'Eggshell Skull' Rule

Question: Six days after he bruised his chest and fractured his ankle as a result of an auto accident, the victim, who had a history of diabetes and coronary artery disease, died from an acute myocardial infarction. The medical expert testified that the accident caused him to develop the AMI because of preexisting risk factors, although an otherwise normal person would not. Which of the following statements is best?

A. A tortfeasor is never liable for damages that are too remote and not foreseeable.

B. The accident did not proximately cause the infarct, so the wrongdoer is liable only for the chest wall and ankle injuries.

C. Under the "eggshell skull" rule, the tortfeasor takes his victim as he finds him, and the defendant here is therefore liable for all injuries, including the AMI.

D. The defendant can legitimately claim no prior knowledge of victim’s preexisting conditions, and therefore cannot foresee an AMI complication.

E. A normal person would not have sustained an AMI under the circumstances, and the law demands only what is reasonable.

Answer: C. In order to be compensated, a plaintiff generally has to satisfy the court that the damage was not too remote. Reasonable foreseeability of the type of harm – not necessarily its extent – is the key inquiry when the remoteness of damage is assessed, and public policy considerations centering on fairness may also come into play.

It has been stated that "starting with the proposition that a negligent person should be liable, within reason, for the consequences of his conduct, the extent of his liability is to be found by asking the one question: Is the consequence fairly to be regarded as within the risk created by the negligence? If so, the negligent person is liable for it, but otherwise not" (Roe v. Minister of Health [1954] 2 Q.B. 66 at 85).

This hypothetical case, adapted from an actual Iowa supreme court decision (Benn v. Thomas 512 N.W.2d 537 [Iowa 1994]), features the legal maxim called the "eggshell skull" rule. This principle of law carves out an exception to the need to inquire into whether any damage is too remote. The "eggshell skull" rule famously stipulates that the tortfeasor takes his victim as he finds him, which means in practical terms that the defendant remains liable for all injuries that he caused in a susceptible plaintiff who had preexisting vulnerabilities.

The doctrine originated in the 1901 English case of Dulieu v. White (2 K.B. 669 [1901]), in which the thin-skulled plaintiff died from a minor accident, whereas a person with a skull of normal thickness would have suffered only a bump on the head. The defendant was found liable for the patient’s death.

In an earlier landmark case, (Vosburg v. Putney, 50 N.W. 403 [Wisc. 1891]), a schoolboy developed an invasive infection of his leg after he was kicked by a fellow classmate. Unbeknown to the perpetrator, the victim had recently been injured on that same leg; the injury was aggravated by the tortious act and the leg had to be amputated. The court held that the tortfeasor was liable for the entire damage, notwithstanding the fact that he was unaware of the victim’s prior leg condition or that he had not intended that degree of harm.

In Smith v. Leech Brain & Co Ltd. ([1962] 2 Q.B. 405), an employee developed lip cancer and eventually died after a piece of molten metal caused a burn to the lip. The affected area was apparently in a precancerous condition. The court held that "the test is not whether these [defendants] could reasonably have foreseen that a burn would cause cancer and that [Mr. Smith] would die. The question is whether these [defendants] could reasonably foresee the type of injury he suffered, namely, the burn. What, in the particular case, is the amount of the damage which he suffers as a result of that burn, depends upon the characteristics and constitution of the victim."

In Stoleson v. United States (708 F.2d 1217 [7th Cir. 1983]), the plaintiff suffered a heart attack that was attributed to nitroglycerin exposure at the munitions plant where she worked. As the employer, the federal government was found liable for failing to protect its workers from such exposure. However, the claimant subsequently developed symptoms that included chest pain, dizziness, shortness of breath, coughing, and vomiting, together with a massive weight gain of more than 100 pounds. The symptoms were diagnosed as hypochondriasis, and became manifest only several years after the original incident, long after she had left the workplace. The court held that if her psychosomatic condition preexisted the heart attack, then the "eggshell skull" rule was applicable, but the plaintiff lost the claim as she had failed to prove causation (that is, that nitroglycerin exposure caused her physical symptoms so many years later).

Issues of remoteness of damage will unlikely feature in medical negligence, as virtually all physical and mental injuries including death are foreseeable in the setting of medical treatment, especially in patients with underlying vulnerabilities. Take as an example a diabetic with peripheral neuropathy and poor circulation. A negligently treated minor foot ulcer may cause the patient to end up with an amputation, whereas such a serious outcome would be unlikely in a nondiabetic. Under the "eggshell skull" rule, the negligent doctor will be liable for all injuries, including the amputation, although not for the preexisting diabetic condition itself.

The "eggshell skull" rule should be distinguished from the "crumbling skull" rule. The latter basically stipulates that compensation must discount the damage that can reasonably be expected to flow normally from any preexisting conditions even in the absence of tortious aggravation.

Dr. Tan is emeritus professor of medicine at the University of Hawaii and director of the St. Francis International Center for Healthcare Ethics. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author at siang@hawaii.edu.

Question: Six days after he bruised his chest and fractured his ankle as a result of an auto accident, the victim, who had a history of diabetes and coronary artery disease, died from an acute myocardial infarction. The medical expert testified that the accident caused him to develop the AMI because of preexisting risk factors, although an otherwise normal person would not. Which of the following statements is best?

A. A tortfeasor is never liable for damages that are too remote and not foreseeable.

B. The accident did not proximately cause the infarct, so the wrongdoer is liable only for the chest wall and ankle injuries.

C. Under the "eggshell skull" rule, the tortfeasor takes his victim as he finds him, and the defendant here is therefore liable for all injuries, including the AMI.

D. The defendant can legitimately claim no prior knowledge of victim’s preexisting conditions, and therefore cannot foresee an AMI complication.

E. A normal person would not have sustained an AMI under the circumstances, and the law demands only what is reasonable.

Answer: C. In order to be compensated, a plaintiff generally has to satisfy the court that the damage was not too remote. Reasonable foreseeability of the type of harm – not necessarily its extent – is the key inquiry when the remoteness of damage is assessed, and public policy considerations centering on fairness may also come into play.

It has been stated that "starting with the proposition that a negligent person should be liable, within reason, for the consequences of his conduct, the extent of his liability is to be found by asking the one question: Is the consequence fairly to be regarded as within the risk created by the negligence? If so, the negligent person is liable for it, but otherwise not" (Roe v. Minister of Health [1954] 2 Q.B. 66 at 85).

This hypothetical case, adapted from an actual Iowa supreme court decision (Benn v. Thomas 512 N.W.2d 537 [Iowa 1994]), features the legal maxim called the "eggshell skull" rule. This principle of law carves out an exception to the need to inquire into whether any damage is too remote. The "eggshell skull" rule famously stipulates that the tortfeasor takes his victim as he finds him, which means in practical terms that the defendant remains liable for all injuries that he caused in a susceptible plaintiff who had preexisting vulnerabilities.

The doctrine originated in the 1901 English case of Dulieu v. White (2 K.B. 669 [1901]), in which the thin-skulled plaintiff died from a minor accident, whereas a person with a skull of normal thickness would have suffered only a bump on the head. The defendant was found liable for the patient’s death.

In an earlier landmark case, (Vosburg v. Putney, 50 N.W. 403 [Wisc. 1891]), a schoolboy developed an invasive infection of his leg after he was kicked by a fellow classmate. Unbeknown to the perpetrator, the victim had recently been injured on that same leg; the injury was aggravated by the tortious act and the leg had to be amputated. The court held that the tortfeasor was liable for the entire damage, notwithstanding the fact that he was unaware of the victim’s prior leg condition or that he had not intended that degree of harm.

In Smith v. Leech Brain & Co Ltd. ([1962] 2 Q.B. 405), an employee developed lip cancer and eventually died after a piece of molten metal caused a burn to the lip. The affected area was apparently in a precancerous condition. The court held that "the test is not whether these [defendants] could reasonably have foreseen that a burn would cause cancer and that [Mr. Smith] would die. The question is whether these [defendants] could reasonably foresee the type of injury he suffered, namely, the burn. What, in the particular case, is the amount of the damage which he suffers as a result of that burn, depends upon the characteristics and constitution of the victim."

In Stoleson v. United States (708 F.2d 1217 [7th Cir. 1983]), the plaintiff suffered a heart attack that was attributed to nitroglycerin exposure at the munitions plant where she worked. As the employer, the federal government was found liable for failing to protect its workers from such exposure. However, the claimant subsequently developed symptoms that included chest pain, dizziness, shortness of breath, coughing, and vomiting, together with a massive weight gain of more than 100 pounds. The symptoms were diagnosed as hypochondriasis, and became manifest only several years after the original incident, long after she had left the workplace. The court held that if her psychosomatic condition preexisted the heart attack, then the "eggshell skull" rule was applicable, but the plaintiff lost the claim as she had failed to prove causation (that is, that nitroglycerin exposure caused her physical symptoms so many years later).

Issues of remoteness of damage will unlikely feature in medical negligence, as virtually all physical and mental injuries including death are foreseeable in the setting of medical treatment, especially in patients with underlying vulnerabilities. Take as an example a diabetic with peripheral neuropathy and poor circulation. A negligently treated minor foot ulcer may cause the patient to end up with an amputation, whereas such a serious outcome would be unlikely in a nondiabetic. Under the "eggshell skull" rule, the negligent doctor will be liable for all injuries, including the amputation, although not for the preexisting diabetic condition itself.

The "eggshell skull" rule should be distinguished from the "crumbling skull" rule. The latter basically stipulates that compensation must discount the damage that can reasonably be expected to flow normally from any preexisting conditions even in the absence of tortious aggravation.

Dr. Tan is emeritus professor of medicine at the University of Hawaii and director of the St. Francis International Center for Healthcare Ethics. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author at siang@hawaii.edu.

Question: Six days after he bruised his chest and fractured his ankle as a result of an auto accident, the victim, who had a history of diabetes and coronary artery disease, died from an acute myocardial infarction. The medical expert testified that the accident caused him to develop the AMI because of preexisting risk factors, although an otherwise normal person would not. Which of the following statements is best?

A. A tortfeasor is never liable for damages that are too remote and not foreseeable.

B. The accident did not proximately cause the infarct, so the wrongdoer is liable only for the chest wall and ankle injuries.

C. Under the "eggshell skull" rule, the tortfeasor takes his victim as he finds him, and the defendant here is therefore liable for all injuries, including the AMI.

D. The defendant can legitimately claim no prior knowledge of victim’s preexisting conditions, and therefore cannot foresee an AMI complication.

E. A normal person would not have sustained an AMI under the circumstances, and the law demands only what is reasonable.

Answer: C. In order to be compensated, a plaintiff generally has to satisfy the court that the damage was not too remote. Reasonable foreseeability of the type of harm – not necessarily its extent – is the key inquiry when the remoteness of damage is assessed, and public policy considerations centering on fairness may also come into play.

It has been stated that "starting with the proposition that a negligent person should be liable, within reason, for the consequences of his conduct, the extent of his liability is to be found by asking the one question: Is the consequence fairly to be regarded as within the risk created by the negligence? If so, the negligent person is liable for it, but otherwise not" (Roe v. Minister of Health [1954] 2 Q.B. 66 at 85).

This hypothetical case, adapted from an actual Iowa supreme court decision (Benn v. Thomas 512 N.W.2d 537 [Iowa 1994]), features the legal maxim called the "eggshell skull" rule. This principle of law carves out an exception to the need to inquire into whether any damage is too remote. The "eggshell skull" rule famously stipulates that the tortfeasor takes his victim as he finds him, which means in practical terms that the defendant remains liable for all injuries that he caused in a susceptible plaintiff who had preexisting vulnerabilities.

The doctrine originated in the 1901 English case of Dulieu v. White (2 K.B. 669 [1901]), in which the thin-skulled plaintiff died from a minor accident, whereas a person with a skull of normal thickness would have suffered only a bump on the head. The defendant was found liable for the patient’s death.

In an earlier landmark case, (Vosburg v. Putney, 50 N.W. 403 [Wisc. 1891]), a schoolboy developed an invasive infection of his leg after he was kicked by a fellow classmate. Unbeknown to the perpetrator, the victim had recently been injured on that same leg; the injury was aggravated by the tortious act and the leg had to be amputated. The court held that the tortfeasor was liable for the entire damage, notwithstanding the fact that he was unaware of the victim’s prior leg condition or that he had not intended that degree of harm.

In Smith v. Leech Brain & Co Ltd. ([1962] 2 Q.B. 405), an employee developed lip cancer and eventually died after a piece of molten metal caused a burn to the lip. The affected area was apparently in a precancerous condition. The court held that "the test is not whether these [defendants] could reasonably have foreseen that a burn would cause cancer and that [Mr. Smith] would die. The question is whether these [defendants] could reasonably foresee the type of injury he suffered, namely, the burn. What, in the particular case, is the amount of the damage which he suffers as a result of that burn, depends upon the characteristics and constitution of the victim."

In Stoleson v. United States (708 F.2d 1217 [7th Cir. 1983]), the plaintiff suffered a heart attack that was attributed to nitroglycerin exposure at the munitions plant where she worked. As the employer, the federal government was found liable for failing to protect its workers from such exposure. However, the claimant subsequently developed symptoms that included chest pain, dizziness, shortness of breath, coughing, and vomiting, together with a massive weight gain of more than 100 pounds. The symptoms were diagnosed as hypochondriasis, and became manifest only several years after the original incident, long after she had left the workplace. The court held that if her psychosomatic condition preexisted the heart attack, then the "eggshell skull" rule was applicable, but the plaintiff lost the claim as she had failed to prove causation (that is, that nitroglycerin exposure caused her physical symptoms so many years later).

Issues of remoteness of damage will unlikely feature in medical negligence, as virtually all physical and mental injuries including death are foreseeable in the setting of medical treatment, especially in patients with underlying vulnerabilities. Take as an example a diabetic with peripheral neuropathy and poor circulation. A negligently treated minor foot ulcer may cause the patient to end up with an amputation, whereas such a serious outcome would be unlikely in a nondiabetic. Under the "eggshell skull" rule, the negligent doctor will be liable for all injuries, including the amputation, although not for the preexisting diabetic condition itself.

The "eggshell skull" rule should be distinguished from the "crumbling skull" rule. The latter basically stipulates that compensation must discount the damage that can reasonably be expected to flow normally from any preexisting conditions even in the absence of tortious aggravation.

Dr. Tan is emeritus professor of medicine at the University of Hawaii and director of the St. Francis International Center for Healthcare Ethics. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk" (2006). For additional information, readers may contact the author at siang@hawaii.edu.