The document discusses the challenges of proving causation in clinical negligence litigation. It identifies causation as the biggest hurdle that plaintiffs face. It notes that under the Bolam test, the standard of care is determined by a responsible body of medical opinion, making it difficult for plaintiffs to establish a breach of duty. When examining causation, courts must determine if the breach could have caused the injury and if it did cause the injury. The document focuses on issues like multiple causation, loss of chance, and proving factual causation given judicial protections of the medical profession under the Bolam test. It argues that medical law should evolve to balance certainty with fairness and respect for human rights.

1. Causation: The Biggest Hurdle
In the Context of clinical Negligence Litigation
Mangala Wijesinghe, Senior Lecturer
Faculty of Law
Gen Sir John Kotelawala Defence University
Abstract
The claimant, in a clinical negligence action, shall prove on a balance of probability that
as a consequence of the defendant’s negligence he has suffered damage. Such damage shall be,
caused by breach of a duty of care, a type recognized by law, and foreseeable. The golden thread
that pervades the fabric of English Medical Law is the so-called Bolam test. It is the sole
criterion of the professional standards of the doctor governing every aspect of medical care;
diagnosis, treatment and advice.
The existence of the Bolam test of the standard of care has presented a profound
difficulty to a claimant in establishing breach of duty of care. Accordingly, the criterion for the
professional standard of the doctor is that it shall accord with a responsible body of medical
opinion. In looking at the cases that have been mainly or exclusively concerned with matters of
causation, there are two questions to be answered: (a) Could the breach cause the injury? a
question of factual causation; (b) Did the breach cause the injury? a question of fact and law.
This discussion will focus on issues such as causal nexus, multiple causation and burden
of proof, loss of chance, omissions and non-disclosure of risks in the context of clinical
negligence litigation, and is based on both primary and secondary sources of Law such as
judicial decisions, academic writings etc.
The protectionist attitude of the judiciary too has placed medical perception of welfare of
patients on a higher pedestal than rights of patients. Such judicial protection of the medical
profession has compounded many aspects of clinical negligence. Problems associated with proof
of factual causation as evident from the discussion provide ample examples. Though, attempts
have been made occasionally to overcome the rigours of the Bolam test the results have been
largely unsuccessful.
A good Medical Law shall be dynamic and shall respond to changing notions of justice
and morality in the contemporary society. Justice and fairness shall not be sacrificed at the altar
of certainty and predictability expected under the common law. The evolving notions of respect
for human rights and professional ethics have given a new opportunity for a creative and
imaginative judiciary to advance the frontiers of Medical Law.
Key Words: clinical negligence, duty of care, Bolam test, standard of care, causation, rights of
patients