Establishing causation is crucial to determine whether a party is liable for harming an individual and how much compensation is owed to the injured. However, establishing causation is not always straightforward and intuitive (i.e., death following a gunshot wound to the head). More often, cases are complex—the cause is not readily apparent, or the outcome can have multiple contributing causes. 

A recent review article by Meilia et al. (2020). discussed the literature on the existing methods of causal analysis¹. Notable methods of causal analysis include: 

• The 2013 guide on disease and injury causation released by the AMA²
• The Forcier-Lacerte (2002)³ medicolegal causal analysis model
• The epidemiology-based approach by Siegerink et al. (2016).⁴
• The 3-step medicolegal causation approach by Freeman et al. (2009)⁵
• The INFERENCE approach was introduced by Meilia et al. (2020)⁶.

Using the appropriate approach to causation is important when evaluating different types of cases with varying degrees of complexity. That being said, a 2016 legal decision from the 10th Circuit US Court of Appeals endorsed the 3-step causal methodology as the generally accepted approach for injury causation. The decision was based on the 2009 Freeman et al. publication that described the application of the methodology to the analysis of spinal disk injury following a traffic crash. 

Q: What are the criteria for the 3-step medicolegal causal methodology when assessing causation?

A brief example of the practical clinical application of the 3-step methodology is as follows: a 51-year-old man developed worsening pain, numbness, and tingling of his right arm along with arm fatigue with activity 

after many years of repetitive box stacking on his job. The EMG was consistent with neurogenic Thoracic Outlet Syndrome. Within this brief description is both a plausible explanation of the injury (chronic inflammatory changes due to repetitive occupational overhead arm movements) and the temporal relationship between the trauma and symptom onset (symptoms worsening gradually after many years on the job). Thus, the first two steps of the analysis are satisfied. Regarding the third step, the patient did not suffer any other neck, shoulder, or arm injuries. Additionally, there was nothing in his history (trauma from a prior accident, participation in sports, or personal situation) outside of his job that would contribute to his symptoms. 

THE TAKEAWAY

Establishing a clear case for causation is just one example of how we can assist you with the medical issues in your cases.  Please reply to this email or call 816-719-8533 to schedule a time to talk.

LET US KNOW HOW WE CAN HELP YOU

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1. Meilia, P. D. I., Freeman, M. D., Herkutanto, & Zeegers, M. P. (2020, March 10). A review of causal inference in forensic medicine – forensic science, medicine and pathology. SpringerLink. https://link.springer.com/article/10.1007/s12024-020-00220-9 ↩︎
2. Association, A. M., Hyman, M. H., Ackerman, W. E., Melhorn, J. M., & Talmage, J. B. (2013). Ama guides to the evaluation of disease and injury causation, second edition. American Medical Association. ↩︎
3. Lacerte, M., & Forcier, P. (2002). Medicolegal causal analysis. Physical medicine and rehabilitation clinics of North America, 13(2), 371–x. https://doi.org/10.1016/s1047-9651(01)00011-0 ↩︎
4. Siegerink, B., den Hollander, W., Zeegers, M., & Middelburg, R. (2016). Causal Inference in Law: An Epidemiological Perspective. European Journal of Risk Regulation, 7(1), 175-186. https://doi.org/10.1017/S1867299X0000547X ↩︎
5. Freeman, M. D., Centeno, C. J., & Kohles, S. S. (2009). A systematic approach to clinical determinations of causation in symptomatic spinal disk injury following motor vehicle crash trauma. PM & R : the journal of injury, function, and rehabilitation, 1(10), 951–956. https://doi.org/10.1016/j.pmrj.2009.07.009 ↩︎
6. Meilia, P. D. I., Zeegers, M. P., Herkutanto, & Freeman, M. (2020). INFERENCE: An Evidence-Based Approach for Medicolegal Causal Analyses. International journal of environmental research and public health, 17(22), 8353. https://doi.org/10.3390/ijerph17228353 ↩︎