Doull v. Foster, 487 Mass. 1

Background

Laura Doull, treated by nurse practitioner Anna C. Foster (and supervised by Dr. Richard J. Miller), was prescribed a topically applied natural progesterone cream for perimenopausal symptoms and used it through spring 2011.
Doull repeatedly complained of shortness of breath during spring 2011 visits; Foster examined her but did not diagnose pulmonary embolism and Miller did not examine her at those visits.
In May 2011 Doull presented with a seizure‑like event, was hospitalized, and diagnosed with pulmonary embolism and chronic thromboembolic pulmonary hypertension (CTEPH); surgical and medical treatments failed and she died of CTEPH in 2015.
Plaintiffs sued for negligence (failure to diagnose), failure to obtain informed consent (re: progesterone cream), and negligent supervision; they later sought to add the cream manufacturer (WIC) shortly before trial, which the trial judge denied.
The jury found negligence for failure to diagnose and for negligent supervision but concluded those breaches did not cause Doull’s injuries or death; plaintiffs sought a new trial and appealed, arguing principally that the trial court should have instructed on a "substantial contributing factor" causation standard instead of a but‑for test.
The Supreme Judicial Court affirmed: it held that the traditional but‑for factual causation standard governs most negligence cases (adopting the Restatement (Third) approach), limited the substantial‑factor approach to rare multiple‑sufficient‑cause (and, with reservation, certain toxic‑exposure) contexts, and rejected plaintiffs’ other procedural and instructional claims.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Appropriate factual causation standard	Court should instruct on "substantial contributing factor" because multiple possible causes and multiple actors existed	But‑for causation is the proper standard in most negligence cases; substantial‑factor test is confusing and unnecessary except in narrow contexts	Held: But‑for standard governs most cases; use special instruction only for rare multiple‑sufficient‑cause situations (per Restatement (Third))
Jury instruction on standard of care / reliance on expert testimony	Jury should have been told to rely on regulations and other practice materials (and that admissions could establish breach) rather than primarily on experts	Expert testimony was central to resolving disputed medical risks; instruction to consider all evidence (including experts) was proper	Held: Instructions were adequate; experts appropriately controlled disputed medical‑risk issues; Foster's admission that she did not warn of clot risk did not alone establish breach without a finding that cream posed that risk
Motion to amend complaint to add manufacturer (WIC) shortly before trial	Plaintiffs argued newly discovered supplier info justified amendment	Defendants argued amendment was untimely and prejudicial given discovery deadline and trial readiness	Held: Trial judge did not abuse discretion in denying amendment for unexplained, untimely delay and potential prejudice
Postverdict contact with jurors	Plaintiffs sought juror contact to question reactions to counsel conduct and possible implicit bias	Defendants sought court approval before juror contact to prevent improper inquiry into deliberations	Held: Judge properly restricted postverdict contact because plaintiffs’ stated purpose risked probing jury deliberations and thought processes

Key Cases Cited

Wainwright v. Jackson, 291 Mass. 100 (Mass. 1935) (defendant must be causally related to plaintiff's injury to be liable)
Glidden v. Maglio, 430 Mass. 694 (Mass. 2000) (causation is an essential element of negligence)
Leavitt v. Brockton Hosp., Inc., 454 Mass. 37 (Mass. 2009) (liability requires both cause in fact and scope of foreseeable risk)
Kent v. Commonwealth, 437 Mass. 312 (Mass. 2002) (distinguishing factual causation from proximate/legal causation)
O'Connor v. Raymark Indus., Inc., 401 Mass. 586 (Mass. 1988) (recognition of difficulties with but‑for causation in toxic/asbestos cases)
Matsuyama v. Birnbaum, 452 Mass. 1 (Mass. 2008) (discussion of substantial contributing factor test in medical malpractice/loss‑of‑chance context)
Paroline v. United States, 572 U.S. 434 (U.S. 2014) (recognizing limits of but‑for causation and contexts requiring alternative causal approaches)
Bostock v. Clayton County, 140 S. Ct. 1731 (U.S. 2020) (illustrative citation on understanding but‑for counterfactual causation)