malpractice cases to the one most

immediate, efficient, and direct cause of the injury. This, however, is the standard for




                                             15
determining the proximate cause rather than a proximate cause. This approach is simply

not in keeping with our historical view of causation.16

       The Fulton approach is incorrect because it requires a reliance on probabilities and

possibilities of things that have not yet occurred, rather than reliance on what has actually

occurred. Plaintiff in this case did have a stroke and was injured; his claim is for an

existing injury, not just the possibility of one. Plaintiff’s injury is no longer a statistical

probability, it is a reality. The focus, once he was injured, is on the connection between

defendants’ conduct and the injury. The relevant inquiry for proximate causation is

whether the negligent conduct was a cause of plaintiff’s injury and whether plaintiff’s

injury was a natural and probable result of the negligent conduct. If so, defendants’

conduct was a proximate cause, even though there may have been other causes. The

analysis for proximate causation is the same whether we are discussing medical

malpractice or ordinary negligence. Defendants’ conduct in this case meets this standard

when the defendants’ actual conduct, rather than plaintiff’s statistical probability of

achieving a better outcome, is the focus of the inquiry.


16
   Common-law rules apply to medical malpractice actions unless specifically abrogated
by statute. See MCL 600.2912(1) which provides:

              A civil action for malpractice may be maintained against any person
       professing or holding himself out to be a member of a state licensed
       profession. The rules of the common law applicable to actions against
       members of a state licensed profession, for malpractice, are applicable
       against any person who holds himself out to be a member of a state
       licensed profession. [Emphasis added.]




                                              16
      In this instance, plaintiff suffered an injury that was more probably than not

proximately caused by the negligence of defendants. As the trial court properly found,

defendants’ negligent conduct increased plaintiff’s risk of stroke from less than 5 to 10

percent to 10 to 20 percent. When viewed in the light most favorable to plaintiff, the

change is from less than 5 percent to 20 percent. As the trial court analyzed, this

represents a change that is greater than 50 percent in this instance. The trial court’s

approach is in keeping with the historical analysis of proximate causation because it

involves a comparative analysis, not a simplistic subtraction formula. Determining what

is “more probable than not” is inherently a comparative analysis. The proper method of

determining whether defendant’s conduct more probably than not proximately caused the

injury involves a comparative analysis, which is dependent upon the facts and

circumstances and expert opinion in a given case.17

      We conclude that Fulton’s simple subtraction analysis is wrong and

unsupportable. While § 2912a(2) does not mandate the use of statistics or require any

particular mathematical formula, the historic analysis of proximate cause must be

followed to wit: the analysis or formulation used cannot require that the cause must be

the proximate cause rather than a proximate cause.

      No single formula can be dispositive for all cases. In this case if we were to use a

standard percentage decrease calculation (meaning that defendants were responsible for

      17
         Comparative analyses could include standard percentage increases, standard
percentage decreases, or other scientifically accepted statistical analyses offered by the
experts.



                                           17
15 percentage points out of the 20 total percentage points of plaintiff’s risk of the bad

result, so that there is a 15/20 chance or 75 percent chance) defendant’s malpractice was a

proximate cause of the injury.18 Similarly, if the evidence is viewed as a standard

percentage increase calculation (meaning that defendant was responsible for 15

percentage points of increase over the 5 percentage points to begin with, thus causing a

300% (15/5) increase in plaintiff’s risk of harm,) defendant’s malpractice was a

proximate cause of the injury.19

       It is also important to emphasize that not all traditional medical malpractice cases

can or will be expressed in statistical or percentage terms, nor is a plaintiff required to

express proximate causation in percentage terms. The plain language of the statute

requires that proximate causation in traditional malpractice cases be expressed by

showing that the defendant’s conduct was more probably than not a cause of the injury,

not by statistical or percentage terms.20


       18
           Moreover, either of the mathematical formulas used as an example (standard
statistical decrease or increase) may not be appropriate in all cases because either could
limit causation to one proximate cause in those cases involving the conduct of more than
one defendant.
       19
         I recognize that Justice CAVANAGH and I differ on whether an increased risk of
harm is a valid statistical method for determining proximate causation in a traditional
malpractice case. However, both Justice CAVANAGH and I agree that claims evaluated in
that manner may be brought; we only disagree about whether those claims proceed as
claims for traditional malpractice or claims for loss-of-opportunity.
       20
          We also recognize that different mathematical formulations can have varying
results and that the results must be viewed in the light most favorable to the nonmoving
party. For example, while percentage increases and percentage decreases would both be
valid methods to determine proximate causation, they can yield different results. In those


                                            18
       Given that Fulton used an incorrect mathematical formula and is being used to

transform the burden of proof in traditional malpractice cases, we must next decide if it

has any continuing validity. We find that it has none in the context of traditional medical

malpractice cases. In Stone, all seven justices of this Court recognized that Fulton’s

analysis was incorrect or should be found to no longer be good law, though their reasons

for doing so varied.21 While I was not a member of this Court when Stone was decided, I

also conclude that Fulton did not correctly set forth the burden of proof necessary to

establish proximate causation as set forth in § 2912a(2). As all justices of this Court have

concluded that Fulton’s analysis of § 2912a(2) is wrong, it is illogical to fail to overrule

Fulton, because by failing to do so, this Court fosters unnecessary confusion for litigants

and the lower courts. Accordingly, we overrule Fulton to the extent that it has led courts

to improperly designate what should be traditional medical malpractice claims as loss-of-

opportunity claims and has improperly transformed the burden of proof in a traditional

malpractice case from a proximate cause to the proximate cause.

       We emphasize that we hold that the second sentence of § 2912a(2) applies only to

medical malpractice cases that plead loss of opportunity and not to those that plead

traditional medical malpractice; we do not address the scope, extent, or nature of loss-of-

opportunity claims as that issue is not before us. Significant questions surround such


instances, if either calculation demonstrates that the plaintiff suffered an injury that more
probably than not was proximately caused by the negligence of the defendant or
defendants, the plaintiff’s case may proceed.
       21
            Stone, 482 Mich at 164 (opinion by TAYLOR, C.J.).



                                             19
claims.22 However, we decline to decide issues that are not necessary to the resolution of

the case before us.

                                   IV. CONCLUSION

       For all the foregoing reasons, we conclude that the Court of Appeals erred in the

present case by reversing the trial court’s denial of summary disposition. The case before

us presents a traditional malpractice claim. It does not present a claim for loss of

opportunity. In traditional malpractice cases, the plaintiff is required to prove that the

defendant’s negligence more probably than not caused the plaintiff’s injury. In this case,

the testimony of plaintiff’s expert witnesses supports plaintiff’s position on proximate

causation. While that testimony is not dispositive, it is sufficient to raise a question of

fact to defeat a motion for summary disposition, allowing the issue to be adjudicated on

the merits by the trier of fact. Finally, we overrule Fulton to the extent that it has led

courts to improperly designate what should be traditional medical malpractice claims as

loss-of-opportunity claims and has improperly transformed the burden of proof in a

traditional malpractice case from a proximate cause to the proximate cause.




       22
          Questions exist about the full scope and extent of loss-of-opportunity claims and
the extent of damages recoverable in those actions, which we do not decide today. For
example, a partial discussion of the scope of loss-of-opportunity claims was at issue in
Wickens v Oakwood Healthcare Sys, 465 Mich 53; 631 NW2d 686 (2001). While Justice
CAVANAGH and I do not fully agree in this case, I do agree with Justice CAVANAGH’s
partial dissent in Wickens that a living person may pursue a claim for loss of opportunity
under the circumstances presented in that case.



                                            20
         Accordingly, we reverse the judgment of the Court of Appeals and remand this

matter to the Court of Appeals for consideration of the issue not decided on appeal in that

court.


         WEAVER, J., concurred with HATHAWAY, J.




                                            21
                            STATE OF MICHIGAN

                                     SUPREME COURT


RAYMOND O’NEAL,

              Plaintiff-Appellant,

v                                                            No. 138180, 138181

ST. JOHN HOSPITAL & MEDICAL
CENTER, RALPH DiLISIO, M.D., and
EFSTATHIOS TAPAZOGLOU, M.D.,

              Defendant-Appellees.


CAVANAGH, J. (concurring).

       I concur in the result. I agree with the majority that the Court of Appeals’

judgment in this case should be reversed because the Court erred by treating this case as a

loss-of-opportunity case instead of a traditional medical malpractice case and, as a result,

erred by requiring plaintiff to meet the requirements in the second sentence of MCL

600.2912a(2). I further agree that Fulton v William Beaumont Hosp, 253 Mich App 70;

655 NW2d 569 (2002), should be overruled to the extent that courts have relied on it to

improperly transform what could be traditional medical malpractice claims into loss-of-

opportunity claims.1 I write separately to express my views on the issues presented.


       1
         Contrary to Justice YOUNG’s assertion, I overrule Fulton only to the extent that it
is implicated in this case. Regardless, I am sincerely baffled about what relevance Chief
Justice KELLY’s views on a former composition of this Court have to do with whether we
should overrule a Court of Appeals case.
      This case raises the issue of what the proper burden of proof for proximate

causation is in medical malpractice cases in which the plaintiff had a preexisting risk of

the bad result that occurred, even absent the defendant’s alleged negligence. I agree with

the lead opinion that the second sentence of MCL 600.2912a(2) is inapplicable to this

case because it only applies to loss-of-opportunity claims and this case does not involve a

loss-of-opportunity claim. Instead, the key issue in this case is the proper interpretation

of the first sentence of MCL 600.2912a(2).

      The first sentence of MCL 600.2912a(2) clearly provides that a plaintiff in any

medical malpractice case, including a traditional medical malpractice case, bears the

burden of showing that it is more probable than not that the plaintiff’s injury was

proximately caused by the defendant’s negligence. Under traditional malpractice law in

Michigan, proximate cause includes two prongs: (1) cause in fact and (2) legal, or

“proximate,” cause.2 See, e.g., Skinner v Square D Co, 445 Mich 153, 162-163; 516

NW2d 475 (1994).         While legal causation relates to the foreseeability of the

consequences of the defendant’s conduct, the cause-in-fact prong “generally requires

showing that ‘but for’ the defendant’s actions, the plaintiff’s injury would not have

occurred.” Id. at 163. The cause-in-fact prong is sometimes also stated as requiring that

“it is more likely than not that the conduct of the defendant was a cause in fact of the

result.” Weymers v Khera, 454 Mich 639, 648; 563 NW2d 647 (1997) (quotation marks

      2
        Because the statute incorporates words and phrases from the common law, it is
appropriate to consider common-law meanings of these phrases. See People v Wright,
432 Mich 84, 92; 437 NW2d 603 (1989).



                                             2
and citations omitted). Thus, even in cases in which there is statistical evidence that the

plaintiff had a risk of the bad result occurring absent negligence,3 a plaintiff may still

meet the cause-in-fact prong of the proximate causation analysis if the plaintiff can show

that it is more probable than not that the defendant’s alleged negligence was a cause in

fact of the bad result occurring. I would hold that this threshold is met if the plaintiff can

show that the alleged negligence was responsible for a majority, or “more than fifty

percent,” of the risk of the bad result occurring. See MCL 600.2912a(2) and Falcon v

Mem Hosp, 436 Mich 443, 450; 462 NW2d 44 (1990).4

       Under this approach, a court should consider the total risk of the bad result that the

plaintiff faced, including the risk caused by the alleged negligence. Then, the court

should consider how much of that risk was created by the negligence. If the negligence

was responsible for more than half of the total risk of the bad result and the plaintiff

suffered that bad result, then the cause-in-fact prong of the proximate cause analysis is

met because it is more probable than not that the defendant’s negligence was a cause in




       3
         I agree with the lead opinion, however, that not all traditional medical
malpractice cases need to be expressed in statistical or percentage terms in order to meet
the “more probable than not” standard.
       4
        If a plaintiff cannot meet the burden for a traditional medical malpractice claim, I
would hold that the plaintiff may still pursue a loss-of-opportunity claim if the plaintiff
can meet the requirements for those claims provided in MCL 600.2912a(2) and Falcon,
as explained in my opinion in Stone v Williamson, 482 Mich 144, 170-179; 753 NW2d
106 (2008).



                                              3
fact of the bad result.5 This approach is consistent with the statutory language “more

probable than not” and with the historical approach to proximate causation.6


       5
         To give a nonmedical example, if I am rolling a die, there is ordinarily a 1 out of
6 chance that I will roll a number one. But if a defendant negligently changes two
additional sides of the die to number ones, then the die will have three number ones.
Now my chances of rolling a number one are 3 out of 6 (or 1/2). If I actually roll a
number one, there is a 2/3 (approximately 67 percent) chance that I rolled a number one
that was created by the defendant’s negligence. Therefore, there is a more than 50
percent chance that I rolled a number one because of the defendant’s negligence, i.e., it is
more probable than not that the defendant’s negligence was a cause in fact of the result.
Notably, this analysis will differ somewhat if the plaintiff’s increased risk of the bad
result is alleged to have been caused by multiple negligent actors, depending on the
timing and the interaction of the various causes.
       6
          Justice YOUNG haphazardly concludes that “the majority” is extending the
exception to the cause-in-fact prong created in Falcon to all medical malpractice claims.
I agree that Falcon created what was essentially an exception to this rule, but I fail to see,
and Justice YOUNG utterly fails to explain, how my approach in this case is an extension
of that rule to all traditional medical malpractice cases. Justice YOUNG himself explains
that “[i]n cases in which the plaintiff alleges that the defendant’s negligence more
probably than not caused the injury, the claim is one of simple medical malpractice [as
opposed to loss-of-opportunity].” (Quotation marks and citation omitted.)

        Setting aside the numerous pages of Justice YOUNG’s opinion that consist only of
irrelevant, hyperbolic, or unsubstantiated commentary, he appears to raise only two
substantive concerns with my approach, and neither provides support for his conclusion
that it does not satisfy the cause-in-fact prong. First, he irrelevantly notes that, as I
concede in footnote 7, this approach is inconsistent with an example I used in Stone.
Second, he alleges that I should not have compared the low end of the possible range of
plaintiff’s risk of the bad result absent negligence to the high end of the range of
plaintiff’s risk with negligence. I think that my approach is perfectly consistent with our
charge to view the evidence in the light most favorable to the plaintiff, given that even
Justice YOUNG explains that the experts testified that plaintiff’s risk was somewhere
between the ranges the experts provided. But regardless, this criticism only challenges
which numbers to use and not the merits of the approach itself, and it would be possible,
as Justice YOUNG prefers, to instead compare the low ends of the ranges, or the high
ends, only to each other. For example, if the alleged negligence increased a plaintiff’s
risk of the bad result from 5 to 10 percent to 30 to 40 percent, then, regardless of which
numbers are compared, the negligence would have been responsible for a majority of the


                                              4
       In adopting this approach, I reject the view that a plaintiff must show that the

defendant’s negligence increased the plaintiff’s risk by more than 50 percentage points,

e.g., from 25 percent to 76 percent, or from 10 percent to 61 percent.7 As noted by the

lead opinion, this approach is inconsistent with the historical approach to proximate

causation. It is also inconsistent with the first sentence in MCL 600.2912a(2) because it

would preclude traditional medical malpractice claims in many cases in which the

defendant’s negligence was more probably than not a cause in fact of the bad result, such

as in a case in which the negligence increased the risk of a bad result from 5 percent to 45

percent.8 I also reject the lead opinion’s “percent-increase” test because it is similarly

inconsistent with a more-probable-than-not standard. The fact that a negligent act caused




plaintiff’s risk of the bad result, and, given that the bad result occurred, it would be more
probable than not that the negligence was a cause in fact of the bad result occurring.
Justice YOUNG fails to address why this logic is incorrect or levy a criticism that actually
supports his conclusion that my approach eviscerates the cause-in-fact requirement.
       7
         To the extent that I endorsed the percentage point approach by way of an
example in my opinion in Stone, I repudiate that position. See Stone, 482 Mich at 177
(opinion by CAVANAGH, J.), stating that a plaintiff whose chance of survival decreased
from 80 to 40 percent could not bring a traditional malpractice claim because it would not
amount to a 50 percent change.
       8
          In this example, the defendant was responsible for 40 percentage points of the
plaintiff’s risk, out of a total of 45 percentage points, meaning that there is a 40 out of 45
chance, or 40/45 (approximately 89 percent) chance, that the defendant’s negligence was
a cause in fact of the bad outcome. In contrast, under the percentage-point approach, the
plaintiff’s burden would not have been met because the increase in risk was 40
percentage points.



                                              5
a 50 percent increase in the risk of a bad result does not demonstrate that it is more

probable than not that the negligence was a cause in fact of the bad result.9

       In this case, plaintiff presented sufficient facts to establish the cause-in-fact prong

of the proximate cause analysis in a traditional medical malpractice claim. Viewing the

facts in the light most favorable to plaintiff, plaintiff’s expert testified that defendants’

alleged negligence increased plaintiff’s risk of the bad result, the stroke, from 5 percent to

20 percent. Defendant was thus responsible for 15 percentage points out of the total 20

percentage points of plaintiff’s risk of the bad result, meaning that there is a 15/20

chance, or 75 percent chance, that defendant’s alleged negligence was a cause in fact of

the bad result.10 Thus, plaintiff has presented evidence sufficient to support his allegation



       9
         For example, if a defendant’s negligence caused an increase in a plaintiff’s risk
of a bad result from 10 percent to 15 percent, this would be a 50 percent increase in risk.
But it is not more probable than not that the defendant’s negligence was a cause in fact
because the defendant would only have been responsible for five out of the total 15
percentage points of the plaintiff’s risk of the bad result, meaning that there is only a 5/15
chance, or an approximately 33 percent chance, that the negligence was a cause in fact of
the bad result. As I explain in footnote 3, however, the plaintiff could still pursue a loss-
of-opportunity claim.
       10
          Although this formulation is mathematically identical to Justice MARKMAN’s
approach, there are very important differences in how we view its utility. I favor
adopting it because it is consistent with the more-probable-than-not standard in the first
sentence of MCL 600.2912a(2) as applied to traditional medical malpractice claims in
which the plaintiff had a risk of the bad result even absent negligence. In contrast, Justice
MARKMAN believes it is required by the second sentence of MCL 600.2912a(2) and,
unlike myself, believes that all medical malpractice claims in which there was a risk of
the bad result occurring even absent negligence should be treated as loss-of-opportunity
claims, regardless of whether the plaintiff can meet the burden of proof for a traditional
medical malpractice claim. As explained in my concurring opinion in Stone, I continue
to think that Justice MARKMAN’s interpretation is inconsistent with the statute’s text and


                                              6
that it is “more probable than not” that defendant’s negligence was a cause in fact of the

stroke occurring.

       For the foregoing reasons, I concur with the lead opinion that the judgment of the

Court of Appeals should be reversed. I would remand the case to the Court of Appeals

for further proceedings.


       KELLY, C.J., concurred with CAVANAGH, J.




Michigan law, including Falcon. Stone, 482 Mich at 179-184 (opinion by CAVANAGH,
J.).



                                            7
                             STATE OF MICHIGAN

                                    SUPREME COURT


RAYMOND O’NEAL,

             Plaintiff-Appellant,

v                                                         No. 138180, 138181

ST. JOHN HOSPITAL & MEDICAL
CENTER, RALPH DiLISIO, M.D., and
EFSTATHIOS TAPAZOGLOU, M.D.,

             Defendant-Appellees.


KELLY, C.J. (concurring).

      I fully join Justice CAVANAGH’s concurring opinion. I write separately because in

his dissent (which Justice CORRIGAN joins), Justice YOUNG continues to quote and

misleadingly characterize a statement I made nearly two years ago off the bench. Post at

1 (YOUNG, J., dissenting). For my response, I refer the reader to my concurring opinion

in Univ of Mich Regents v Titan Ins Co, ___ Mich ___, ___; ___ NW2d ___ (2010)

(KELLY, C.J., concurring).


                                                      Marilyn Kelly
                              STATE OF MICHIGAN

                                     SUPREME COURT


RAYMOND O’NEAL,

              Plaintiff-Appellant,

v                                                         No. 138180

ST. JOHN HOSPITAL & MEDICAL
CENTER, RALPH DiLISIO M.D. and
EFSTATHIOS TAPAZOGLOU, M.D.,

              Defendant-Appellees.


WEAVER, J., (concurring).

       I concur fully with and sign Justice HATHAWAY’s opinion. I write separately to

note that by overruling the Court of Appeals’ decision in Fulton, we are not overruling

precedent from this Court. Justice YOUNG’s dissent, however, attempts to mislead the

public into thinking that this Court is overruling such precedent by introducing a

discussion of stare decisis into this case.

       Justice YOUNG’S dissent lists 12 cases that have been overruled by this Court in

the past 18 months. While Justice YOUNG may feel aggrieved by this Court overruling

those 12 cases, amongst those cases were some of the most egregious examples of

judicial activism that did great harm to the people of Michigan. Those decisions were

made by the “majority of four,” including Justice YOUNG, under the guise of ideologies

such as “textualism” and “judicial traditionalism.”
       As I stated in my concurrence in Univ of Mich Regents v Titan Ins Co, ___ Mich

___, ___ ; ___ NW2d ___ (2010), I agree with the sentiment recently expressed by Chief

Justice Roberts of the United States Supreme Court in his concurrence to the decision in

Citizens United v Fed Election Comm, 558 US ___, ___; 130 S Ct 876, 920; 175 L Ed 2d

753, 806 (2010), when he said that

       stare decisis is neither an “inexorable command,” Lawrence v. Texas, 539
       U. S. 558, 577 [123 S Ct 2472; 156 L Ed 2d 508] (2003), nor “a mechanical
       formula of adherence to the latest decision,” Helvering v. Hallock, 309 U.
       S. 106, 119 [60 S Ct 444; 84 L Ed 604] (1940) . . . . If it were, segregation
       would be legal, minimum wage laws would be unconstitutional, and the
       Government could wiretap ordinary criminal suspects without first
       obtaining warrants. See Plessy v. Ferguson, 163 U. S. 537 [16 S Ct 1138;
       41 L Ed 256] (1896), overruled by Brown v. Board of Education, 347 U. S.
       483 [74 S Ct 686; 98 L Ed 873] (1954); Adkins v. Children's Hospital of D.
       C., 261 U. S. 525 [43 S Ct 394; 67 L Ed 785] (1923), overruled by West
       Coast Hotel Co v. Parrish, 300 U. S. 379 [57 S Ct 578; 81 L Ed 703]
       (1937); Olmstead v. United States, 277 U. S. 438 [48 S Ct 564; 72 L Ed
       944] (1928), overruled by Katz v. United States, 389 U. S. 347 [88 S Ct
       507; 19 L Ed 2d 576] (1967).

Chief Justice Roberts further called stare decisis a “principle of policy” and said that it “is

not an end in itself.” Id. at ___; 130 S Ct at 920; 175 L Ed 2d at 807. He explained that

“[i]ts greatest purpose is to serve a constitutional ideal—the rule of law. It follows that in

the unusual circumstance when fidelity to any particular precedent does more to damage

this constitutional ideal than to advance it, we must be more willing to depart from that

precedent.” Id at ___; 130 S Ct at 921; 175 L Ed 2d at 807. It appears that Justice

YOUNG does not agree with Chief Justice Roberts.




                                              2
       The consideration of stare decisis and whether to overrule wrongly decided

precedent always includes service to the rule of law through an application and exercise

of judicial restraint, common sense, and a sense of fairness—justice for all.1


                                                        Elizabeth A. Weaver




       1
       Justice YOUNG’s apparent contempt for the common law and common sense can
be seen in his 2004 article in the Texas Review of Law and Politics, where Justice
YOUNG stated:

             Consequently, I want to focus my remarks here on the
       embarrassment that the common law presents—or ought to present—to a
       conscientious judicial traditionalist. . . .

              To give a graphic illustration of my feelings on the subject, I tend to
       think of the common law as a drunken, toothless ancient relative, sprawled
       prominently and in a state of nature on a settee in the middle of one’s
       genteel garden party. Grandpa’s presence is undoubtedly a cause of
       mortification to the host. But since only the most ill-bred of guests would
       be coarse enough to comment on Grandpa’s presence and condition, all
       concerned simply try ignore him. [Young, A judicial traditionalist
       confronts the common law, 8 Texas Rev L & Pol 299, 301-302 (2004).]



                                             3
                             STATE OF MICHIGAN

                                     SUPREME COURT


RAYMOND O’NEAL,

              Plaintiff-Appellant,

v                                                             No. 138180, 138181

ST. JOHN HOSPITAL & MEDICAL
CENTER, RALPH DiLISIO, M.D., and
EFSTATHIOS TAPAZOGLOU, M.D.,

              Defendants-Appellees.


MARKMAN, J. (concurring in the result only).

       Unlike the majority, I conclude that this is a lost-opportunity case because it is

possible that the bad outcome here, i.e., suffering a stroke, would have occurred even if

plaintiff had received proper treatment. However, I concur in the result reached by the

majority because plaintiff has raised a genuine issue of material fact regarding whether he

suffered a greater than 50 percent loss of an opportunity under MCL 600.2912a.

Therefore, I agree with the majority that the judgment of the Court of Appeals should be

reversed and this case should be remanded to the Court of Appeals for it to consider

defendants’ remaining issue on appeal, i.e., the admissibility of the expert testimony

proffered by plaintiff. However, I strongly disagree with the analysis of the majority and

believe that it will lead to confusion and unnecessary litigation.
                             I. STATUTE AND CASELAW

       MCL 600.2912a(2) provides:

               In an action alleging medical malpractice, the plaintiff has the
       burden of proving that he or she suffered an injury that more probably than
       not was proximately caused by the negligence of the defendant or
       defendants. In an action alleging medical malpractice, the plaintiff cannot
       recover for loss of an opportunity to survive or an opportunity to achieve a
       better result unless the opportunity was greater than 50%.[1]

In Fulton v William Beaumont Hosp, 253 Mich App 70; 655 NW2d 569 (2002), the Court

of Appeals held that a lost-opportunity plaintiff must prove that his loss was greater than

50 percentage points.     That is, the difference between the plaintiff’s premalpractice

chance to achieve a better result and the plaintiff’s postmalpractice chance to achieve a

better result must be greater than 50 percentage points.2

       In Stone v Williamson, 482 Mich 144; 753 NW2d 106 (2008), although all seven

justices concluded that Fulton was wrongly decided, this Court could not overrule Fulton

because, while four justices concluded that Fulton was a lost-opportunity case, six

justices concluded that Stone was not a lost-opportunity case. See Stone, 482 Mich at

164 n 14 (opinion by TAYLOR, C.J.) (“[B]ecause a majority of justices hold that this is

not a lost-opportunity case, the issue of the correctness of Fulton, cannot be reached, and


       1
         For a discussion of the common law that existed before the enactment of this
statutory provision, see my concurring opinion in Stone v Williamson, 482 Mich 144; 753
NW2d 106 (2008) (MARKMAN, J., concurring).
       2
         As I did in Stone, I use the term “premalpractice chance” to refer to the plaintiff’s
chance to survive or achieve a better result with proper treatment, and the term
“postmalpractice chance” to refer to the plaintiff’s chance to survive or achieve a better
result without proper treatment.



                                              2
Fulton’s approach remains undisturbed as the method of analyzing lost-opportunity

cases.”).3 In Stone, Chief Justice TAYLOR and Justices CORRIGAN and YOUNG concluded

that the loss-of-an-opportunity provision is “unenforceable.” Stone, 482 Mich at 147

(opinion by TAYLOR, C.J.).       They concluded that if the plaintiff’s premalpractice

opportunity to achieve a better result was greater than 50 percent, the plaintiff could bring

a traditional medical-malpractice action.     However, if the plaintiff’s premalpractice

opportunity to achieve a better result was 50 percent or less, the plaintiff could not bring

a traditional medical-malpractice action or a lost-opportunity action because lost-

opportunity actions are no longer allowed under the language of the statute.

       Justices CAVANAGH, KELLY, and WEAVER concluded in Stone that if the

percentage point difference between the plaintiff’s premalpractice opportunity to achieve

a better result and his postmalpractice opportunity to achieve a better result was greater

than 50 percentage points, the plaintiff could bring a traditional medical-malpractice

action. However, if the percentage point difference was 50 points or less, the plaintiff

could only bring a lost-opportunity action and would have to prove that his

premalpractice opportunity to achieve a better result was greater than 50 percent.




       3
         Because a majority of justices now believes that neither Fulton nor the instant
case are lost-opportunity cases, Fulton is now apparently overruled at least with regard to
the determination concerning whether a case is a traditional medical-malpractice action
or a lost-opportunity action. However, because a majority of the justices conclude that
the instant case is not a lost-opportunity case, Fulton’s method of analyzing lost-
opportunity cases is unaffected by the decision in this case.



                                             3
       Finally, in Stone, I concluded that a lost-opportunity case is “one in which it is at

least possible that the bad outcome would have occurred even if the patient had received

proper treatment.” Id. at 186 (MARKMAN, J., concurring).4 I further concluded that in

order for a lost-opportunity plaintiff to prevail, he must prove that his lost opportunity

was greater than 50 percent. And,

       [i]n order to determine whether the “lost opportunity” was greater than 50
       percent, the postmalpractice chance of obtaining a better result must be
       subtracted from the premalpractice chance, the postmalpractice chance
       must then be subtracted from 100, the former number must be divided by
       the latter number, and then this quotient must be multiplied by 100 to
       obtain a percentage. [Id.]

“If this percentage is greater than 50, the plaintiff may be able to prevail; if this

percentage is 50 or less, then the plaintiff cannot prevail.” Id.

                             II. PROBLEMS WITH FULTON

       As I observed in Stone, the first problem with Fulton is that it requires a loss of

more than 50 percentage points, while MCL 600.2912a(2) requires a loss of more than 50

percent.

               The Court of Appeals in Fulton . . . concluded that because the
       plaintiff’s premalpractice chance of survival was 85 percent and her
       postmalpractice chance of survival was 60 percent to 65 percent, her “lost
       opportunity” was 20 percent to 25 percent and, thus, because the plaintiff’s
       “lost opportunity” was not greater than 50 percent, she could not recover
       under MCL 600.2912a(2). However, Fulton did not offer any explanation
       as to why it merely subtracted the postmalpractice chance from the
       premalpractice chance to determine the “lost opportunity.” This might have

       4
        “By contrast, if there is no question that the proper treatment would have resulted
in a good outcome, then the patient who has suffered a bad outcome has a traditional
medical-malpractice action.” Stone, 482 Mich at 186 (MARKMAN, J., concurring).



                                              4
       been the correct method of determining the “lost opportunity” if MCL
       600.2912a(2) required that such a loss be “greater than 50 percentage
       points.” However, MCL 600.2912a(2) requires that the “lost opportunity”
       be “greater than 50%.” There is a significant distinction between 50
       percentage points and 50 percent. As Dr. Roy Waddell, a board-certified
       orthopedic surgeon in Grand Rapids, has explained: “A decrease in survival
       rate from 50 percent to 10 percent is a 40-percentage-point decrease, but it
       is an 80 percent decrease.” Waddell, A doctor’s view of “opportunity to
       survive”: Fulton’s assumptions and math are wrong, 86 Mich B J 32, 33
       (March 2007) (emphasis in original). Similarly, a reduction in wages from
       $5 an hour to $1 an hour is not a 4 percent reduction in wages; rather, it is
       an 80 percent reduction in wages. [Id. at 196 (emphasis in the original).]

As I also observed in my concurring opinion in Stone, Justice CAVANAGH made this same

mistake in his concurring opinion in Stone:

              Like the Court of Appeals in Fulton, Justice CAVANAGH offers no
       explanation as to why he repeatedly calculates the “lost opportunity” in
       terms of the percentage points lost rather than the actual percentage lost
       when MCL 600.2912a(2) clearly states that the “lost opportunity” must be
       “greater than 50%,” not greater than 50 percentage points. These statistical
       concepts are utterly distinct. [Id. at 196 n 11.]

I am pleased that Justice CAVANAGH and the other justices who signed his opinion in

Stone (Chief Justice KELLY and Justice WEAVER) now apparently recognize this

analytical error, and that they now “repudiate” that position. Thus, a majority of the

justices of this Court now agree that MCL 600.2912a(2) requires us to determine whether

the lost opportunity is “greater than 50%,” not whether the lost opportunity is greater than

50 percentage points.

       The other problem with Fulton, that Justice CAVANAGH and his colleagues in the

majority also now apparently recognize, is that “it does not differentiate between those

patients who would have survived regardless of whether they received proper or improper




                                              5
treatment and those patients who needed the proper treatment in order to survive.” Id. at

197.5 As I observed in Stone:

              Such a differentiation is necessary because only those in the latter
       group have truly suffered a “lost opportunity” as a result of the improper
       treatment. That is, if a patient would have survived regardless of whether
       he received proper or improper treatment, the improper treatment cannot be
       said to have caused him to lose an opportunity to survive. On the other
       hand, if the patient would have survived only if he had received the proper
       treatment, the improper treatment can be said to have caused him to lose an
       opportunity to survive. MCL 600.2912a(2) requires us to determine
       whether the patient more likely than not fell into the latter category rather
       than the former category, because the statute only allows a plaintiff to
       recover for a “loss of an opportunity” that was “greater than 50%” and that
       was “caused by the negligence of the defendant . . . .” Dr. Waddell’s
       calculation does just that:

                   (Premalpractice chance) - (Postmalpractice chance)
                             100-(Postmalpractice chance)

       5
          Although the majority describes their formula in considerably different terms
than I did in Stone, the same result is produced under either formula. That is, regardless
of whether the formula is described as I do [(premalpractice chance of better result) -
(postmalpractice chance of better result)]/[100 - (postmalpractice chance of better
result)], or, as the majority now does [(postmalpractice chance of worse result) -
(premalpractice chance of worse result)]/[(postmalpractice chance of worse result)], the
same figure is obtained. Given Justice CAVANAGH’s forceful criticisms of my formula in
Stone, it is encouraging that we are now in agreement on this critical point. See, e.g.,
Stone, 482 Mich at 183-184 (CAVANAGH, J., dissenting) (“the Waddell formula [which I
adopted in Stone and to which I continue to adhere] is blatantly inconsistent with the
language of MCL 600.2912a(2)”; “[i]t is inconceivable that Justice MARKMAN can read
the [statute] and conclude that it should be translated into this formula”; “[t]he approach
taken by Justice MARKMAN and Dr. Waddell requires [the statute] to be rewritten”; “the
Waddell approach leads to such anomalous results that it cannot possibly reflect the
intention of the Legislature”). While Justice CAVANAGH is correct that he employs the
formula to determine whether plaintiff’s cause of action is a traditional medical-
malpractice action or a lost-opportunity action, and I use it to determine whether plaintiff
has satisfied the greater-than-50-percent requirement, we agree nonetheless that the
number produced by the formula represents the opportunity that the plaintiff lost as a
result of the defendant’s negligence.



                                             6
The quotient resulting from this numerator and denominator is then
multiplied by 100 to obtain a percentage. This number must be “greater
than 50%” in order to satisfy the requirement of the second sentence of
MCL 600.2912a(2). For instance, if the patient’s premalpractice chance to
achieve a better result was 80 percent and, as a result of the defendant’s
malpractice, the patient’s postmalpractice chance is reduced to 20 percent,
the patient has suffered a 75 percent loss of an opportunity to survive.[6]

        What the Waddell formula essentially does is test the sufficiency of
the expert testimony, which is typically presented in the form of two
statistics: the likelihood that a patient would have had a good outcome with
proper treatment (the “[premalpractice chance]”) and the likelihood that a
patient would have had a good outcome with negligent treatment (the
“[postmalpractice chance]”). The Waddell formula allows a court analyzing
this data to determine whether the plaintiff, when the patient has
experienced a bad outcome, has created a question of material fact
concerning whether proper treatment more likely than not would have made
a difference. The formula does this by identifying the universe of patients
who would have had a bad outcome (the denominator) and the subset of
those patients who could have been favorably treated (the numerator).

       It is easiest to start with the formula’s denominator. This
denominator consists of the universe of all patients who would have had a
bad outcome, for whatever reason. This group includes two subsets of
patients: those who would have had a bad outcome because they received
negligent treatment, and those who would have had a bad outcome despite
receiving proper treatment.        The formula identifies this group by
subtracting from 100 the percentage of patients who would have had a good
outcome even without proper treatment; in other words, it subtracts the
“[postmalpractice chance]” from 100. In this way, a court can take the
expert’s statistics and identify those patients who were not treated properly
and who experienced a bad outcome. A patient who is the subject of a
medical-malpractice action is a member of this group. But we cannot
determine whether the patient is a member of this group because he or she
was denied the proper treatment or because he or she would have suffered a
bad outcome even with proper treatment.

       One more calculation must then be made in order to answer the
dispositive question posed by the statute: whether it is more likely than not
that the patient would have benefited from proper treatment or, put another

6
    [(80 - 20)/(100 -20)] x 100 = 75%.



                                         7
way, whether the “opportunity to survive or . . . to achieve a better result”
was “greater than 50%.” MCL 600.2912a(2). A court has to determine
what percentage of those patients with a bad outcome (those patients in the
denominator) would have benefited from treatment. This brings us to the
Waddell formula’s numerator. The numerator consists of those patients
who would have had a bad outcome only if they had been negligently
treated. It is calculated by subtracting the “[postmalpractice chance]” from
the “[premalpractice chance],” thus identifying those patients who required
treatment to avoid a bad outcome.

        Once the numerator and denominator have been calculated,
comparison of these two numbers by their quotient allows a court to
reasonably determine whether improper treatment more likely than not
made a difference in the patient’s outcome. If the number of patients who
would have had a bad outcome only if they had been negligently treated
(the numerator) comprises more than half of the number of patients who
would have had a bad outcome overall (the denominator), then the plaintiff
has established that proper treatment more likely than not would have made
a difference. In other words, when this has been shown, the plaintiff has
created a question of material fact concerning whether the “opportunity”--
the benefit that would have been realized by a group of patients from the
treatment that was not given to this specific patient-- was greater than 50
percent. Such a plaintiff has presented adequate expert testimony to
establish a “lost opportunity” cause of action within the meaning of the
statute.

      As Dr. Waddell has explained:

       “[T]he intent of the law is to disallow damages unless it can be
shown that proper treatment creates a better than even (“greater than
50%”) chance of survival of the patients who would have died without
treatment. In other words, if appropriate treatment cannot save at least half
of the patients who otherwise would have died, then you do not have
sufficient evidence to show that the negligence made the difference in the
adverse outcome (death). Conversely, if good treatment can save more
than half of the patients who otherwise would have died, then you have
adequate evidence that the poor treatment or negligence was likely to blame
for the bad outcome. This is exactly what this definition of opportunity
measures.” [Waddell, 86 Mich B J at 33 (emphasis in original).]

MCL 600.2912a(2) only allows a plaintiff to recover for a “loss of an
opportunity” that was “greater than 50%” and that was “caused by the
negligence of the defendant . . . .” Use of Dr. Waddell’s formula, which
generates the actual percentage lost rather than the number of percentage


                                     8
       points lost, and excludes those who would have achieved a good result
       regardless of the malpractice, best ensures, in my judgment, that these
       statutory requirements are satisfied. That is, this calculation would impose
       liability, in accordance with MCL 600.2912a(2), in those instances in
       which the medical care received more likely than not affected whether the
       patient survived. [Id. at 197-202.]

                                    III. APPLICATION

       In the instant case, plaintiff alleged that defendants failed to timely and properly

treat his acute chest syndrome, a serious complication of sickle-cell disease, and that, as a

result, he suffered a stroke. More specifically, plaintiff alleged that defendants should

have performed an exchange blood transfusion in which the patient’s abnormal blood is

taken out and replaced with normal blood, rather than a simple blood transfusion in

which normal blood is simply added to the patient’s abnormal blood.7 Plaintiff’s expert

witness testified that there was a 10 to 20 percent chance of stroke without proper

treatment, but that with proper treatment there would have been only a 5 to 10 percent

chance of stroke. In other words, with proper treatment plaintiff had a 90 to 95 or more

percent chance of not suffering a stroke, and without proper treatment he had an 80 to 90

percent chance of not suffering a stroke. That is, plaintiff’s premalpractice chance to

achieve a better result was, at best, 95 percent, and his postmalpractice chance was, at

worst, 80 percent.     Pursuant to the Waddell calculation, plaintiff lost a 75 percent

opportunity to achieve a better result:


       7
        An exchange blood transfusion was not performed until after plaintiff suffered a
stroke. As a result of the stroke, plaintiff suffers from partial paralysis of his left leg and
complete loss of function of his left hand and arm.



                                              9
                          95 - 80 x 100 = 75%
                         100 - 80

Therefore, plaintiff has raised a genuine issue of material fact regarding whether he

suffered a greater than 50 percent loss of an opportunity under MCL 600.2912a(2). For

these reasons, I agree with the majority that the judgment of the Court of Appeals should

be reversed and this case should be remanded to the Court of Appeals for it to consider

defendants’ remaining issue on appeal, i.e., the admissibility of the expert witness

testimony proffered by plaintiff.

                              IV. MAJORITY’S ANALYSIS

       Although I agree with the majority that the Court of Appeals should be reversed, I

strongly disagree with its analysis.

     A. LOST OPPORTUNITY VS. TRADITIONAL MEDICAL MALPRACTICE

                 1. GREATER-THAN-50-PERCENT REQUIREMENT

       On the one hand, the majority concludes that whether the plaintiff’s lost

opportunity is greater than 50 percent determines whether the plaintiff’s action is a lost-

opportunity action or a traditional medical-malpractice action. I find this conclusion to

be completely illogical. Either the defendant’s negligence has caused the plaintiff to

suffer the injury, or it has caused the plaintiff to suffer a loss of an opportunity to achieve

a better result-- the better result being not to suffer the injury. How substantial the

plaintiff’s lost opportunity is determines whether he satisfies the “greater than 50%”

requirement of MCL 600.2912a(2), not whether the plaintiff’s action constitutes a lost-

opportunity action in the first place. As I stated in Stone:



                                              10
              In order to satisfy traditional medical-malpractice action
       requirements, there must be no question that the proper treatment would
       have resulted in a good outcome (at least with regard to the specific injury
       suffered by the patient), because if there is any chance that a patient who
       received proper treatment might nevertheless have suffered the specific bad
       outcome ultimately suffered by the patient, it cannot be proved that the
       improper treatment caused the bad outcome. If there is any chance that the
       proper treatment could have resulted in the bad outcome, the chances of a
       good outcome with proper treatment and the chances of a good outcome
       with improper treatment must be compared. That is, under those
       circumstances, although the plaintiff cannot prove that the defendant’s
       malpractice caused the bad outcome because the bad outcome might have
       occurred even with proper treatment, the plaintiff may be able to prove that
       the defendant’s malpractice increased the patient’s chances of obtaining a
       bad outcome and, thus, caused him or her to suffer a “lost opportunity” to
       achieve a better result. This is the only coherent concept of a “lost
       opportunity” cause of action under MCL 600.2912a(2). [Stone, 482 Mich
       at 271 (MARKMAN, J., concurring).]

Because it is possible that the bad outcome in this case, i.e., suffering a stroke, might

have occurred even if plaintiff had received proper treatment, the instant case constitutes

a lost-opportunity action.

                             2. PLAINTIFF’S PLEADINGS

       On the other hand, the lead opinion concludes that “the second sentence of

§ 2912a(2) applies only to medical malpractice cases that plead loss of opportunity, and

not to those that plead traditional medical malpractice . . . .” That is, the lead opinion

concludes that whether the plaintiff’s action constitutes a lost-opportunity action or a

traditional medical-malpractice action is a function of whether the plaintiff has used the

magic words “lost opportunity” in his pleading. If he did not, the action is a traditional

medical-malpractice action and the plaintiff need not concern himself with satisfying the

greater-than-50-percent requirement of MCL 600.2912a(2). However, if the plaintiff did



                                            11
use the words “lost opportunity” in his pleading, the action is a lost-opportunity action

and the plaintiff must satisfy the greater-than-50-percent requirement of MCL

600.2912a(2). Besides being utterly inconsistent with the majority’s own conclusion that

a lost opportunity greater than 50 percent determines whether the plaintiff’s action

constitutes a lost-opportunity action or a traditional medical-malpractice action, it is also

inconsistent with the well-established principle that Michigan courts are “not bound by a

party’s choice of label for its action [because this would] put form over substance . . . .”

St. Paul Fire & Marine Ins Co v Littky, 60 Mich App 375, 378-379; 230 NW2d 440

(1975). Instead, as we explained in Maiden v Rozwood, 461 Mich 109, 135; 597 NW2d

817 (1999), “the gravamen of plaintiff's action is determined by considering the entire

claim.” (Emphasis added.)

       Thus, just as whether a plaintiff labels an action as an ordinary negligence action

does not control whether that action is, in fact, an ordinary negligence action or a

medical-malpractice action, see Bryant v Oakpointe Villa Nursing Ctr, Inc, 471 Mich

411; 684 NW2d 864 (2004), whether a plaintiff labels an action as a traditional medical-

malpractice action or a lost-opportunity action cannot control whether the plaintiff’s

action is, in fact, a traditional medical-malpractice action or a lost-opportunity action.

This established principle ensures that the governing law, and not the label the parties

attach to that law, controls the outcome of an action. As the United States Supreme Court

has observed, any other approach would allow a party to avoid the requirements of a

legislative mandate simply by artful pleading. See Allis-Chalmers Corp v Lueck, 471 US

202, 211; 105 S Ct 1904; 85 L Ed 2d 206 (1985). Yet this is exactly what the lead


                                             12
opinion would allow a plaintiff to do in relation to the requirements of MCL

600.2912a(2).    Apparently, according to the justices joining the lead opinion, all a

plaintiff need do to avoid the “greater than 50%” requirement in MCL 600.2912a(2) is to

omit the words “lost opportunity” in his complaint. Thus, no artfulness is even required

to nullify this particular statute under their theory.

       Indeed, in light of the lead opinion, the discussions in the various opinions in this

case concerning appropriate formulas for determining loss of opportunity seem pointless.

For what plaintiff, and what competent plaintiff’s attorney, would ever plead a lost-

opportunity claim if it could be so easily avoided? Simply put, under the lead opinion’s

rule, would the lost-opportunity doctrine enacted by the Legislature even continue to

exist as a viable legal doctrine in this state? Would a court have any power to apply the

actual law, or would it be required to participate in a charade of the plaintiff’s (and the

lead opinion’s) making? As an example, could a public official plaintiff avoid having to

prove actual malice in a defamation case by simply leaving the words “public official”

out of his pleading? Could a plaintiff suing a public entity entitled to governmental

immunity avoid such immunity by simply omitting that the defendant is a public entity

from his pleading? Could an independent contractor transmute himself into an employee

by simply asserting such in his pleading?

            B. WHICHEVER FORMULA BEST SERVES THE PLAINTIFF

       The lead opinion offers no explanation, and I can think of none, to support its

alternative “standard percentage increase calculation” formula, other than the fact the

justices signing the lead opinion believe that it somehow indicates that plaintiff has


                                               13
suffered a 300 percent loss of an opportunity! However, none of this really seems to

matter to the justices signing the lead opinion because in the end they conclude that MCL

600.2912a(2) does not require “any particular mathematical formula,” and that if “either

calculation,” or, indeed, some other yet-to-be-discovered calculation, demonstrates a

greater than 50 percent lost opportunity, the plaintiff’s case may proceed, because “the

results must be viewed in the light most favorable to the non-moving party.” This is

simply nonsensical. Although it is true that evidence is to be viewed in a light most

favorable to the non-moving party, Dressel v Ameribank, 468 Mich 557, 561; 664 NW2d

151 (2003), which, as in this case, will almost invariably be the plaintiff, this is the first I

have heard of a judicially created rule that we are to construe an unambiguous law in a

light most favorable to one side or the other. Needless to say, and for reasons that are

apparent, the lead opinion does not bother to cite any authority in support of such a rule.

Is there some logical reason for this rule other than an apparent desire by the lead justices

to place a finger on the scales of justice on behalf of the plaintiff class? Is this rule

limited to lost-opportunity cases or is it equally applicable to all medical-malpractice

actions? Why is such a rule appropriate in a lost-opportunity case, but not in other realms

of the civil law? When is such a default interpretation of the law warranted, and when is

it not? If the law does not require “any particular formula,” why does the lead opinion

devote such attention to identifying the two formulas that it does identify? Why not just

devise a third formula under which the plaintiff will always prevail? Could it possibly be




                                              14
that the lead justices may be confusing their own personal political philosophies with the

dictates of the actual law that they pledged to uphold?8

                                   V. CONCLUSION

       As I summarized in Stone:

              A “lost opportunity” action is one in which it is possible that the bad
       outcome would have occurred even if the patient had received proper
       treatment. On the other hand, if there is no question that the proper
       treatment would have resulted in a good outcome and the patient has
       suffered a bad outcome, the plaintiff possesses a traditional medical-
       malpractice action. In order for a traditional medical-malpractice plaintiff
       to prevail, the plaintiff must prove that the bad outcome was more probably
       than not caused by the defendant’s malpractice. In order for a “lost
       opportunity” plaintiff to prevail, the plaintiff must prove that the “lost
       opportunity” to achieve a better result was more probably than not caused
       by the defendant’s malpractice and that the “lost opportunity” was greater
       than 50 percent. In order to determine whether the “lost opportunity” was
       greater than 50 percent, the postmalpractice chance of obtaining a better
       result must be subtracted from the premalpractice chance; the
       postmalpractice chance must then be subtracted from 100; the former
       number must be divided by the latter number; and then this quotient must
       be multiplied by 100 to obtain a percentage. The calculation can be
       summarized as follows:

       8
         The lead opinion indicates that the justices signing that opinion now support
“Justice CAVANAGH’s dissent in Wickens [v Oakwood Healthcare Sys, 465 Mich 53; 631
NW2d 686 (2001)] that a living person may pursue a claim for loss of opportunity under
the circumstances presented in that case.” What this gratuitous observation has to do
with the instant case, I have not a clue. Do the justices signing the lead opinion also
support Justice CAVANAGH’s dissent in People v Gardner, 482 Mich 41; 753 NW2d 78
(2008), or any one of his other random dissents? Given that three justices previously
supported Justices CAVANAGH’s dissent (Chief Justice KELLY, and Justices CAVANAGH
and WEAVER), by indicating that she now supports Wickens, Justice HATHAWAY seems
to be signaling that there is now majority support in favor of such dissent. Unfortunately,
this type of behavior seems to have become the new majority’s modus operandi--
unnecessarily sowing uncertainty, doubt and confusion into the law by gratuitously
questioning prior cases decided by the former majority. For more discussion on this, see
my dissent in McCormick v Carrier, __ Mich __; __ NW2d __ (2010).



                                            15
                    (Premalpractice chance) - (Postmalpractice chance)
                             100 - (Postmalpractice chance)

       If this percentage is greater than 50, the plaintiff may be able to prevail; if
       this percentage is 50 or less, then the plaintiff cannot prevail. [Stone, 482
       Mich at 218-219 (MARKMAN, J., concurring).][9]

       As discussed earlier, because it is possible that the bad outcome in this case, i.e.,

suffering a stroke, would have occurred even if plaintiff had received proper treatment,

the instant case is, in fact, a lost-opportunity action, and because plaintiff has raised a

genuine issue of material fact regarding whether he suffered a greater than 50 percent loss

of an opportunity under MCL 600.2912a, I agree with the majority that the judgment of

the Court of Appeals should be reversed and this case should be remanded to the Court of

Appeals for it to consider defendants’ remaining issue on appeal, i.e., the admissibility of

the expert witness testimony proffered by plaintiff.

       However, I emphatically disagree with the majority’s incoherent analysis and the

implications of such analysis. The majority effectively transforms a lost-opportunity

action into a traditional medical-malpractice action, for no other apparent reason than to

afford plaintiffs with larger potential recoveries. Instead of limiting a plaintiff’s recovery


       9
         However, the present status of the law seems to be, pursuant to the lead opinion
and Justice CAVANAGH’s concurring opinion, that if the plaintiff’s lost opportunity is
greater than 50 percent (the calculation of which is anyone’s guess in view of the
different tests of these two opinions), the plaintiff can bring a traditional medical-
malpractice action, but, if the plaintiff’s lost opportunity is not greater than 50 percent,
then the plaintiff can only bring a lost-opportunity action. And, pursuant to Fulton, a
lost-opportunity plaintiff must prove that the difference between his premalpractice
chance of achieving a better result and his postmalpractice chance of achieving a better
result is greater than 50 percentage points. Neither of these conclusions is, to say the
least, consistent with my own reading of the statute.



                                             16
to the opportunity that he or she may have lost as a result of the defendant’s negligence,

the majority now expands the plaintiff’s recovery to include potentially all damages

related to his medical condition, even though the plaintiff may well have suffered the

condition even had he received perfect medical treatment.          Thus, having already

undermined the Legislature’s attempt at medical-malpractice reform, see e.g., Bush v

Shabahang, 484 Mich 156; 772 NW2d 272 (2009); Potter v McLeary, 484 Mich 397; 774

NW2d 1 (2009); and ADM File No. 2009-13, 485 Mich __, __ (order entered February

16, 2010), the majority now embarks upon transforming medical-malpractice law in

exactly the opposite direction of that sought by the Legislature. At the same time, the

differing formulas, and non-formulas, adopted by the majority, as well as the internal

inconsistencies in its analysis, will only produce more confusion in an already confused

area of the law, and more litigation in an already heavily litigated area of the law. The

clearest principle of law that can be gleaned from the lead opinion is also the least

principled of its asserted principles-- the adoption of whichever formula best serves the

plaintiff. Not much more than this “principle” really needs to be understood concerning

the essence of the lead opinion’s analysis.


       CORRIGAN, J., concurred with MARKMAN, J., with respect to parts IV(A)(2) and

(B) only.




                                              17
                             STATE OF MICHIGAN

                                    SUPREME COURT


RAYMOND O’NEAL,

             Plaintiff-Appellant,

v                                                         No. 138180, 138181

ST. JOHN HOSPITAL & MEDICAL
CENTER, RALPH DiLISIO, M.D., and
EFSTATHIOS TAPAZOGLOU, M.D.,

             Defendants-Appellees.


CORRIGAN, J. (dissenting).

     I fully join Justice YOUNG’s dissenting opinion. I also join part IV(A)(2) and part

IV(B) of Justice MARKMAN’s opinion concurring in the result only.


                                                     Maura D. Corrigan
                           STATE OF MICHIGAN

                                    SUPREME COURT


RAYMOND O’NEAL,

             Plaintiff-Appellant,

v                                                          Nos. 138180, 138181

ST. JOHN HOSPITAL & MEDICAL
CENTER, RALPH DiLISIO, M.D., and
EFSTATHIOS TAPAZOGLOU, M.D.,

             Defendant-Appellees.


YOUNG, J. (dissenting).

      Our new Chief Justice established the “agenda” for the newly reconstituted Court

in her recent comments captured by the press:

            We the new majority [Chief Justice KELLY and Justices
      CAVANAGH, WEAVER, and HATHAWAY] will get the ship off the shoals
      and back on course, and we will undo a great deal of the damage that
      the Republican-dominated court has done. Not only will we not neglect
      our duties, we will not sleep on the bench.[1]




      1
         She Said, Detroit Free Press, December 10, 2008, p 2A. Chief Justice KELLY
objects that I “continue to quote and misleadingly characterize a statement [she] made
nearly two years ago off the bench.” Ante at ___ (KELLY, C.J., concurring). As my
dissenting opinion in Univ of Michigan Regents v Titan Ins Co, ___ Mich ___; ___
NW2d ___ (2010) (YOUNG, J., dissenting), explains at length, my characterization of her
statement is not misleading. Chief Justice KELLY’s remarks both set an agenda for
undoing the precedents of the previous 10 years and are especially mean-spirited in light
of the political attacks against former Chief Justice TAYLOR during the 2008 campaign.
There are many cases this term that can be said to exemplify the new majority's

commitment to “undo . . . the damage” of the prior majority, but this case certainly

qualifies as a first among equals. Here, not only do my colleagues in the “new majority”

destroy the doctrinal integrity of medical malpractice law, they do so in highly fractured

opinions that will require a Venn diagram for the bench and bar to construct the points at

which four of them agree on any governing principle of law. The new majority has thus

made it more difficult to determine what it has done today. Perhaps this is intended.

        Chaos and confusion in the law only promote more litigation. The decisions the

new majority has issued today in this case will thus benefit only those who profit from

litigating medical malpractice cases. The rest of us desire to know what legal rules

control our rights and obligations, and we desire and deserve to know them before we

act. The citizens of this state are entitled to that kind of clarity in the decisions from the

state’s senior court, not the disorder this Court has sown today. Today’s decision returns

this Court to an era in which the bench and bar must decipher this Court’s split opinions

in order to figure out what principles of law they collectively articulate.2 It is no small

challenge to respond in dissent to the various opinions that shred our medical malpractice

laws.




        2
        See, e.g., Smith v Dep’t of Pub Health, 428 Mich 540; 410 NW2d 749 (1987), for
a model case in the same chaotic vein as today’s split decisions. It exemplifies the era to
which this Court returns in this case.



                                              2
      Despite the Legislature’s codification of the traditional obligation to prove that

alleged malpractice “more probably than not” caused a plaintiff’s injury,3 20 years ago, in

Falcon v Mem Hosp, this Court waded into the realm of policy-making and judicially

created the lost opportunity doctrine as an exception to the traditional and statutorily

codified causation standard of proof.4 Even after the Legislature subsequently recognized

the lost opportunity doctrine,5 it also expressly retained the traditional requirement that

“[i]n an action alleging medical malpractice, the plaintiff has the burden of proving that

he or she suffered an injury that more probably than not was proximately caused by the

negligence of the defendant or defendants.”6

      Until today, this Court has always made clear that when a traditional medical

malpractice claim was at issue, the more-probable-than-not standard of causation applied

and required the plaintiff to “‘exclude other reasonable hypotheses with a fair amount of

certainty.’”7 However, as the Court did in Falcon, today the majority makes a radical

transformation of medical malpractice law and again jettisons traditional causation

doctrine by equating causation of the injury with risk of the injury. But, unlike in

Falcon, the new majority here does not recognize merely an exception to the traditional

      3
          1977 PA 272.
      4
          Falcon v Mem Hosp, 436 Mich 443; 462 NW2d 44 (1990).
      5
          See MCL 600.2912a, as amended by 1993 PA 78.
      6
          MCL 600.2912a(2).
      7
        Skinner v Square D Co, 445 Mich 153, 166; 516 NW2d 475 (1994) (citation
omitted).



                                            3
malpractice requirement of “but for” causation, it essentially eliminates the traditional

rule entirely by importing that exception into all malpractice cases. In declaring this case

to be a “traditional” medical malpractice claim, the new majority applies the relaxed

causation rules that previously had applied only to lost opportunity claims. After today,

therefore, all malpractice claims will be treated under relaxed causation principles

previously applied only to lost opportunity claims. This is a tectonic shift in our law, for

which there is no basis but the preference of the justices in the new majority to foster

more legal chaos that will promote litigation in this area of the law. This shift is

significant because a traditional medical malpractice injury creates liability for the entire

injury, while a lost opportunity claim creates liability only for that portion of the

increased risk of injury attributable to a defendant.8 Make no mistake: Although Justice

CAVANAGH feigns that he is unaware of the significant change in the law being made in

this case, the reduced burden of persuasion and the broader scope of damages permitted

is the reason the new majority now applies lost opportunity causation principles to all

medical malpractice claims.9

       Rather than attempting to give meaning to the words of the statute at issue in this

case, the new majority performs a spectacularly hubristic feat in treating a statutory

       8
        See Falcon, 436 Mich at 471 (opinion by LEVIN, J.) (“In this case, 37.5 percent
times the damages recoverable for wrongful death would be an appropriate measure of
damages.”).
       9
        See n 52 of this opinion for further elaboration on the significance of Justice
CAVANAGH’s repudiation of the position he took just two years ago in Stone v
Williamson, 482 Mich 144, 175-177; 753 NW2d 106 (2008) (opinion by CAVANAGH, J.).



                                             4
medical malpractice claim as though it were a mere matter of common law and thus

subject to its revisionary powers. What is more, these justices have decided to use those

extraconstitutional powers to circumvent the Legislature’s explicit decision to retain

traditional causation rules. The new majority has chosen “free form” to change the law to

match its policy preference that no legal doctrines shall exist to eliminate any claim of

medical malpractice—even those doctrines codified by our Legislature to accomplish this

very goal.

       For someone who campaigned on the theme that more of this Court’s precedent

should be preserved,10 we are surprised at how eagerly Justice HATHAWAY has striven in

this case to overturn precedent—even to the extent of offering her own new views that

precedent is not a serious barrier to any change desired by the new majority.11

       The dicta in Justice HATHAWAY’s opinion bears out her newfound position on

stare decisis because her opinion purports to opine on “the full scope and extent of loss-

of-opportunity claims,”12 even while denying that such a claim is involved in this case.

In doing so, Justice HATHAWAY engages in a completely gratuitous assault on this
       10
          Berg, Hathaway attacks, Michigan Lawyers Weekly, October 27, 2008
(“‘People need to know what the law is,’ Hathaway said. ‘I believe in stare decisis.
Something must be drastically wrong for the court to overrule.’”); Lawyers’ election
guide: Judge Diane Marie Hathaway, Michigan Lawyers Weekly, October 30, 2006
(quoting Justice HATHAWAY, then running for a position on the Court of Appeals, as
saying that “[t]oo many appellate decisions are being decided by judicial activists who
are overturning precedent”).
       11
        See, e.g., Univ of Mich Regents v Titan Ins Co, ___ Mich ___, ___; ___ NW2d
___ (2010) (HATHAWAY, J., concurring).
       12
            Ante at ___ (opinion by HATHAWAY, J.).



                                             5
Court’s decision in Wickens v Oakwood Healthcare Sys.13 Wickens involved a claim for

the lost opportunity to survive, and it was brought by a living plaintiff—someone who

had not yet lost her opportunity to survive. No justice even contends that plaintiff in this

case has asserted a claim for the lost opportunity to survive, and therefore it is completely

unnecessary for Justice HATHAWAY to opine on whether the majority or dissent correctly

interpreted the question whether a living plaintiff could recover for the loss of an

opportunity to survive.

       Ordinarily, this fact would hinder any justice from engaging in a discussion on the

scope of a claim for the lost opportunity to survive that is not implicated in the case

before the Court. Justice HATHAWAY, though, is not constrained to consider only the

legal issues she claims are involved here because, consistent with the new majority’s

“agenda,”14 she has a desire to overrule in one fell swoop as many cases decided by the

“Republican-dominated court” as she can. Unfazed by the inconvenient fact that Wickens

is irrelevant to any question posed by this case, Justice HATHAWAY’s opinion observes

that it “agree[s] with Justice CAVANAGH’S partial dissent in Wickens . . . .”15 Such dicta

do not yet operate to overturn this Court’s decision in Wickens. Nevertheless, given that

Justice HATHAWAY is now the fourth sitting justice on this Court to support the partial




       13
            Wickens v Oakwood Healthcare Sys, 465 Mich 53; 631 NW2d 686 (2001).
       14
            See the text accompanying n 1 of this opinion.
       15
            Ante at ___ (opinion by HATHAWAY, J.).



                                              6
dissenting opinion in Wickens, it is safe to conclude that the majority opinion in Wickens

has, more probably than not, lost a substantial part of its opportunity to survive.16

       Finally, the new majority overrules the Court of Appeals decision in Fulton v

William Beaumont Hosp to the extent it is inconsistent with their opinions.17 However,

again, the new majority overreaches; Fulton applies only to lost opportunity cases, not to

traditional medical malpractice cases, and the new majority’s decision to convert claims

previously considered lost opportunity claims into traditional medical malpractice claims

serves to eliminate the application of Fulton. The new majority’s deliberate decision to

repudiate Fulton in this expansive manner, provides further support for my claim that it

now applies lost opportunity principles to all medical malpractice claims.

       For these reasons and more, I vigorously dissent. I believe that the new majority

has intentionally mischaracterized this as a “traditional” medical malpractice claim

because plaintiff’s expert testimony unquestionably established that the alleged

malpractice was not the “but for” cause of plaintiff’s injury. Were the new majority’s

characterization of this case as a traditional medical malpractice claim accurate, I would

affirm for failure of proofs. However, because I believe this to be a lost opportunity case,


       16
         One could read this dicta in Justice HATHAWAY’s opinion as a signal that the
new majority will overrule Wickens. However, the majority has already so signaled in its
order granting leave to appeal in Edry v Adelman, 485 Mich 901 (2009). Edry was
decided on narrow evidentiary grounds, Edry v Adelman, 486 Mich ___; ___ NW2d ___
(2010), but, as Justice HATHAWAY’s decision in this case exemplifies, its decision was
decidedly not a reaffirmation of the continued vitality of Wickens.
       17
            Fulton v William Beaumont Hosp, 253 Mich App 70; 655 NW2d 569 (2002).



                                              7
I would vacate as improvidently granted our September 30, 2009, order granting leave to

appeal.     I continue to adhere to the position stated in the lead opinion in Stone v

Williamson that the second sentence of MCL 600.2912a(2) codifying the lost opportunity

remedy is unenforceable as enacted.18 Because the Legislature has not clarified the

intention of its 1993 amendment of § 2912a(2), vacating the grant order is the most

appropriate course of action.

                          I. FACTS AND PROCEDURAL HISTORY

       Because none of the opinions that collectively create a majority elaborates on the

facts necessary to decide this case, I present the following complete recitation of the

pertinent facts and procedural history of this case.

       Plaintiff, Raymond O’Neal, suffers from sickle cell anemia, a genetic condition

that produces an increased amount of abnormally shaped red blood cells in his

bloodstream.19 In January 2003, plaintiff’s progressively worsening chest pain developed

into acute chest syndrome (ACS), a known complication of sickle cell anemia.20 To treat

ACS, a patient must undergo blood transfusions to reduce the amount of abnormal red

blood cells.       The difference between and effectiveness of two types of blood

transfusions—standard transfusions and exchange transfusions—is at issue in this case.

Standard transfusions add healthy red blood cells to the patient’s existing blood supply
       18
            Stone, 482 Mich at 144 (opinion by TAYLOR, C.J.).
       19
        Beers & Berkow, eds, The Merck Manual of Diagnosis and Therapy (17th ed)
(Whitehouse Station, NJ: Merck & Co, Inc, 1999), pp 877-878.
       20
            Id. at 879.



                                              8
and thereby reduce the patient’s percentage of abnormal red blood cells. Exchange

transfusions are more complicated, but they also more aggressively treat the blood

abnormality because they physically remove existing abnormal red blood cells and

replace them with healthy red blood cells.

       On January 23 through 24, 2003, plaintiff received a standard transfusion of three

units of blood cells. He received two additional units of blood cells in another standard

transfusion on January 28, 2003. Plaintiff suffered a stroke on the right side of his brain

on February 1, 2003. Plaintiff received a third transfusion—an exchange transfusion—on

February 2 through 3, 2003. Plaintiff’s condition stabilized after this final transfusion,

but he alleged permanent injury as a result of the stroke, including partial paralysis of his

left leg and loss of function of his left hand and arm.

       Plaintiff filed the instant medical malpractice complaint, alleging that defendants

failed to comply with the appropriate standard of care, which required them to “arrange

for exchange transfusions” to treat plaintiff’s ACS on or before January 28, 2003. He

also alleged that “[p]erformance of [an] exchange transfusion prior to the . . . stroke

would have prevented the stroke from occurring.”

       Plaintiff retained and deposed three expert witnesses to testify on his behalf on the

issue of causation. Dr. John Luce, a pulmonary care specialist, testified that reducing

plaintiff’s abnormal hemoglobin count to under 30 percent would have made it “probable

that he would not have” suffered the stroke, although he acknowledged that plaintiff still

could have suffered the stroke even with such a reduced abnormal hemoglobin count.

Because no data existed on the frequency of strokes in adult sickle cell patients, Dr.


                                              9
Richard Stein, a hematologist, extrapolated from existing data on the effects of aggressive

transfusion therapy on children with sickle cell disease. He testified that “more likely

than not” plaintiff would have avoided a stroke if he had received aggressive transfusion

therapy, what plaintiff alleged is the appropriate standard of care. Dr. Griffin Rodgers,

also a hematologist, provided the most detailed testimony regarding the causal

relationships between the stroke, plaintiff’s underlying medical condition, and

defendants’ alleged malpractice. He explained that sickle cell patients generally have a

baseline risk of stroke that is significantly higher than the average population. Moreover,

plaintiff’s ACS further increased his baseline risk of stroke to between 10 and 20 percent.

Dr. Rodgers testified that, with aggressive transfusion therapy, the plaintiff’s risk of

stroke would have “been cut in half,” that is, to between 5 and 10 percent. Stated

otherwise, plaintiff’s opportunity to avoid a stroke would have been between 90 and 95

percent with aggressive transfusion therapy, but it was reduced to between 80 and 90

percent without aggressive transfusion therapy. Thus, under either treatment regime,

plaintiff’s experts testified that it was more likely than not that plaintiff would avoid a

stroke.

          Defendants moved for summary disposition, arguing that Dr. Rodgers’s testimony

regarding plaintiff’s lost opportunity to avoid a stroke failed to satisfy the requirement of

MCL 600.2912a(2)21 and Fulton v William Beaumont Hosp,22 that the opportunity to

          21
         MCL 600.2912a(2) provides, in pertinent part: “In an action alleging medical
malpractice, the plaintiff cannot recover for loss of an opportunity to survive or an
opportunity to achieve a better result unless the opportunity was greater than 50%.”



                                             10
achieve a better result must decrease by more than 50 percentage points. The trial court

denied defendants’ motion, noting that defendants “[didn’t] have a clue about what

[Fulton] says.”

       After the Court of Appeals denied defendants’ interlocutory application for leave

to appeal, in lieu of granting leave to appeal, we remanded this case to the Court of

Appeals for consideration as on leave granted.23 On remand, the Court of Appeals

reversed the trial court’s denial of summary disposition in an unpublished opinion per

curiam.24 The majority opinion held that plaintiff’s claim was a lost opportunity claim,

that Fulton required the loss of opportunity to be greater than 50 percentage points, and

that the loss of opportunity here was, at most, 15 percentage points. The concurring

opinion concluded that plaintiff also failed to present sufficient evidence of proximate

causation because his “preexisting medical condition” precluded him from satisfying “his

burden of establishing the existence of a genuine factual dispute concerning whether

defendants’ alleged professional negligence ‘more probably tha[n] not’ proximately

caused his stroke.”25

       We granted leave to appeal and directed the parties to brief:



       22
            Fulton v William Beaumont Hosp, 253 Mich App 70; 655 NW2d 569 (2002).
       23
            O’Neal v St John Hosp & Med Ctr, 477 Mich 1087 (2007).
       24
        O’Neal v St John Hosp & Med Ctr, unpublished opinion per curiam of the Court
of Appeals, issued November 4, 2008 (Docket Nos. 277317 and 277318).
       25
            Id. at 2 (JANSEN, J., concurring).



                                                 11
             (1) whether the requirements set forth in the second sentence of
      MCL 600.2912a(2) apply in this case; (2) if not, whether the plaintiff
      presented sufficient evidence to create a genuine issue of fact with regard to
      whether the defendants’ conduct proximately caused his injury; or (3) if so,
      whether Fulton v William Beaumont Hosp, 253 Mich App 70 (2002), was
      correctly decided, or whether a different approach is required to correctly
      implement the second sentence of § 2912a(2).[26]

                              II. LEGAL BACKGROUND

      The lead opinion in Stone aptly summarized the pertinent legal background

relevant to this case, including the distinction between traditional malpractice claims and

lost opportunity claims that the majority now eviscerates:

             In the first Michigan case to refer to the legal theory of “the value of
      lost chance,” the Court of Appeals explained: “This theory is potentially
      available in situations where a plaintiff cannot prove that a defendant’s
      actions were the cause of his injuries, but can prove that the defendant’s
      actions deprived him of a chance to avoid those injuries.” Vitale v Reddy,
      150 Mich App 492, 502; 389 NW2d 456 (1986). The Court in Vitale noted
      that allowing such claims would expand existing common law, and it
      declined to do so, stating that such a decision “is best left to either the
      Supreme Court or the Legislature.” Id. at 504. . . .

              In accord with this analysis, this Court has stated: “The lost
      opportunity doctrine allows a plaintiff to recover when the defendant’s
      negligence possibly, i.e., [by] a probability of fifty percent or less, caused
      the plaintiff’s injury.” Weymers v Khera, 454 Mich 639, 648; 563 NW2d
      647 (1997) (emphasis added). The Weymers Court aptly described the lost-
      opportunity doctrine as “the antithesis of proximate cause.” Id. In cases in
      which the plaintiff alleges that the defendant’s negligence more probably
      than not caused the injury, the claim is one of simple medical malpractice.
      Id. at 647-648.

             In Falcon v Mem Hosp, 436 Mich 443; 462 NW2d 44 (1990), this
      Court first recognized a claim for lost opportunity to survive. Falcon was a
      wrongful-death case in which this Court allowed a claim to go forward

      26
           O’Neal v St John Hosp & Med Ctr, 485 Mich 901 (2009).



                                            12
even though the plaintiff’s granddaughter would have had only a 37.5
percent chance of surviving a medical accident had she received proper
care. Because proper medical procedures had not been followed, the
granddaughter’s chance of surviving the accident went to essentially zero.
The lead opinion in Falcon admitted that the plaintiff could not show that
the malpractice had more likely than not caused her granddaughter’s death,
but could show that it had caused her granddaughter to lose a “substantial
opportunity of avoiding physical harm.” Id. at 470 (LEVIN, J.). The lead
opinion disavowed the traditional rule that requires a plaintiff to show that,
but for the defendant’s negligence, the patient would not have suffered the
physical harm, saying that the “more probable than not standard, as well as
other standards of causation, are analytic devices—tools to be used in
making causation judgments.” Id. at 451. Instead, despite the fact that the
plaintiff could not show that the doctor’s malpractice had more probably
than not caused her granddaughter’s death, the plaintiff had a claim because
the malpractice did cause her granddaughter harm. The 37.5 percent
chance for a better outcome was “hardly the kind of opportunity that any of
us would willingly allow our health care providers to ignore.” Id. at 460.
This harm occurred before the granddaughter’s death, at the moment
“[w]hen, by reason of the failure to implement [certain] procedures,” she
was denied any opportunity of living. Id. at 469, 471 n 44. The lead
opinion characterized its holding as requiring the plaintiff to show, more
probably than not, that the malpractice reduced the opportunity of avoiding
harm: “failure to protect [the granddaughter’s] opportunity of living.” Id. at
469. Loss of her 37.5 percent opportunity of living, the lead opinion stated,
“constitutes a loss of a substantial opportunity of avoiding physical harm.”
Id. at 470.

        The lead opinion in Falcon thus concluded that the loss-of-
opportunity claim accrued not when the patient died, but at the moment she
went from having a 37.5 [percent] chance of survival to having no chance
of survival. Under this theory, a plaintiff would have a cause of action
independent of that for the physical injury and could recover for the
malpractice that caused the plaintiff to go from a class of patients having a
“good chance” to one having a “bad chance.” Without this analysis, the
plaintiff in Falcon would not have had a viable claim because it could not
have been shown that the defendant more probably than not caused the
physical injury. Until Falcon, medical-malpractice plaintiffs alleging that
the defendant’s act or omission hastened or worsened the injury (such as by
failing to diagnose a condition) had to prove that the defendant’s
malpractice more probably than not was the proximate cause of the injury.
See, e.g., Morgan v Taylor, 434 Mich 180; 451 NW2d 852 (1990);



                                     13
Naccarato v Grob, 384 Mich 248, 252; 180 NW2d 788 (1970); Skeffington
v Bradley, 366 Mich 552; 115 NW2d 303 (1962).

       When the Court decided Falcon, MCL 600.2912a read:

       “In an action alleging malpractice the plaintiff shall have the burden
of proving that in light of the state of the art existing at the time of the
alleged malpractice:

        “(a) The defendant, if a general practitioner, failed to provide the
plaintiff the recognized standard of acceptable professional practice in the
community in which the defendant practices or in a similar community, and
that as a proximate result of the defendant failing to provide that standard,
the plaintiff suffered an injury.

        “(b) The defendant, if a specialist, failed to provide the recognized
standard of care within that specialty as reasonably applied in light of the
facilities available in the community or other facilities reasonably available
under the circumstances, and as a proximate result of the defendant failing
to provide that standard, the plaintiff suffered an injury.”

        Three years after Falcon, the Legislature enacted 1993 PA 78,
amending MCL 600.2912a to add the second subsection. In its entirety, the
statute as amended reads:

        “(1) Subject to subsection (2), in an action alleging malpractice, the
plaintiff has the burden of proving that in light of the state of the art
existing at the time of the alleged malpractice:

        “(a) The defendant, if a general practitioner, failed to provide the
plaintiff the recognized standard of acceptable professional practice or care
in the community in which the defendant practices or in a similar
community, and that as a proximate result of the defendant failing to
provide that standard, the plaintiff suffered an injury.

        “(b) The defendant, if a specialist, failed to provide the recognized
standard of practice or care within that specialty as reasonably applied in
light of the facilities available in the community or other facilities
reasonably available under the circumstances, and as a proximate result of
the defendant failing to provide that standard, the plaintiff suffered an
injury.




                                     14
             “(2) In an action alleging medical malpractice, the plaintiff has the
      burden of proving that he or she suffered an injury that more probably than
      not was proximately caused by the negligence of the defendant or
      defendants. In an action alleging medical malpractice, the plaintiff cannot
      recover for loss of an opportunity to survive or an opportunity to achieve a
      better result unless the opportunity was greater than 50%.” [New language
      emphasized.]

             As can be seen, the Legislature retained the already-existing
      language, making it subsection 1 of the statute. Both subsection 1(a) and
      subsection 1(b) require the plaintiff to show that, “as a proximate result of
      the defendant failing to provide [the appropriate standard of practice or
      care], the plaintiff suffered an injury.” Further, the Legislature added
      subsection 2. Specifically, the first sentence of this new subsection codifies
      and reiterates the common-law requirement that a plaintiff show that the
      defendant’s malpractice more probably than not caused the plaintiff’s
      injury. The second sentence of subsection 2 adds that, in medical-
      malpractice cases, a “plaintiff cannot recover for loss of an opportunity to
      survive or an opportunity to achieve a better result unless the opportunity
      was greater than 50%.” However, one must keep in mind that the relevant
      caselaw when subsection 2 was enacted held that the lost-opportunity
      doctrine applies “in situations where a plaintiff cannot prove that a
      defendant’s actions were the cause of his injuries . . . .” Vitale, [150 Mich
      App] at 502 (emphasis added). That is, the first sentence of subsection 2
      requires plaintiffs in every medical-malpractice case to show the
      defendant’s malpractice proximately caused the injury while, at the same
      time, the second sentence refers to cases in which such proof not only is
      unnecessary, but is impossible.[27]

      Thus, in contrast with traditional malpractice claims, the very nature of the lost

opportunity doctrine allows a plaintiff to recover in the absence of proximate causation

between the alleged malpractice and the physical injury suffered. The lead opinion in

Stone determined that “the two sentences of subsection 2 create a paradox, allowing




      27
           Stone, 482 Mich at 152-157 (opinion by TAYLOR, C.J.).



                                           15
claims in the second sentence while precluding them by the first sentence.”28 In this case,

Justice HATHAWAY’s opinion and Justice CAVANAGH’s concurring opinion altogether

avoid the implications of this paradox by essentially applying the lost opportunity

analysis (which never required “but for” causation) to a traditional medical malpractice

claim that, until today, always required “but for” causation. In doing so, the new

majority radically alters proximate causation doctrine by casting aside the traditional

component of “but for” causation and by replacing causation of the injury with

consideration only of the increased risk of the injury. This is a revolutionary change in

our law and represents a change that not even the Falcon Court dared to make.

       A necessary component of proximate causation is “but for” causation, or causation

in fact.29 As this Court has previously held:

              As a matter of logic, a court must find that the defendant’s
       negligence was a cause in fact of the plaintiff’s injuries before it can hold
       that the defendant’s negligence was the proximate or legal cause of those
       injuries.

              Generally, an act or omission is a cause in fact of an injury only if
       the injury could not have occurred without (or “but for”) that act or
       omission. While a plaintiff need not prove that an act or omission was the
       sole catalyst for his injuries, he must introduce evidence permitting the jury
       to conclude that the act or omission was a cause.

             It is important to bear in mind that a plaintiff cannot satisfy this
       burden by showing only that the defendant may have caused his injuries.
       Our case law requires more than a mere possibility or a plausible

       28
            Id. at 157.
       29
        Weymers v Khera, 454 Mich 639, 647; 563 NW2d 647 (1997), citing Skinner,
445 Mich at 162-163.



                                            16
      explanation. Rather, a plaintiff establishes that the defendant’s conduct was
      a cause in fact of his injuries only if he “set[s] forth specific facts that
      would support a reasonable inference of a logical sequence of cause and
      effect.”[30]

      As Justice CAVANAGH has himself previously concluded, plaintiffs must present

evidence of proximate causation that “‘must exclude other reasonable hypotheses with a

fair amount of certainty.’”31 By allowing plaintiff’s claim to proceed as a traditional

medical malpractice claim, the new majority today eviscerates the distinction between the

weaker causation allowed in lost opportunity claims and the “but for” causation that has

always been required in traditional medical malpractice claims.

                                   III. APPLICATION

          A. PLAINTIFF ASSERTED A LOST OPPORTUNITY CLAIM
       BECAUSE THERE IS NO “BUT FOR” CAUSATION BETWEEN THE
      ALLEGED MALPRACTICE AND THE PHYSICAL INJURY SUFFERED.

      As stated, the crux of a lost opportunity claim is that a plaintiff cannot show that,

more probably than not, the alleged malpractice proximately caused his injuries. This is

because a plaintiff need only show that the alleged malpractice merely reduced his

opportunity to achieve a better result. Accordingly, whether a claim is a traditional

malpractice claim or a claim for the loss of an opportunity to achieve a better result

depends on whether the alleged malpractice proximately caused the alleged injury.




      30
          Craig v Oakwood Hosp, 471 Mich 67, 87; 684 NW2d 296 (2004), quoting
Skinner, 445 Mich at 174.
      31
           Skinner, 445 Mich at 166 (CAVANAGH, C.J.) (citation omitted).



                                            17
       Contrary to the new majority’s position, this case presents a prototypical lost

opportunity claim because no proximate causation exists between the alleged malpractice

and plaintiff’s physical injury. Plaintiff’s experts testified that plaintiff’s underlying

medical condition—sickle cell anemia complicated by ACS—increased his risk of stroke

above that of a healthy person and even above that of a sickle cell patient who has not

developed ACS. Plaintiff’s underlying medical condition created a heightened chance of

suffering a stroke, with or without the alleged malpractice. As Dr. Rogers, who provided

the most detail of plaintiff’s causation experts, testified, plaintiff would have had a 5 to

10 percent chance of suffering a stroke even if he had been treated according to the

plaintiff’s proposed standard of care.

       The evidence here, therefore, does not “‘exclude other reasonable hypotheses

[of the cause of injury] with a fair amount of certainty,’”32 as is required to prove “but

for” causation in a traditional medical malpractice action. Plaintiff’s expert testified that,

in the absence of the alleged medical malpractice, plaintiff had between a 90 percent and

95 percent chance of avoiding a stroke.         The alleged medical malpractice reduced

plaintiff’s chance of avoiding a stroke to between 80 percent and 90 percent. Even

looking at the evidence in the light most favorable to the plaintiff, there is no basis for a

fact-finder to conclude that defendants’ actions more probably than not caused plaintiff’s

injury. But this is unimportant because the new majority now only requires causation for

the increased risk of injury.

       32
            Id. (emphasis added).



                                             18
         Simply stated, the plaintiff has not asserted, and neither Justice HATHAWAY’s

opinion nor Justice CAVANAGH’s concurring opinion assert—that the alleged medical

malpractice increased his chance of suffering a stroke by the more than 50 percentage

points required to prove proximate causation.33 This fact irrefutably establishes that

the plaintiff asserts a lost opportunity claim, not a traditional medical malpractice

claim.

 B. THE CONCLUSION THAT PLAINTIFF HAS ASSERTED A TRADITIONAL
MEDICAL MALPRACTICE CLAIM AND HAS SATISFIED THE REQUIREMENTS
     OF “BUT FOR” CAUSATION IS A DANGEROUS DEPARTURE FROM
              TRADITIONAL CAUSATION REQUIREMENTS.

         As stated, in determining that plaintiff’s claim is a traditional medical malpractice

claim, the new majority today applies relaxed causation rules that previously had applied

only to lost opportunity claims—claims involving an increased risk of injury that did not

rise to the level of proximate causation. These relaxed rules are inconsistent with the

position that three of the justices of the new majority have taken previously on what

evidence is required for a plaintiff to prove a traditional medical malpractice claim.34

Such claims have always required “but for” causation. After today’s shift, therefore, all


         33
         See Falcon v Mem Hosp, 436 Mich 443, 450; 462 NW2d 44 (1990) (opinion by
LEVIN, J.) (characterizing the traditional approach to “but for” causation as “measured as
more than fifty percent” and concluding that a 37.5 percentage point reduction in the
opportunity for surviving could not prove “but for” causation). Thus no one, not even
those in the Falcon decision who created an exception, has ever required less than a
“more than 50 percentage point” change in order to establish a traditional medical
malpractice claim. Just two years ago, Justices CAVANAGH, WEAVER, and KELLY
reaffirmed this position. See Stone, 482 Mich at 175-177 (opinion by CAVANAGH, J.).
         34
              See id.



                                              19
malpractice claims will be established using principles that could only have applied to

lost opportunity claims. Few can miss how significant a departure this is from all of this

Court’s medical malpractice jurisprudence that preceded this case.

  1. THREE JUSTICES TODAY REPUDIATE THE TRADITIONAL CAUSATION
       PRINCIPLES THAT THEY REAFFIRMED JUST TWO YEARS AGO.

       The new majority appears to be of the view that the less said about its radical

rewriting of this statute the better.    When a judge is “doing” policy rather than

interpreting the law, it is apparently not required to maintain a consistent position or

explain a fundamental change in position. Certainly, such disclosures are probably not

desired by jurists whose positions are undergoing radical “revision.” I commend the

reader to compare the positions taken today by Chief Justice KELLY and Justices

CAVANAGH and WEAVER with those taken just two years ago in Stone.35 These three

justices now repudiate the traditional proximate cause requirements that they previously

recognized and applied at that time.

       In Stone, Justice CAVANAGH, writing for himself and Justices KELLY and

WEAVER, held that a traditional medical malpractice action required “but for” causation.

He specifically posed a hypothetical example in which a plaintiff’s opportunity to achieve

a better result was reduced by 40 percentage points, from 80 percent to 40 percent. Thus,

this hypothetical plaintiff’s risk of suffering a bad result increased from 20 percent to 60

percent as a result of the alleged medical malpractice. According to Justice CAVANAGH

       35
         See id. Justice CAVANAGH at least has the forthrightness to indicate that he
today repudiates this position. Ante at ___ (CAVANAGH, J., concurring).



                                            20
just two years ago, this hypothetical plaintiff “could not meet the more-probably-than-not

standard of causation . . . .”36 Today these same three justices declare that a much

smaller reduction in the opportunity to achieve a better result—from 90 to 95 percent to

80 to 90 percent—now satisfies the causation standard of a traditional malpractice case.

This is not a product of the rule of law. This is a naked display of judicial whimsy and

aggressive policy-making.

   2. JUSTICE HATHAWAY’S OPINION MISREADS CASELAW TO REDEFINE
       PROXIMATE CAUSE AND TO DO AWAY WITH THE TRADITIONAL
   REQUIREMENT THAT A PLAINTIFF PROVE A “BUT FOR” CAUSE UNDER
               THE MORE-PROBABLE-THAN-NOT STANDARD

       Justice HATHAWAY’s opinion places much emphasis on the fact that our caselaw

indicates that “a plaintiff need not prove that an act or omission was the sole catalyst for

his injuries,”37 in recognition that any given injury may have more than one proximate

cause. It then uses this fact of logic and causation to create a false distinction that

radically refashions proximate causation and negates the traditional requirement—as

previously articulated even by Justice CAVANAGH—that proof of “but for” causation

must “exclude other reasonable hypotheses with a fair amount of certainty.”38

       The proposition that any injury may have more than one proximate cause is an

unremarkable one for anyone who understands the principles of “but for” causation. An


       36
            Stone, 482 Mich at 177 (opinion by CAVANAGH, J.).
       37
            Craig, 471 Mich at 87.
       38
            Skinner, 445 Mich at 166 (emphasis added; quotation marks and citation
omitted).



                                            21
injury that involves a series of individual occurrences before it is manifested will have

multiple “but for” causes. However, in such a case, each of these causes must be

proved to have produced the injury under the more-probable-than-not standard, not

merely proved to have increased the risk of injury, as this case does.

       One of this Court’s cases on traditional causation, Brackins v Olympia, Inc,

illustrates this point.39 The plaintiff, a roller skating instructor, fell while roller skating at

the defendant’s rink. He alleged that another skater had clipped his right skate and that,

“as a result his skates became locked with his right foot and skate behind his left skate.”40

Furthermore, the plaintiff claimed that he could not have prevented the fall “because his

left skate struck a ridge or inequality in the floor of the rink . . . .”41 The defendant rink

owner sought summary disposition because it claimed that the proximate cause of the

plaintiff’s injury was the other skater clipping the plaintiff’s skate, not the flaw in the rink

surface. To be sure, the other skater’s action was a “but for” cause of the plaintiff’s

injury, as the injury would not have occurred without it. However, this Court concluded

that the skating rink surface was also a proximate cause of the plaintiff’s injury:

               Defendant is not absolved from liability for its negligence because of
       the act of the other skater . . . . The proofs support the conclusion . . . that
       plaintiff fell because of the roughness of, or the inequality in, the floor of
       the skating rink. Defendant’s negligence, if not the sole proximate cause of
       the accident, was, in any event, a proximate cause.[42]
       39
            Brackins v Olympia, Inc, 316 Mich 275; 25 NW2d 197 (1946).
       40
            Id. at 277.
       41
            Id.
       42
            Id. at 283 (emphasis added).


                                               22
Each of the “but for” causes in Brackins could be proved with near certainty.

Accordingly, the Brackins Court concluded that both “but for” causes more probably than

not directly caused the plaintiff’s injury, and therefore it affirmed the jury’s award of

damages to the plaintiff against the defendant. Nevertheless, in recognizing that an

injury may have more than one “but for” cause, this Court has always, until now,

required the traditional burden of proving that each particular “but for” cause more

probably than not produced the injury.43

       The dual “but for” causes in Brackins are very different from the situation in the

instant case. Here, all that plaintiff can show is that defendants’ alleged malpractice

exacerbated plaintiff’s preexisting sickle cell anemia to the extent of increasing his risk of


       43
           Justice HATHAWAY claims that this position “would allow recourse for the
negligent actions of medical providers only in those instances in which one provider’s
conduct is at issue and only when no preexisting medical condition exists.” Ante at ___
(opinion by HATHAWAY, J.). This is patently false. First, as stated, there can be multiple
“but for” causes for a particular injury, including the negligent conduct of multiple
medical providers. Each of these hypothetical negligent acts, however, must themselves
be “but for” causes, like the chain reaction of events that caused the roller skating injury
in Brackins. Second, a medical provider’s negligence may, more probably than not, be a
“but for” cause of an injury even when the plaintiff has a preexisting condition. This was
the very situation that this Court encountered in Stone. The plaintiff in Stone alleged that
a timely diagnosis of an aortic aneurysm would have given him a 95 percent chance of
attaining a good result. Instead, his aneurysm ruptured, requiring emergency surgery and
ultimately amputation of his legs. According to the plaintiff’s experts, “misdiagnosed
patients whose aneurysms rupture have only a 10 percent chance to achieve a good
result.” Stone, 482 Mich at 148 (opinion by TAYLOR, C.J.). Thus, even though the
plaintiff had a preexisting medical condition, the defendants’ misconduct increased the
plaintiff’s probability of suffering a bad result from 5 percent to 90 percent. This
increase of 85 percentage points provided a sufficient factual basis to defeat the
defendant’s motion for judgment notwithstanding the verdict.



                                             23
suffering a stroke by between 5 and 10 percentage points. Plaintiff has simply not proved

that the alleged malpractice caused his stroke, nor has he “exclude[d]” the “other

reasonable hypothes[i]s”—his preexisting sickle cell anemia—“with a fair amount of

certainty.”44 Thus, plaintiff’s preexisting sickle cell anemia could well have operated to

injure him even in the absence of defendants’ alleged malpractice.

   3. JUSTICE HATHAWAY’S AND JUSTICE CAVANAGH’S OPINIONS TAKE
    INAPPROPRIATE LIBERTIES WITH PLAINTIFF’S EXPERT STATISTICAL
           EVIDENCE BY FAILING TO COMPARE LIKE WITH LIKE

       Even in applying their radical new approach to proximate causation, the justices in

the new majority only reach their desired result by manipulating the expert’s statistical

evidence in ways inconsistent with the expert’s own use of the statistical evidence and,

similarly, in ways inconsistent with the uncontroversial and essential principle of

statistical methodology of comparing “like with like.” The new majority’s inappropriate

use of the statistical evidence presented in this case provides further proof that it is

engaging in result-driven jurisprudence. Only this motivation could support such a

mathematically illiterate presentation.

       Justice HATHAWAY’s opinion declares, under the guise of requiring “results [to] be

viewed in the light most favorable to the nonmoving party,”45 that any mishmash of

figures that yields a result of greater than 50 percent will establish proximate causation

between the alleged malpractice and plaintiff’s injury sufficient to defeat summary

       44
            Skinner, 445 Mich at 166 (quotation marks and citation omitted).
       45
            Ante at ___ (opinion by HATHAWAY, J.).



                                             24
disposition. Thus, while Justice HATHAWAY’s opinion expressly declines to adopt any

particular mathematical formula for determining whether proximate cause exists in a

given case, it essentially adopts every formula that an attorney or judge can manufacture.

This is not a serious analysis—“statistical” or otherwise. Justice HATHAWAY’s opinion is

simply an invitation for the artful manipulation of probability figures and calls to mind

the adage Mark Twain once attributed to Benjamin Disraeli, that there are “three kinds of

lies: lies, damned lies, and statistics.”46

       Two of the formulas that Justice HATHAWAY’s opinion identifies by name bear

closer analysis. Her opinion indicates that the evidence in this case can be “viewed as a

standard percentage increase calculation. . . .”47       The flaw in using this “standard

percentage increase calculation” in a traditional medical malpractice case is obvious.

Such a calculation would turn the facts of Falcon—a case in which no justice

believed that the plaintiff could prove “but for” causation using a more-probable-

than-not standard48—into a traditional medical malpractice case.



       46
         Twain, My Autobiography: “Chapters” from the North American Review
(Mineola, NY: Dover Publications, Inc, 1999), p 208.
       47
            Ante at ___ (opinion by HATHAWAY, J.).
       48
           Falcon, 436 Mich at 460 (opinion by LEVIN, J.) (“[I]t cannot be said, more
probably than not, that [defendant] caused [plaintiff’s] death.”); id. at 472-473 (BOYLE,
J., concurring) (“I concur in the recognition of ‘lost opportunity to survive’ as injury for
which tort law should allow recovery in proportion to the extent of the lost chance of
survival . . . provided that the negligence of the defendant more probably than not caused
the loss of opportunity.”); id. at 473 (RILEY, C.J., dissenting) (“[I]t is uncontested that the
plaintiff cannot show that defendant’s negligence caused the decedent’s death . . . .”).



                                              25
       In Falcon, the plaintiff’s decedent, Nena Falcon, suffered an amniotic fluid

embolism, “an unpreventable complication” of childbirth.49 A woman who suffers this

complication has a 62.5 percent probability of dying, even if it is treated immediately.

Because of alleged malpractice, however, Nena Falcon’s amniotic fluid embolism was

not treated immediately. This alleged malpractice increased her chance of death to 100

percent.50     Under the “standard percentage increase calculation” used by Justice

HATHAWAY to support her radical departure from requiring traditional proximate

causation in this case, the defendant’s alleged malpractice in Falcon was responsible for

increasing Nena Falcon’s chance of dying by 37.5 percentage points over the preexisting

62.5 percentage point chance of dying. This represents a 60 percent increase in her

chance of dying (37.5/62.5), and satisfies Justice HATHAWAY’s conclusion that any

formula that reaches the magic number of more than 50 percent is satisfactory. Justice

HATHAWAY’s opinion has, therefore, taken a judicially created aberration of proximate

causation, Falcon, and applied it so that she can satisfy the proximate cause component

of a traditional medical malpractice claim. Fortunately, Justice HATHAWAY’s opinion is

the only opinion that adopts this approach, so this “standard percentage increase

calculation” does not, therefore, have support from a majority of this Court.

       However, a second approach used by Justice HATHAWAY that I wish to discuss

does appear to have the support from a majority of this Court—what Justice HATHAWAY

       49
            Falcon, 436 Mich at 454 (opinion by LEVIN, J.).
       50
            Id. at 454 n 16.



                                             26
calls the “standard percentage decrease calculation.”51 This approach takes the pre- and

postmalpractice probabilities of suffering the injury and calculates what proportion of the

postmalpractice probability of injury is attributable to the malpractice. The percentage

approach is found nowhere in this Court’s proximate cause jurisprudence, yet both

Justice HATHAWAY’s opinion and Justice CAVANAGH’s concurring opinion apply it to

conclude that plaintiff has made the requisite showing of probable cause to defeat

defendant’s motion for summary disposition.

      As stated, three of the justices who support this approach do so in opposition to

their previously stated positions.52 Moreover, Justice HATHAWAY’s opinion and Justice



      51
           Ante at ___ (opinion by HATHAWAY, J.).
      52
          Under the hypothetical example Justice CAVANAGH posed in Stone, a plaintiff
whose risk of suffering a bad result increases from 20 percent to 60 percent is unable to
prove causation under the more-probable-than-not standard. This is because the
plaintiff’s risk has not increased by the more than 50 percentage points traditionally
required to prove “but for” causation. Justice CAVANAGH applies a very different
approach today, and, under that approach, his hypothetical Stone plaintiff would be able
to prove causation. Whatever innocence Justice CAVANAGH now feigns in treating both
that hypothetical case and the instant case as traditional medical malpractice cases, he is
unequivocally converting what used to be a lost opportunity case into a traditional
medical malpractice case.

        A plaintiff who has a preexisting medical condition is only able to prove “but for”
causation when the alleged malpractice increases the plaintiff’s risk of suffering a “bad
result” by more than 50 percentage points. Otherwise, there is no way to exclude, as
Justice CAVANAGH (and this Court) has previously required, all “other reasonable
hypotheses with a fair amount of certainty.” Skinner, 445 Mich at 166 (quotation marks
and citation omitted). The approach adopted by the opinions of Justices HATHAWAY and
CAVANAGH negates this basic requirement of proximate cause and would allow a
plaintiff to recover for a bad result even in situations in which other, nonmalpractice
“causes” for the result predominated in creating it.



                                            27
CAVANAGH’s concurring opinion apply the new standard in an especially troubling

fashion. It is a truism in statistical methodology that one marshaling statistical evidence

to support causation must apply the principle of ceteris paribus by “comparing like with

like.”53 The new majority violates this basic principle of statistical analysis to reach its

desired result. The expert testimony indicated that plaintiff’s chance of suffering a stroke

would have been reduced from the range of 10 to 20 percent to the range of 5 to 10

percent if plaintiff had been treated according to the asserted standard of care.            In


       The new majority’s approach would allow a plaintiff to recover in full from a
doctor who, for example, failed to diagnose cancer at its earliest stages, but still
diagnosed it at a stage where it was much more probable than not that a patient would
survive. To put figures on this situation, suppose a plaintiff's risk of dying from cancer is
1 percent if it is caught at its earliest stages. A doctor who fails to catch the cancer at that
stage, but who catches it and treats it at a stage where the risk of dying from cancer is 3
percent, then, is liable, under the new majority’s new approach, for the entire injury,
should one occur, because the failure to diagnose contributed to 2/3 of the risk of injury.
This is true, according to the new majority, even though the doctor only decreased the
patient's chance of surviving by 2 percentage points, from 99 percent to 97 percent.

        By shifting many lost opportunity claims into traditional medical malpractice
claims, the new majority creates additional liability of a defendant for the entire injury,
not just for the increased risk of injury, as lost opportunity claims provide. See Falcon,
436 Mich at 471 (opinion by LEVIN, J.) (“In this case, 37.5 percent times the damages
recoverable for wrongful death would be an appropriate measure of damages.”). This
shift in determining a defendant’s liability is essential to understanding what the new
majority is trying to accomplish in this case. Now plaintiffs need only prove that a
doctor’s negligence contributed to the risk of injury, not that his negligence actually
caused the injury. And no amount of pretended ignorance about the significance of these
changes by members of the new majority alters their fundamental and radical impact on
this area of the law.
       53
          See Lewis-Beck, Bryman, & Liao, eds, 1 The SAGE Encyclopedia of Social
Science Research Methods (Thousand Oaks, Cal: SAGE Publications, Inc, 2004), p 117
(“Ceteris paribus . . . refers to the process of comparing like with like when asserting a
causal relationship or the effect of one variable on another.”).



                                              28
clarifying these statistical ranges, the expert concluded that plaintiff’s likelihood of

suffering a stroke would have been “cut in half” under the standard of care urged by

plaintiff. In other words, the upper end of the range of plaintiff’s likelihood of suffering a

stroke was “cut in half,” from 20 percent to 10 percent, and the lower end of that range

was also “cut in half,” from 10 percent to 5 percent. Rather than comparing like with

like—the lower end of each range or the upper end of each range—a majority of this

Court fallaciously compares the lower end of one range (5 percent) with the upper end of

the other (20 percent). They do so in order to conclude that the alleged malpractice

caused 75 percent of plaintiff’s chance of suffering a stroke (15/20).54 This failure to

“compare like with like” is a patent error of statistical analysis, but it gets the majority

where it needs to go to support its conclusion that plaintiff has established “but for”

cause.

         Finally, Justice HATHAWAY’s opinion concludes that “plaintiff established a

question of fact on the issue of proximate causation because plaintiff’s experts opined

that defendants’ negligence more probably than not was the proximate cause of the

plaintiff’s injuries.”55 This statement might have had more relevance if it had been


         54
          The new majority calculates that defendants’ alleged malpractice caused an
increase in plaintiff’s risk of suffering a stroke by 15 percentage points (5 percent risk
without malpractice subtracted from 20 percent risk with malpractice). They then divide
that figure by plaintiff’s 20 percent risk of a stroke with malpractice to conclude that the
alleged malpractice caused 75 percent of plaintiff’s chance of suffering a stroke. See
ante at ___ (opinion by HATHAWAY, J.); ante at ___ (CAVANAGH, J., concurring).
         55
              Ante at ___ (opinion by HATHAWAY, J.).



                                              29
supported by the experts’ actual statistical evidence of plaintiff’s chances of suffering the

stroke. However, as discussed above, plaintiff’s experts were unable to show proximate

causation between the alleged malpractice and plaintiff’s stroke. All they were able to

show was a connection between the alleged malpractice and plaintiff’s increased

likelihood of suffering a stroke, from between 5 to 10 percent to between 10 to 20

percent. Justice HATHAWAY’s analysis, such as it is, allows an expert to say certain

“magic words” about proximate causation, while presenting statistical evidence to the

contrary.

       As stated, this case is a prototypical lost opportunity case because plaintiff cannot

establish that, more probably than not, defendants proximately caused his stroke because

he was predisposed to suffer one, his risk being in the range of 5 to 10 percent, even with

medical care that satisfied plaintiff’s proposed standard of care.          Accordingly, I

vigorously dissent from the conclusion of a majority of this Court that plaintiff asserted a

traditional medical malpractice claim and would instead conclude that plaintiff asserted a

lost opportunity claim.

         C. MCL 600.2912a(2) IS (STILL) UNENFORCEABLE AS ENACTED

       Because the new majority concludes that plaintiff’s claim is a traditional medical

malpractice claim, it does not need to reach the question whether plaintiff’s claim meets

the requirements of the second sentence of MCL 600.2912a(2), which applies only to lost

opportunity claims. The decision of the new majority to treat this case as a traditional

medical malpractice claim, of course, obviates the need for interpreting the second

sentence of MCL 600.2912a(2) because the new majority essentially treats all medical


                                             30
malpractice claims under the weakened Falcon causation standard heretofore applicable

only to lost opportunity claims. Therefore, the decision of the new majority to overrule

the Court of Appeals decision in Fulton, to the extent Fulton drew a line between lost

opportunity cases and traditional medical malpractice cases, also does away with Fulton’s

application of the sentence in § 2912a(2) that applies to lost opportunity cases. Fulton

only applies to lost opportunity cases. By concluding that the instant case sounds in

traditional medical malpractice, the new majority essentially writes the decision in Fulton

out of existence. Thus, its expansive decision in this case is characteristic of the new

majority that overreaches in its decisions in order to achieve its own preferred policy

outcomes.56


      56
          Although the “new majority” has only been in existence 18 months, it has an
impressive record of overturning cases consistent with the Chief Justice’s promise to
“undo . . . the damage that the Republican-dominated court has done.” She Said, Detroit
Free Press, December 10, 2008, p 2A.

        By my count, the new majority has now overturned this term 12 cases in addition
to the one that it overturns today:

       1. In People v Feezel, 486 Mich 184; 783 NW2d 67 (2010), the new majority
overruled People v Derror, 475 Mich 316; 715 NW2d 822 (2006).

       2. In McCormick v Carrier, ___ Mich ___; ___ NW2d ___ (2010), the new
majority overruled Kreiner v Fischer, 471 Mich 109; 683 NW2d 611 (2004).

      In Lansing Sch Ed Ass'n v Lansing Bd of Ed, ___ Mich ___; ___ NW2d ___
(2010), the new majority overruled the following cases:

      3. Lee v Macomb Co Bd of Comm'rs, 464 Mich 726; 629 NW2d 900
      (2001);

      4. Crawford v Dep’t of Civil Serv, 466 Mich 250; 645 NW2d 6 (2002);


                                            31
      5. Nat’l Wildlife Federation v Cleveland Cliffs Iron Co, 471 Mich 608; 684
      NW2d 800 (2004);

      6. Associated Builders & Contractors v Dep’t of Consumer & Indus Servs
      Dir, 472 Mich 117, 124-127; 693 NW2d 374 (2005);

      7. Mich Chiropractic Council v Comm’r of the Office of Fin & Ins Serv,
      475 Mich 363; 716 NW2d 561 (2006);

      8. Rohde v Ann Arbor Pub Sch, 479 Mich 336; 737 NW2d 158 (2007);

      9. Mich Citizens for Water Conservation v Nestlé Waters North America
      Inc, 479 Mich 280, 302-303; 737 NW2d 447 (2007); and

      10. Manuel v Gill, 481 Mich 637; 753 NW2d 48 (2008).

      11. In Bezeau v Palace Sports Entertainment, Inc, ___ Mich ___; ___ NW2d ___
(2010), the new majority expressly overruled the limited retroactive effect of
Karaczewski v Farbman Stein & Co, 478 Mich 28; 732 NW2d 56 (2007).

      12. In Univ of Mich Regents v Titan Ins Co, ___ Mich ___; ___ NW2d ___ (2010),
the new majority overruled Cameron v Auto Club Ins Ass’n, 476 Mich 55; 718 NW2d
784 (2006).

        Given this list of “lately departed” decisions of the “Republican-dominated
Court,” killing one Court of Appeals case such as Fulton—even if entirely irrelevant to
the question the new majority purports to address here—is hardly surprising for the new
majority which, before its members became the majority, were individually and
collectively notably more “hawkish” on preserving precedent. See Pollard v Suburban
Mobility Auth for Regional Transp, 486 Mich 963, 963-965 (2010) (YOUNG, J.,
dissenting statement). As in three other cases decided this term, Justice WEAVER repeats
her tired and unsuccessful attempt to defend her changing position on stare decisis. Ante
at ___ (WEAVER, J., concurring). See also Univ of Mich Regents, ___ Mich at ___
(WEAVER, J., concurring); Lansing Sch Ed Ass’n, ___ Mich at ___ (WEAVER, J.,
concurring); McCormick, ___ Mich at ___ (WEAVER, J., concurring). Her position does
not become any more convincing with repetition. My dissenting opinion in Univ of Mich
Regents, ___ Mich at ___ (YOUNG, J., dissenting), explains in full why Justice WEAVER’s
position is merely an attempt to justify stark judicial policy-making.



                                           32
      The Legislature added subsection (2) to MCL 600.2912a shortly after the Falcon

Court created the new claim for loss of an opportunity to survive. The new subsection

provides:

              In an action alleging medical malpractice, the plaintiff has the
      burden of proving that he or she suffered an injury that more probably than
      not was proximately caused by the negligence of the defendant or
      defendants. In an action alleging medical malpractice, the plaintiff cannot
      recover for loss of an opportunity to survive or an opportunity to achieve a
      better result unless the opportunity was greater than 50%.[57]

      As the lead opinion in Stone aptly observed, there are multiple problems in

determining whether the requirements of MCL 600.2912a(2) apply in any particular case.

As stated above, the two sentences are internally inconsistent and, therefore, create a

paradox:

              [T]he first sentence of this new subsection codifies and reiterates the
      common-law requirement that a plaintiff show that the defendant’s
      malpractice more probably than not caused the plaintiff’s injury. The
      second sentence of subsection 2 adds that, in medical-malpractice cases, a
      “plaintiff cannot recover for loss of an opportunity to survive or an
      opportunity to achieve a better result unless the opportunity was greater
      than 50%.” However, one must keep in mind that the relevant caselaw
      when subsection 2 was enacted held that the lost-opportunity doctrine
      applies “in situations where a plaintiff cannot prove that a defendant’s
      actions were the cause of his injuries . . . .” Vitale, [150 Mich App] at 502
      (emphasis added). That is, the first sentence of subsection 2 requires
      plaintiffs in every medical-malpractice case to show the defendant’s
      malpractice proximately caused the injury while, at the same time, the
      second sentence refers to cases in which such proof not only is
      unnecessary, but is impossible.[58]


      57
           MCL 600.2912a(2).
      58
           Stone, 482 Mich at 156-157 (opinion by TAYLOR, C.J.).



                                            33
      Even ignoring the internal inconsistency, the second sentence of subsection (2) is

incomprehensible as written. Subsequent to the amendment, the split Court of Appeals

panel in Fulton offered two contradictory interpretations of the second sentence, neither

of which was consistent with the text of that sentence as enacted. The Fulton majority

determined that “MCL 600.2912a(2) requires a plaintiff to show that the loss of the

opportunity to survive or achieve a better result exceeds fifty percent.”59 As the lead

opinion in Stone indicated, this interpretation “improperly adds to the statute the words

‘loss of,’ effectively replacing the word ‘opportunity’ where it is used the second time

with the phrase ‘loss of opportunity.’”60 Thus, the Fulton majority essentially rewrote the

second sentence of § 2912a(2) to include the following bracketed words: “In an action

alleging medical malpractice, the plaintiff cannot recover for loss of an opportunity to

survive or an opportunity to achieve a better result unless the [loss of] opportunity was

greater than 50%.”

      The dissenting judge in Fulton did not fare any better. His interpretation of MCL

600.2912a(2) required a plaintiff “‘to show that, had the defendant not been negligent,

there was a greater than fifty percent chance of survival or a better result.’”61 This


      59
           Fulton, 253 Mich App at 83.
      60
           Stone, 482 Mich at 159 n 9 (opinion by TAYLOR, C.J.).
      61
         Fulton, 253 Mich App at 91 (SMOLENSKI, J., dissenting), quoting Wickens v
Oakwood Healthcare System, 242 Mich App 385, 392; 619 NW2d 7 (2000). The
published Court of Appeals decision in Wickens was not controlling in Fulton because
this Court had already reversed in part and vacated in part that published decision.
Wickens v Oakwood Healthcare System, 465 Mich 53; 631 NW2d 686 (2001).



                                            34
interpretation essentially rewrote the second sentence of § 2912a(2) to include the

following bracketed word: “In an action alleging medical malpractice, the plaintiff cannot

recover for loss of an opportunity to survive or an opportunity to achieve a better result

unless the [initial] opportunity was greater than 50%.”

       Thus, both the majority and the dissent in Fulton inserted additional words into the

statute. Their reasons for doing so were identical: each believed the additional language

was necessary to enforce the perceived legislative intent to respond to the Falcon Court’s

creation of the lost opportunity claim. However, these multiple interpretations show that,

even if they were correct that the amendment was a legislative response to Falcon, the

scope of such response was far from clear.

       In the end, the lead opinion in Stone concluded:

              It is confounding to attempt to ascertain just what the Legislature
       was trying to do with this amendment. . . .

              As written, the second sentence of MCL 600.2912a(2) can be made
       understandable only by adding words or by redefining “injury” in a way
       significantly contrary to the mass of caselaw at the time the sentence was
       added. . . . None of these multiple, contradictory interpretations can be
       shown to be the “correct” construction of legislative intent. Choosing
       between them can only be a guess. . . . Accordingly, I conclude that the
       second sentence of subsection 2 cannot be judicially enforced because
       doing so requires the Court to impose its own prerogative on an act of the
       Legislature.[62]




       62
            Stone, 482 Mich at 160-161 (opinion by TAYLOR, C.J.).



                                             35
Since this Court’s split opinions in Stone, the Legislature has not clarified the confusion

surrounding the appropriate interpretation of MCL 600.2912a(2). Therefore, my position

remains that the provision is unenforceable as enacted.

       The decision by the new majority that this case represents a traditional medical

malpractice case further muddles this important area of the law. Moreover, three justices

of the new majority have changed their published positions over the past several years on

the nature of the evidence required to prove proximate cause.

       If the numerous fractured decisions and inconsistent opinions of the members

of this Court fail to demonstrate that this statute is impossible to interpret

reasonably, then it is hard to envision a better illustration that MCL 600.2912a(2) is

inherently internally inconsistent and cannot be parsed.

                                    IV. CONCLUSION

       Confusion and uncertainty in the law prevent citizens from arranging their affairs

in a predictable fashion. This Court initially created uncertainty in adopting the lost

opportunity claim in Falcon because it was so profoundly at odds with traditional

principles of causation. It is no wonder that the Legislature had difficulty reconciling

“Falcon causation” with the traditional causation that the Legislature clearly desired to

maintain in medical malpractice claims. Today, the new majority has created even more

uncertainty in interpreting the legislative response to Falcon. While the result in this case

undoubtedly serves the interests of lawyers who litigate medical malpractice cases, it

poorly serves the people of this state to have the law become even more

incomprehensibly muddled. This is not an accidental act, but one intentionally designed


                                             36
to thwart the legislative directive that the plaintiff prove the traditional requirement of

proximate cause in every “action alleging medical malpractice . . . .”63 Judges, as neutral

arbiters whose function is merely to interpret the laws enacted through the democratic

process, should not be agents of “societal change” they desire, and they certainly should

not contribute to confusion and chaos in the law. The new majority’s resolution of this

case fails on both counts.

       Plaintiff’s claim is a prototypical lost opportunity claim. As such, the second

sentence of MCL 600.2912a(2) expressly controls plaintiff’s claim. However, I continue

to maintain that § 2912a(2) is unenforceable as enacted, and I reiterate former Chief

Justice TAYLOR’s call for the Legislature “to reexamine its goal and the policies it wishes

to promote and strive to better articulate its intent in that regard.”64 Today, that call is

more urgent than it was just two years ago.

       Today is a sad day for predictability in Michigan law. The disorder sown by the

new majority in their several opinions speaks poorly of the quality of decision-making in

this Court.     Doctrinal destruction aside, the obvious manipulation of the statistical

evidence by the justices of the new majority to achieve their goal of creating a cause of

action when the proofs have failed is itself worthy of condemnation.




       63
            MCL 600.2912a(2).
       64
            Stone, 482 Mich at 165 (opinion by TAYLOR, C.J.).



                                              37
      For all of the reasons stated, I vigorously dissent from overreaching by the new

majority and, instead, would vacate as improvidently entered this Court’s September 30,

2009, order granting leave to appeal.


      CORRIGAN, J., concurred with YOUNG, J.




                                          38
