Friday, March 10, 2017

Pennsylvania Commonwealth Court Citing AMA Causation Guides (Second Edition) and its Reference to the Bradford Hill Criteria

            The AMA Guides to the Evaluation of Permanent Impairment, now in its Sixth Edition, is an iconic text well known to all in our field.  And, of course, in my state (Pennsylvania), the manual is under full-frontal assault in our Supreme Court.  Protz v. WCAB (Derry Area School District), 124 A.3d 406 (Pa. Commw. 2015), appeal granted, ___ A.3d ___ (Pa. 2016).  (2016 Pa. LEXIS 501 (Pa. Mar. 22, 2016), argued Nov. 1, 2016).

            Less well known is another book: the AMA Guides to the Evaluation of Disease and Injury Causation.  This book, in its Second Edition, has the goal of assisting health care providers in generating expert opinions on causation “based on a careful review of the [patient’s] clinical findings, workplace exposures, and the literature linking (or not linking) the exposure of concern and the condition in question.”  Of course, you will discern from this description that the book is a bodacious valentine (792 pages), to evidence-based medicine (EBM). (Note: I was a lay reviewer of the book.)  

             In the spirit of promoting EBM, the authors feature a short subchapter (pp. 688-91), describing the “Bradford Hill Criteria.”  They are described in Wikipedia as follows: “The Bradford Hill criteria, otherwise known as Hill’s Criteria for causation, are a group of guidelines that can be useful for providing evidence of a causal relationship between a putative cause and an effect, established by the English epidemiologist Sir Austin Bradford Hill (1897–1991) in 1965.” 

            It’s clear that the lawyers at Chartwell, the Pennsylvania law firm, know all about the book and Hill’s Criteria.  In their truculent opposition to presumption-based firefighter cancer claims, on behalf of the City of Philadelphia, it is obvious that defense counsel has used (and is using) this manual in cross-examination of the cancer-victims’ causation expert.  They have done so to try (in all reported cases, successfully), to discredit the expert’s testimony as not being based on EBM principles.  In affirming several of the cancer claim denials, the Commonwealth Court has noted the Hill Criteria and its most immediate source in AMA Causation Guides

            One can’t say that the court is ratifying the Hill Criteria.  This is so as the opinions are simply affirming trial judge credibility determinations.  Still, surely lawyers and judges have been better educated about the contemporary thinking about causation in disease (and other) cases, through the court’s exploration of the guidelines. 

            It’s worth noting, in this regard, that the court in the past has been very permissive in what expert medical proofs the trial judge can accept.  In this latter respect, a memorable declaration: the WCJ can “reject a whole school of science if he wishes ….” Wheeling Pitt v. WCAB (Bruce), 827 A.2d 564 (Pa. Commw. 2003).

             Will this permissive approach survive as the rule? Perhaps so.  Still, effective counsel (on both sides), in occupational disease, and other non-obvious cases, will now surely be considering the Hill Criteria.  

             A postscript: The intrigue in Pennsylvania will continue.  In this regard, the most prominent of the Philadelphia firefighter cancer cases has now been accepted by the Supreme Court. See City of Philadelphia v. WCAB (Sladek), 144 A.3d 1011 (Pa. Commw. 2016) (allocatur granted).

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