Donna Cisson v. C. R. Bard, Incorporated , 810 F.3d 913 ( 2016 )


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  •                               PUBLISHED
    UNITED STATES COURT OF APPEALS
    FOR THE FOURTH CIRCUIT
    No. 15-1102
    In Re: C.R. BARD, INCORPORATED, MDL. No. 2187,
    Pelvic Repair System Products Liability Litigation
    ------------------------------
    DONNA CISSON; DAN CISSON,
    Plaintiffs - Appellees,
    v.
    C.R. BARD, INCORPORATED,
    Defendant – Appellant,
    SAMUEL S. OLENS, Attorney General of the State of Georgia,
    Intervenor.
    ------------------------------
    FEDERATION OF DEFENSE & CORPORATE COUNSEL; PRODUCT LIABILITY
    ADVISORY COUNCIL, INCORPORATED; COOK BIOTECH INCORPORATED;
    CHAMBER OF COMMERCE OF THE UNITED STATES OF AMERICA; COOK
    INCORPORATED; COOK MEDICAL LLC,
    Amici Supporting Appellant,
    PUBLIC JUSTICE; NATIONAL CENTER FOR HEALTH,
    Amici Supporting Appellees.
    No. 15-1137
    In Re: C.R. BARD, INCORPORATED, MDL. No. 2187,
    Pelvic Repair System Products Liability Litigation
    ------------------------------
    DONNA CISSON; DAN CISSON,
    Plaintiffs - Appellants,
    v.
    C.R. BARD, INCORPORATED,
    Defendant – Appellee,
    SAMUEL S. OLENS, Attorney General of the State of Georgia,
    Intervenor.
    ------------------------------
    FEDERATION OF DEFENSE & CORPORATE COUNSEL; CHAMBER OF
    COMMERCE OF THE UNITED STATES OF AMERICA; PRODUCT LIABILITY
    ADVISORY COUNCIL, INCORPORATED,
    Amici Supporting Appellee,
    PUBLIC JUSTICE; NATIONAL CENTER FOR HEALTH,
    Amici Supporting Appellants.
    Appeals from the United States District Court for the Southern
    District of West Virginia, at Charleston.   Joseph R. Goodwin,
    District Judge. (2:11-cv-00195)
    Argued:   September 16, 2015                 Decided:   January 14, 2016
    Before GREGORY, AGEE, and DIAZ, Circuit Judges.
    2
    Affirmed by published opinion. Judge Gregory wrote the opinion,
    in which Judge Agee and Judge Diaz joined.
    ARGUED:   Elliot H. Scherker, GREENBERG TRAURIG, P.A., Miami,
    Florida, for Appellant/Cross-Appellee.     Anthony J. Majestro,
    POWELL & MAJESTRO, PLLC, Charleston, West Virginia, for
    Appellees/Cross-Appellants.   Julie Adams Jacobs, OFFICE OF THE
    ATTORNEY GENERAL OF GEORGIA, Atlanta, Georgia, for Intervenor.
    ON BRIEF: Lori G. Cohen, R. Clifton Merrell, II, Sean P. Jessee,
    Atlanta, Georgia, Daniel I.A. Smulian, GREENBERG TRAURIG, LLP,
    New York, New York; Brigid F. Cech Samole, Jay A. Yagoda,
    GREENBERG TRAURIG, P.A., Miami, Florida; Melissa Foster Bird,
    NELSON MULLINS RILEY & SCARBOROUGH, Huntington, West Virginia,
    for Appellant/Cross-Appellee.    Allison Van Laningham, TURNING
    POINT LITIGATION, Greensboro, North Carolina; Henry G. Garrard,
    III, Josh B. Wages, BLASINGAME, BURCH, GARRARD, ASHLEY PC,
    Athens, Georgia, for Appellees/Cross-Appellants.      Samuel S.
    Olens, Attorney General, W. Wright Banks, Jr., Deputy Attorney
    General, OFFICE OF THE ATTORNEY GENERAL OF GEORGIA, Atlanta,
    Georgia, for Intervenor.       Debra Tedeschi Varner, MCNEER,
    HIGHLAND, MCMUNN & VARNER LC, Clarksburg, West Virginia; Stacy
    A. Broman, MEAGHER & GEER PLLP, Minneapolis, Minnesota, for
    Amicus Federation of Defense & Corporate Counsel. Chilton Davis
    Varner, Stephen B. Devereaux, Madison H. Kitchens, Atlanta,
    Georgia, Jeffrey S. Bucholtz, Paul Alessio Mezzina, KING &
    SPALDING LLP, Washington, D.C., for Amici Product Liability
    Advisory Council, Inc. and Chamber of Commerce of the United
    States; Hugh F. Young, Jr., PRODUCT LIABILITY ADVISORY COUNCIL,
    INC., Reston, Virginia, for Amicus Product Liability Advisory
    Council, Inc.; Kathryn Comerford Todd, Sheldon Gilbert, NATIONAL
    CHAMBER LITIGATION CENTER, INC., Washington, D.C., for Amicus
    Chamber of Commerce of the United States.      Douglas B. King,
    WOODEN & MCLAUGHLIN LLP, Indianapolis, Indiana, for Amici Cook
    Incorporated, Cook Medical LLC, and Cook Biotech Incorporated.
    Michael J. Quirk, Esther E. Berezofsky, Joseph Alan Venti,
    WILLIAMS CUKER BEREZOFSKY, LLC, Philadelphia, Pennsylvania, for
    Amici Public Justice, P.C., and National Center for Health
    Research.
    3
    GREGORY, Circuit Judge:
    On August 15, 2013, a jury awarded Donna Cisson $250,000 in
    compensatory       damages    on    a    design      defect      and    failure     to    warn
    claim      against     C.R.    Bard,       Inc.      (“Bard”),          and     awarded     an
    additional $1,750,000 in punitive damages.                        The punitive damages
    award was split pursuant to a Georgia statute, with seventy-five
    percent going to the State of Georgia and twenty-five percent
    going to Cisson.         This was the first jury verdict arising from
    multi-district        litigation         involving        more     than        70,000    cases
    against     the    proprietors      of    transvaginal           mesh    medical        devices
    used to treat pelvic organ prolapse and other pelvic issues, of
    whom Bard is one.
    We    address    several      issues      on    appeal.           The     first    issue
    raised by Bard is the district court’s refusal to admit evidence
    relating      to     Bard’s    compliance            with     the        Food     and     Drug
    Administration’s (“FDA”) Section 510(k) product safety process
    (“510(k) process”).           Second, Bard challenges the denial of its
    motion in limine asking the district court to exclude evidence
    and argument pertaining to a material data safety sheet (“MSDS”)
    produced for polypropylene, a key material in the Avaulta Plus
    surgical mesh.         Bard argues that the MSDS relied on by Cisson
    was   hearsay      outside    any   exception.            Third,        Bard    appeals    the
    district     court’s    jury    instruction          on     causation,         arguing    that
    under controlling Georgia law the court should have told jurors
    4
    that causation must be demonstrated by expert testimony stated
    to a reasonable degree of medical probability.            Bard also argues
    that, as a matter of law, the evidence Cisson presented to prove
    causation was insufficient to meet this more rigorous standard.
    Bard’s final challenge on appeal is to the constitutionality of
    the punitive damages award, which it argues is excessive and in
    violation of the Due Process Clause.         In a cross-appeal, Cisson
    argues that the district court committed constitutional error by
    failing to find that the Georgia split-recovery statute violates
    the Takings Clause.      For the reasons that follow, we affirm the
    district court on all issues.
    I.
    Cisson was implanted with the Avaulta Plus, a transvaginal
    mesh medical device developed and marketed by Bard, on May 6,
    2009,   to    address   pelvic   organ   prolapse   and    stress   urinary
    incontinence.     The surgery was performed by Dr. Brian Raybon, a
    physician who had provided input to Bard during the development
    of the Avaulta Plus and who trained other physicians to use the
    device.      Prior to her procedure, Cisson received warnings about
    a number of risks that could result from the surgical implant
    and signed a consent form acknowledging these warnings.               Three
    months after the surgery, Cisson’s doctor diagnosed “an adhesion
    band” of scar tissue running across her vagina that was taut
    5
    like a “banjo string” and was causing Cisson pain.                           Dr. Raybon
    resected the mesh, which involved cutting out a thick band of
    scar tissue and mesh encased in the tissue.                         Three weeks after
    the resection surgery, Cisson returned to Dr. Raybon who said
    she was healing well and should return in a year.                            Instead, a
    few months later, Cisson went to a different doctor who referred
    her to Dr. John Miklos.               Dr. Miklos explanted the Avaulta Plus
    from Cisson’s body, although complete removal of the mesh was
    not possible.
    Complaining that the surgical mesh marketed by Bard caused
    ongoing     “loss      of     sexual     feeling”        and      “severe    pain     with
    intercourse and otherwise,” Cisson filed a lawsuit against Bard
    in March 2011 in the Northern District of Georgia.                          Bard already
    faced suits from other claimants dating back to 2009, and the
    Judicial     Panel          for   Multidistrict            Litigation        had      begun
    transferring      these       cases    to    the       Southern    District      of   West
    Virginia in 2010.             In re Avaulta Pelvic Support Sys. Prods.
    Liab. Litig., 
    746 F. Supp. 2d
    . 1362 (J.P.M.L 2010).                                Cisson’s
    suit was added to these and would later become the first to
    reach a jury verdict.
    On    June   4,    2013,     Bard      won    summary     judgment     on   Cisson’s
    claims     for    negligent       inspection,           marketing,      packaging      and
    selling,    manufacturing         defect,        and    breach    of   warranty.        The
    district    court      allowed    claims      for      design     defect,    failure    to
    6
    warn, and loss of consortium to proceed to trial.                             During the
    trial, Cisson focused both her design defect and failure to warn
    claims on several alleged dangers presented by the Avaulta Plus.
    Expert witnesses were brought to testify that the design of the
    device’s      arms,     used    to     anchor      the   Avaulta       Plus    inside     a
    patient’s body, resulted in ongoing pain to a patient as long as
    the device was implanted.              Experts also testified that the pores
    in the mesh component of the Avaulta Plus were too small and
    that the mesh was subject to shrinking after implantation, with
    the result being a rigid scar plate and increasing tension on
    internal      tissue.          Cisson’s      experts     further       testified     that
    polypropylene, from which the monofilament used in the Avaulta
    Plus   mesh    was    made,     may    be    attacked    by     the    patient’s    body,
    causing inflammation of the tissue and degradation of the mesh.
    Slides   were       presented    to    the    jury     that   Cisson’s     expert,      Dr.
    Bernd Klosterhalfen, testified showed the polypropylene of the
    Avaulta Plus in Cisson’s body was being attacked, causing a scar
    plate to form.
    Beyond presenting evidence that the Avaulta Plus had caused
    her injuries, Cisson also painted a picture of Bard as ignoring,
    and at times hiding from others, the warning signs that its
    product could cause injuries.                     There was substantial argument
    regarding       a     MSDS      Bard        received      from        Phillips     Sumika
    Polypropylene         Company        (“Phillips”),        the     corporation        that
    7
    manufactured        the    polypropylene         pellets     used       to        extrude    the
    Avaulta Plus mesh.           The MSDS contained an explicit warning that
    polypropylene should not be used in short- or long-term human
    implantations.            Internal      e-mails    showed       that    Bard        executives
    knew   about      the     MSDS,   and    that     they   sought        to    prevent       their
    monofilament        suppliers       from    learning       of     the        warning.         In
    addition     to   raising     its    hearsay       objection       to       the    MSDS,    Bard
    countered      that     polypropylene        had    been     used       for       decades     in
    clinical      settings      and   that     the    warning       was     with       respect    to
    polypropylene pellets, not to the extruded monofilament used in
    the Avaulta Plus.
    Bard argued to the jury that its product was similar to the
    Avaulta      Classic—a      predecessor      surgical       mesh       device       that    Bard
    contended had been safely used for years—and that it had taken
    appropriate steps to ensure biocompatibility and product safety.
    Bard argued to the judge (on evidentiary motions) that it was
    unfair to allow Cisson to attack its product’s safety while Bard
    was prevented from presenting evidence that it complied with the
    FDA’s 510(k) process.
    The   jury     ultimately        credited    Cisson’s       evidence,         awarding
    damages for the design defect and failure to warn claims.                                    The
    jury returned a verdict for Bard on the consortium claim.                                   Bard
    timely noted this appeal.
    8
    II.
    Bard’s first claim on appeal is that the district court
    abused        its    discretion       by    granting          Cisson’s    motion     in   limine
    asking the court to exclude all evidence that Bard had complied
    with         the    FDA’s   510(k)     process.               Bard   sought    to    admit    the
    evidence to show that its conduct was reasonable.                                   Bard argued
    that this was relevant to its defense to the design defect claim
    under Georgia’s product liability case law, as well as to the
    question of punitive damages.                       The district court excluded the
    evidence           under    Federal        Rule    of     Evidence       402   for     lack    of
    relevance,           and    under   Rule      403       for    being     substantially        more
    prejudicial than probative.                   We affirm the court’s ruling based
    on Rule 403 and therefore need not address its reliance on Rule
    402. 1
    1
    We also need not address Bard’s contention that state law,
    rather than federal, controls the question—at least not at any
    great length.   Because this is a diversity case, the “general
    rule” is that federal courts apply state substantive law and
    federal procedural law. Hottle v. Beech Aircraft Corp., 
    47 F.3d 106
    , 109 (4th Cir. 1995).      As procedural rules, the Federal
    Rules of Evidence control over conflicting state evidentiary
    rules in diversity cases.    
    Id. Only where
    a state evidentiary
    rule is “bound-up” with substantive state policy will it control
    over the federal rule. 
    Id. at 110.
    This is not such a case.
    First, Bard fails to point to a state evidentiary rule
    contradicting Rule 403.    Instead, Bard argues that regulatory
    compliance has been ruled relevant in numerous Georgia product
    liability cases. But the rulings Bard points to are just that—
    rulings, not rules. Bard does not demonstrate that Georgia law
    requires evidence of regulatory compliance to be admitted in all
    (Continued)
    9
    A.
    Although   Rule    403     will    “generally         favor      admissibility,”
    United   States   v.     Wells,    
    163 F.3d 889
    ,    896   (4th    Cir.      1998),
    district    courts     are      granted     “broad          discretion”     to       decide
    “whether    the   probative        value        of   evidence      is     substantially
    outweighed by the danger of unfair prejudice, misleading the
    jury, or confusion of the issues,” Minter v. Wells Fargo Bank,
    N.A., 
    762 F.3d 339
    , 349 (4th Cir. 2014).                       “[E]xcept under the
    most ‘extraordinary’ of circumstances, where that discretion has
    been   plainly    abused,”      this     Court       will    not   overturn      a    trial
    court’s Rule 403 decision.               United States v. Simpson, 
    910 F.2d 154
    , 157 (4th Cir. 1990) (quoting United States v. Heyward, 
    729 F.2d 297
    , 301 n.2 (4th Cir. 1984)) (internal quotation marks
    omitted).
    Cisson’s claim for design defect is controlled by Georgia
    product liability law.            Georgia uses a “risk-utility” test for
    product liability claims, requiring the trial court to “evaluate
    cases regardless of probative value or prejudicial effect, so
    there is no competing rule.
    Second, Bard fails to demonstrate that the alleged rule is
    sufficiently    “bound-up”    with  substantive    state   policy.
    Regulatory compliance is one of at least thirteen non-exclusive
    factors Georgia courts consider under the risk-utility test—
    hardly   a   cornerstone   of   the  state’s   product   liability
    jurisprudence.   Ga. Suggested Pattern Jury Instruction, Vol. I:
    Civil Cases § 62.650 (5th ed. 2015).
    10
    design defectiveness under a test balancing the risks inherent
    in   a    product     design    against    the   utility       of     the   product    so
    designed.”          Banks v. ICI Americas, Inc., 
    450 S.E.2d 671
    , 674
    (Ga. 1994).          This test includes some reliance on “negligence
    principles,” and “incorporates the concept of ‘reasonableness,’
    i.e., whether the manufacturer acted reasonably in choosing a
    particular product design, given the probability and seriousness
    of   the    risk . . . ,        the   usefulness       of    the     product    in    that
    condition, and the burden on the manufacturer to . . . eliminate
    the risk.” 
    Id. at 673-74.
                Bard argues that compliance with the
    510(k)      process    was     important    to    its       design    defect    defense
    because it shows that the company’s conduct was reasonable.
    Assuming     without    deciding       that    the        510(k)   compliance
    evidence     is     relevant,    under     Georgia’s        risk-utility       test   the
    probative value of that evidence must depend on the extent to
    which the regulatory framework safeguards consumer safety.                             The
    510(k) process allows some medical devices to avoid the strict
    safety      testing    requirements        imposed      by    the     Medical    Device
    Amendments (“MDA”) to the Federal Food, Drug, and Cosmetic Act,
    so long as the device is “substantially equivalent” to a pre-
    1976 device already in use at that time.                     See Medtronic, Inc. v.
    Lohr, 
    518 U.S. 470
    , 493 (1996).                  Thus, devices approved under
    the 510(k) process “may be marketed without premarket approval”
    as would be required by the MDA, although they “are subject to
    11
    ‘special controls . . . that are necessary to provide adequate
    assurance of safety and effectiveness.’”                     Talley v. Danek Med.,
    Inc.,   
    179 F.3d 154
    ,    160    (4th     Cir.      1999)   (quoting      21    U.S.C.
    § 360c(a)(1)(B)).         In    this     respect,         although    the     process      is
    certainly not a rubber stamp program for device approval, it
    does    operate   to    exempt       devices       from    rigorous      safety     review
    procedures.
    While some courts have found evidence of compliance with
    the 510(k) equivalence procedure admissible in product liability
    cases, the clear weight of persuasive and controlling authority
    favors a finding that the 510(k) procedure is of little or no
    evidentiary    value.          The    Supreme       Court    has     regarded       product
    clearance     accomplished           through       the    510(k)      process       as     “a
    qualification     for    an     exemption         rather     than    a   requirement.”
    Riegel v. Medtronic, Inc., 
    552 U.S. 312
    , 322 (2008).                          This is in
    part because the “process impose[s] no requirements with respect
    to the design of the device.”                     Duvall v. Bristol-Myers-Squibb
    Co., 
    103 F.3d 324
    , 329 (4th Cir. 1996).                     “Thus, even though the
    FDA may well examine 510(k) applications . . . with a concern
    for the safety and effectiveness of the device,” the agency’s
    clearance rests only on whether the device is “substantially
    equivalent to one that existed before 1976” before allowing it
    “to    be   marketed    without        running      the     gauntlet     of    the       [MDA
    premarket approval] process.”             
    Lohr, 518 U.S. at 493-94
    .
    12
    Bard points out that much of this precedent stems from the
    Supreme Court’s decision in Lohr, and argues that the case and
    its progeny should not be controlling here.                        Bard argues that
    because Lohr held only that state common law claims were not
    preempted by the MDA and the 510(k) process, 
    id., and not
    that
    compliance with the 510(k) process was inadmissible as evidence
    to refute such claims, it is an inapposite precedent.                           However,
    the Supreme Court held that state law product liability claims
    were   not   preempted    because      the    510(k)       does   not     amount     to   a
    safety    regulation     requiring        device         producers      to    meet      any
    established design standards.             
    Id. The entire
    analysis turned
    on the Court’s finding that “the § 510(k) exemption process was
    intended to . . . maintain the status quo with respect to the
    marketing    of    existing     medical      devices       and    their      substantial
    equivalents,” not impose new regulatory requirements on devices.
    
    Id. at 494.
          Numerous courts, including this one, have relied on
    that reasoning in cases over the past two decades, and at a
    minimum the Supreme Court’s statements about the 510(k) process
    (repeated    most    recently    in    2008)       are    very    persuasive       as     to
    whether and how compliance speaks to the relative safety of a
    device.
    Nor is Bard helped by FDA statements claiming that “the
    principles of safety and effectiveness underlie the substantial
    equivalence       determination”      that    is    the     heart    of      the   510(k)
    13
    review process.               2014 Guidance for Industry and Staff:                           The
    510(k) Program:              Evaluating Substantial Equivalence in Premarket
    Notifications           6.     Such   statements      merely       show    that        the    FDA
    believes an equivalence determination is sufficient to “provide
    a reasonable assurance of safety and effectiveness,” 
    id. at 7,
    but this was also the case when the Supreme Court found the
    510(k)   process         insufficiently        tied-up      with    safety       to    preempt
    state tort actions, 
    Lohr, 518 U.S. at 493-94
    , and again when the
    Court    called         the    process    an    “exemption”        and     not     a    safety
    “requirement,” 
    Riegel, 552 U.S. at 322
    .                      Bald assertions by the
    FDA do little to alter the analysis of the basic question:                                    How
    much information does 510(k) clearance provide a jury about the
    safety   of    the       underlying      product,     and    is    the    value        of    this
    information        substantially          outweighed     by       the     possibility         of
    prejudice in a particular case?
    Turning, then, to the district court’s ruling, it is clear
    that the court did not abuse its discretion by excluding Bard’s
    evidence      of    510(k)       clearance.         In   one       of    several       related
    rulings, the court stated that bringing in such evidence would
    result in a “mini-trial” about (1) the strengths and weaknesses
    of the process and (2) whether Bard had in fact made all of the
    disclosures        it    should    have    made     during    the       process.        Bard’s
    evidence would have initiated a battle of experts:                                    Bard was
    prepared to characterize the review process as “thorough” and
    14
    “robust” and the FDA’s clearance of the Avaulta Plus as “an
    affirmative safety . . . decision” based on “specific safety and
    efficacy findings.”         JA 613-15.         Cisson was prepared to argue,
    as she has done before this Court, that these characterizations
    wildly inflate the significance of the process, and that in any
    event Bard failed to make necessary disclosures to the FDA.
    All of this, the district court reasoned, presented “the
    very substantial dangers of misleading the jury and confusing
    the   issues.”       JA    1251.      The      court   expressed     concern     that
    subjecting the jury to many hours, and possibly days, of complex
    testimony    about      regulatory    compliance       could    lead    jurors     to
    erroneously conclude that regulatory compliance proved product
    safety.     In   other     words,    having     a   “mini-trial”     could     easily
    inflate the perceived importance of compliance and distract the
    jury from the central question before it—whether Bard’s design
    was unreasonable based on any dangers it posed versus the costs
    required to avoid them.            While 510(k) clearance might, at least
    tangentially,     say     something    about     the   safety   of     the    cleared
    product, it does not say very much that is specific.                         The vast
    majority    of   courts    have    said   so,    and   having   been    thoroughly
    briefed not only by the parties but by several amici, we say so
    again today.       As such, the district court did not abuse its
    discretion when it determined that allowing the 510(k) evidence
    15
    in on the question of design defect would be substantially more
    prejudicial than probative.
    B.
    Bard also argues that evidence of 510(k) compliance would
    have    been   particularly        relevant     on   the     question      of   punitive
    damages.       Under    Georgia     law,     punitive      damages    are       available
    where    there   is    “clear      and   convincing        evidence”       of   “willful
    misconduct,      malice,      fraud,     wantonness,         oppression,        or    that
    entire    want   of    care     which    would       raise    the    presumption        of
    conscious indifference to consequences.”                   Ga. Code Ann. § 51-12-
    5.1(b).        And     Georgia      courts      have    noted       that    regulatory
    “compliance does tend to show” this high willfulness standard
    has not been met.          Barger v. Garden Way, Inc., 
    499 S.E.2d 737
    ,
    743 (Ga. App. 1998).
    Although the question remains one of federal, not state,
    evidentiary law, federal courts are not likely to disagree with
    the Georgia courts that evidence regarding regulatory compliance
    (or     non-compliance)       is    often       relevant     to     the    willfulness
    inquiry.       See Restatement (Third) of Torts, Prod. Liab. § 4.
    Nevertheless, Bard’s argument is ultimately unpersuasive.                            While
    such evidence may be relevant, the compliance at issue in this
    case was, at most, minimally so.                 Again, the 510(k) process has
    been repeatedly characterized as something less than a safety
    requirement, gaining the applicant an exemption from regulation
    16
    rather than subjecting the applicant to regulation.                      
    Riegel, 552 U.S. at 322
    ; see also Almy v. Sebelius, 
    679 F.3d 297
    , 308 (4th
    Cir. 2012); Rodriguez v. Stryker Corp., 
    680 F.3d 568
    , 574 (6th
    Cir. 2012) (“The 510(k) process does not comment on safety.”).
    Thus, the decision to pursue 510(k) clearance was a choice to
    minimize the burden of compliance, potentially cutting in favor
    of punitive damages.        See Anastasi v. Wright Med. Tech., Inc.,
    
    16 F. Supp. 3d
    .   1032,    1036-37       (E.D.   Mo.     2014)    (finding    that
    defendant   chose   the    FDA    510(k)    process      to    “avoid    the   safety
    reviews,    including     clinical    trials,      required        for    pre-market
    approval under FDA regulations”).             As such, the district court
    is entitled to put 510(k) evidence before the jury, but it is
    not obligated to do so.          The court was within its discretion to
    determine that the value of putting the controversy over the
    510(k)   process,   and    Bard’s    compliance       or      non-compliance     with
    that process, before the jury was substantially outweighed by
    the likelihood of confusing the issues and misleading the jury.
    C.
    This Court does not reach the district court’s ruling that
    the 510(k) evidence could be excluded as irrelevant under Rule
    402 because the evidence was properly excluded under Rule 403.
    The district court’s Rule 403 ruling implicitly indicates that
    even if the evidence is relevant, it is insufficiently relevant
    to warrant admission.            We agree that the district court was
    17
    within its discretion in denying admission of the evidence using
    the lower standard in Rule 403, and therefore decline to address
    the more difficult question presented by the Rule 402 ruling.
    III.
    The second issue on appeal is whether the district court
    erred   when   it   overruled   Bard’s   hearsay   objections   to   the
    admission of a MSDS pertaining to polypropylene, a material used
    in the construction of the Avaulta Plus implanted in Cisson’s
    body.   There is, of course, a presumption that hearsay will not
    be admitted into evidence in federal courts.       Fed. R. Evid. 802.
    The MSDS in question in this case read in pertinent part as
    follows:
    MEDICAL APPLICATION CAUTION:     Do not use this . . .
    material in medical applications involving permanent
    implantation in the human body . . . .       Do not use
    this . . . material in medical applications involving
    brief or temporary implantation in the human body or
    contact with internal body fluids or tissues, unless
    the   material   has   been   provided   directly   from
    [Phillips]   under   an    agreement   which   expressly
    acknowledges the contemplated use.
    JA 4826.
    The district court accepted Cisson’s argument that the MSDS
    could come in as non-hearsay for the limited purpose of showing
    that the statement was made and that Bard was aware of it.           The
    court also ruled, sua sponte, that the MSDS was admissible for
    18
    its   truth   under   the    hearsay   exceptions        contained        in    Federal
    Rules of Evidence 803(17), 803(18), and 807.
    We review the district court’s applications of the hearsay
    rules, like applications of all Federal Rules of Evidence, for
    abuse of discretion, and its interpretations of such rules de
    novo.     Precision Piping & Instruments, Inc. v. E.I. du Pont de
    Nemours & Co., 
    951 F.2d 613
    , 619 (4th Cir. 1991).                     Doing so, we
    reverse    the    district     court’s      rulings      as     to    the       hearsay
    exceptions.       However,    we    affirm    the     decision       to   admit      the
    evidence as non-hearsay, finding that any use of the evidence by
    the plaintiff that went beyond the limited purpose for which it
    was admitted as non-hearsay resulted in harmless error and was
    not prejudicial to Bard’s defense. 2
    A.
    Rule 803(17), titled “Market Reports and Similar Commercial
    Publications,”     creates     an   exception       to    the    prohibition           on
    hearsay    for   “market    quotations,      lists,    directories,            or   other
    2 Cisson argues that Bard waived its right to attack the
    MSDS rulings on appeal by failing to continually object. Bard,
    however, was relieved of this obligation by Rule 103(b) once the
    court had “definitively” ruled on the matter.      Fed. R. Evid.
    103(b).     Cisson also argues that Bard waived this attack by
    introducing earlier versions of the MSDS for discussion by its
    witnesses, but this, of course, was in response to the district
    court overruling Bard’s several objections to admission of the
    MSDS.    Once a court has definitively decided evidence can come
    in, the opposing party must be allowed to defend against that
    evidence without losing its otherwise well-preserved objection.
    19
    compilations that are generally relied on by the public or by
    persons in particular occupations.”                    Fed. R. Evid. 803(17).                The
    district     court       ruled    that    the     MSDS    qualified        as    an    “other
    compilation” within this exception.                    We disagree.
    The district court’s ruling relied on its interpretation of
    the term “other compilation” in Rule 803(17).                              A question of
    interpretation going to the scope of the rule is reviewed de
    novo.      See Precision 
    Piping, 951 F.2d at 619
    .                        Our analysis is
    guided by ejusdem generis, a statutory canon of interpretation
    holding     that    where    a     statute      contains      an    exemplary         list    of
    objects     to     which    it     applies,       a    general     term    that       follows
    specific     ones    will     be    limited       in    its     meaning     by    the    more
    specific terms that preceded it.                      Circuit City Stores, Inc. v.
    Adams,     
    532 U.S. 105
    ,    114-15     (2001).         The    district         court’s
    reliance     on     the    general       term—“other       compilations”—concluding
    Rule 803(17)’s exemplary list makes the canon applicable.
    The narrower terms listed by the rule—“market quotations,
    lists,     directories”—are         items     that     recite      established        factual
    information.        In general, a MSDS might contain similarly factual
    information.        But in this case, Cisson sought to use a portion
    of   the   MSDS     that    was    not    factual       but   rather      operated       as    a
    warning     and    disclaimer       of    liability       for      the    self-interested
    issuing party.            The warning from Phillips that polypropylene
    should not be used in human implants was an opinion the company
    20
    issued    within       the     MSDS    for    self-interested       reasons,    and   it
    therefore       bears     no     resemblance       to    the      factual,    list-type
    documents enumerated in Rule 803(17).
    An advisory note to Rule 803(17) states that “[t]he basis
    of trustworthiness” for evidence admitted under the exception
    should be “the motivation of the compiler to foster reliance by
    being accurate.”             Fed. R. Evid. 803(17), advisory comm. note
    (1972).        Disclaimers of the sort in the MSDS are not typically
    so motivated, being intended instead to prevent any use of a
    product that might create a liability.                        Cisson has offered no
    proof     or    argument        that    the    disclaimer         warrants    the   same
    presumption       of    reliability      afforded       to   market   quotations      and
    directories, and a disclaimer clearly lacks the hallmarks of
    reliability that make market reports an exception.                       The district
    court therefore erred in holding the MSDS admissible for its
    truth under Rule 803(17).
    B.
    Rule       803(18),       titled    “Statements         in   Learned    Treatises,
    Periodicals,       or        Pamphlets,”      creates        an   exception    to     the
    prohibition on hearsay when a statement in such publications is
    (1) “called to the attention of an expert witness on cross-
    examination or relied on by the expert on direct examination”;
    (2) the reliability of that statement is established “by the
    expert’s admission or testimony, by another expert’s testimony,
    21
    or   by   judicial    notice”;   and   (3)    the   statement   is   read   into
    evidence rather than being received as an exhibit.                     Fed. R.
    Evid. 803(18).       The district court ruled, again sua sponte, that
    the MSDS could come in for the truth of the matter asserted as a
    “pamphlet” within the exception.             Again, we disagree.     We review
    this application of Rule 803(18) for abuse of discretion.
    The MSDS, as used in this case, does not meet any of the
    rule’s three facial requirements.             First, it was not “relied on
    by [an] expert on direct examination,” nor was it “called to the
    attention of an expert witness on cross-examination”:                 Cisson’s
    expert witnesses did not address the MSDS, and Bard’s witnesses
    attacked     the     MSDS   on   direct      examination.       Second,      the
    publication was not “established as a reliable authority” for
    the same reasons—because Cisson’s witnesses did not address the
    MSDS and Bard’s witnesses attacked it, no witness testifying at
    trial ever sought to demonstrate the reliability of the MSDS.3
    Finally, Cisson introduced the MSDS as an exhibit rather than
    having it read into evidence as required by the rule.                  Fed. R.
    Evid. 803(18).        Therefore, without addressing whether the MSDS
    presented in this case could have qualified as a “pamphlet,” we
    3Nor did the district court invoke judicial notice to
    establish the reliability of the MSDS. The reliability of the
    MSDS warning was clearly in dispute at trial, and judicial
    notice would have been improper.
    22
    find that the district court abused its discretion by admitting
    it under Rule 803(18) because the reliability of the evidence
    was not established according to the rule’s requirements.
    C.
    Rule     807,     titled     the    “Residual           Exception,”      creates     a
    hearsay       exception    for    certain       statements        not      covered   by   any
    exceptions in Rule 803 or 804.                        Fed. R. Evid. 807.              For a
    statement        to     come    under     this        exception       it     must    contain
    “circumstantial guarantees of trustworthiness,” be used to prove
    “a material fact,” and be “more probative on the point for which
    it     is     offered    than     any     other       evidence”       available      through
    “reasonable       efforts.”         
    Id. We review
       the     district     court’s
    application of the rule here for an abuse of discretion, noting
    however that the residual hearsay exception “was meant to be
    invoked sparingly.”             
    Heyward, 729 F.2d at 299
    (quotation marks
    omitted).
    As discussed in more detail below, the MSDS was hardly the
    best        evidence    available       that        polypropylene       was    potentially
    dangerous       for     human    implantation.           The     relative      dangers     of
    polypropylene in pellet and monofilament form was an issue that
    received substantial attention from both parties’ experts who
    themselves relied on studies, reports, empirical evidence, and
    tissue        sample     slides     evidencing           Ms.     Cisson’s       particular
    pathology.        The warning in the MSDS, on the other hand, was
    23
    nothing    more      than   an    assertion      made        by    the     self-interested
    manufacturer of polypropylene that the product should not be
    implanted in humans.              The MSDS made no attempt to explain why
    polypropylene might be dangerous or how Phillips had come to
    this    conclusion.         Because        there    was          ample    other       evidence
    available to address polypropylene’s viability as a material for
    surgical implants, we find that the district court abused its
    discretion in finding, again sua sponte, that the MSDS could
    come in for its truth under Rule 807.
    D.
    Having reviewed and reversed the district court’s several
    sua sponte rulings that the MSDS could come in for its truth
    under    various      hearsay      exceptions,         we    now     turn       to    Cisson’s
    original    rationale       for    offering      the    MSDS:            that    it    was   not
    offered    as   hearsay.          Cisson    argued,         and    the     district        court
    agreed, that the warning in the MSDS would not be hearsay if it
    was offered to show only that Phillips made, and Bard received,
    the warning statement.              Bard does not dispute this on appeal,
    but    argues   instead     that     Cisson      used       the    MSDS    for       its   truth
    during the trial and that it was therefore offered as hearsay
    without an exception.             Having thoroughly reviewed the record we
    have    found   no    reversible     error,      and        we    therefore      affirm      the
    district court’s admission of the MSDS.
    24
    “Out-of-court        statements        constitute         hearsay        only    when
    offered in evidence to prove the truth of the matter asserted.”
    Anderson     v.    United      States,      
    417 U.S. 211
    ,    219     (1974).        A
    statement that would otherwise be hearsay may nevertheless be
    admissible if it is offered to prove something other than its
    truth, and this includes statements used to charge a party with
    knowledge of certain information.                   Gardner v. Q.H.S., Inc., 
    448 F.2d 238
    , 244 (4th Cir. 1971) (finding out-of-court statements
    admissible      “to     show    defendants’        knowledge     of     the    harm    their
    product could inflict, provided only that [the statements] were
    brought to the attention of the defendants”); see United States
    v. Macias-Farias, 
    706 F.3d 775
    , 781 (6th Cir. 2013).                            “[W]hether
    an    out-of-court       assertion     is   hearsay       depends      on     its    use”   at
    trial.    David F. Binder, Hearsay Handbook § 1:9 (4th ed. 2015).
    Cisson originally sought to introduce the MSDS to show that
    Bard had received the warning from Phillips, one of many safety-
    related    “red    flags”       she   argued      demonstrated         Bard’s       knowledge
    that its product might be unsafe.                       This was used to support
    Cisson’s       argument        that   the      company        should        have     further
    investigated       the     safety     of     the       Avaulta       Plus     rather    than
    marketing the product immediately.                     Cisson insists that during
    the    trial      she    did    not    rely       on    the     MSDS     to     show    that
    polypropylene was unsafe or to prove causation.                               Bard argues,
    however, that “[h]aving secured . . . a ruling that the MSDS was
    25
    admissible for its truth, Plaintiffs took full advantage of the
    rulings” by using the document to show that polypropylene was
    unsuitable       for     implantation             and     contributed       to     Cisson’s
    injuries.       Appellant’s R. Br. 30.                  Cisson’s position ultimately
    proves more convincing for two reasons.                          First, throughout the
    trial    Cisson        consistently           limited       use     of     the    MSDS     to
    establishing that Bard received the warning and then responded
    either   by     ignoring    it    or    withholding         it    from    other    parties.
    Second, even if Cisson did at any time use the MSDS for its
    truth, she did so in a way that did not prejudice the defendant.
    Roger     Darois,     Bard’s          Vice       President    of     Research      and
    Advanced       Technology,       was     the        key    witness       Cisson    used    to
    establish that Bard had received, and then ignored and withheld,
    the MSDS warning regarding human implantation.                            Throughout that
    testimony, Cisson’s attorney pressed Darois on Bard’s response
    to the warning, pointing out that (1) the company did not reach
    out to Phillips to clarify why the warning had been added to the
    MSDS    in   2007   after    decades         of     polypropylene        production,      (2)
    Bard’s supplier of monofilament refused to continue supplying
    processed       polypropylene          for     medical       applications         after    it
    learned of the MSDS warning, and (3) Darois told Bard staff
    members to take steps that would prevent Phillips from learning
    that Bard was implanting medical devices made with polypropylene
    into human patients.
    26
    As Bard pointed out in its appeal on the 510(k) issue,
    Georgia     product    liability          law     incorporates           reasonableness
    principles, ICI 
    Americas, 450 S.E.2d at 673-74
    , and the punitive
    damages     standard   in   Georgia         requires         a    jury    to    find     the
    defendant was willful and wanton in its disregard for the safety
    of others, Ga. Code Ann. § 51-12-5.1(b).                          It seems clear that
    Cisson    used   the   MSDS,    at    least       with       regard      to    the    Darois
    testimony     (which   again        was     the       most       significant     exchange
    involving    the   MSDS),      to    show       Bard’s       conduct     was    not    only
    unreasonable     but   “would       raise       the    presumption        of    conscious
    indifference to consequences.”                 
    Id. None of
    the questions to
    Darois went to proving the actual truth of the MSDS warning,
    that is, the testimony did not address whether polypropylene was
    actually dangerous or could have caused Cisson’s injuries.
    Bard argues that Cisson relied on the MSDS as substantive
    evidence of causation not only during the Darois testimony, but
    throughout the trial, claiming that “Plaintiffs’ counsel went so
    far as to tell the jury that it could . . . find for Plaintiffs
    based solely on the MSDS.”            Appellant’s R. Br. 30.                  It is first
    worth noting that this assertion stands in stark contrast to
    Bard’s characterization of the MSDS testimony in its closing
    argument at trial:
    The MSDS sheet.   Think about it.  Go back to your
    notes. Think about it. Not a single witness for the
    plaintiff talked about the MSDS sheet.    Nobody[.]
    27
    . . . .       [T]heir  experts,  Dr.   Brennan   and
    Dr. Klosterhalfen and Dr. Hoyte, they didn’t talk
    about it.   Nobody linked it up.  Nobody linked this
    issue up.
    JA 6578.      At that time, Bard apparently felt that the MSDS
    simply had not been used in a way that could support causation,
    but on appeal it argues Cisson ubiquitously abused the district
    court’s mistaken ruling that the MSDS could be used for its
    truth, causing an incurable prejudice to Bard.               At oral argument
    Bard’s counsel called the MSDS the “centerpiece” of Cisson’s
    case to the jury.       Oral Argument 15:05.       Having reviewed a great
    deal of the more than 7000 pages of record before us (not only
    the portions cited by Bard to support its contentions, but many
    more pages of testimony, transcripts, exhibits, and rulings), we
    find Bard’s characterization generally overwrought.                  We tend to
    agree instead with their earlier statements to the jury that
    Cisson    never   sought    to   link    the    MSDS   to   the     question   of
    causation.
    There is, however, one statement made by Cisson’s counsel
    that has given us some pause.           After bringing up the MSDS during
    closing    arguments,      Cisson’s     trial   counsel     said,    “Now,     the
    interesting thing about that is you can dismiss all the experts.
    You can say, well, this expert is biased and that expert is
    biased.      But Phillips Sumika, they don’t have a dog in the
    hunt.”    JA 6537.   On its face, the statement appears to instruct
    28
    the jury that the MSDS is more reliable than the experts and can
    therefore establish causation.                         But we need not decide whether
    the statement was an attempt to use the MSDS to overcome adverse
    expert       testimony         on    the     question        of    causation,         because      that
    single       stray       comment       was      not    enough       to    prejudice         Bard     and
    require       a    new     trial.          Federal        courts     of    appeal       review       the
    fairness of district court proceedings “without regard to errors
    or defects which do not affect the substantial rights of the
    parties.”          28 U.S.C. § 2111; McDonough Power Equip., Inc. v.
    Greenwood, 
    464 U.S. 548
    , 553-54 (1984).                                  To find the alleged
    error    harmless,          “we       need      only      be      able    to    say     ‘with      fair
    assurance, after pondering all that happened without stripping
    the erroneous action from the whole, that the judgment was not
    substantially swayed by the error.’”                               United States v. Heater,
    
    63 F.3d 311
    ,       325    (4th       Cir.    1995)       (quoting        United       States    v.
    Nyman, 
    649 F.2d 208
    , 211 (4th Cir. 1980)).
    The     alleged         error       in   this      case     was    harmless         for   three
    reasons.           First,           Bard     has      pointed       to    only       one     actually
    problematic statement from Cisson’s counsel over the course of a
    ten day trial.             Although Bard cites several parts of the record
    it claims show the MSDS being used for its truth, the only one
    that    is    at     all    convincing          is     the     “dismiss        all    the    experts”
    statement.         For example, Bard argues that the MSDS was used as
    substantive evidence of causation in Cisson’s opening argument,
    29
    citing JA 2358-60.                That portion of the transcript, however,
    shows Cisson’s attorney explaining to jurors that the MSDS was
    produced by the polypropylene manufacturer, that it contained a
    warning that material should not be used in implants, that the
    MSDS (and its warning) was in Bard’s possession, and that Bard
    should have taken the warning seriously by verifying that the
    material was safe for its medical device.                       None of that goes to
    causation, and all of it supports Cisson’s contention that the
    MSDS was being used to show Bard was warned about potential
    dangers and acted irresponsibly in response to that warning.
    Bard cites other parts of the opening argument, but these show
    Cisson’s attorney referring to the MSDS, not as scientific proof
    that polypropylene is unsafe, but rather as a “red flag” and a
    “safety     alert”         that    should     have       put    Bard     on    notice    to
    investigate further.
    Bard also points to a portion of the Darois testimony at JA
    4424-27 (and a related exhibit at JA 4652-54), but the questions
    and   answers         on   those    pages    demonstrate        only   that      Bard   was
    attempting       to    keep      Phillips    in    the   dark    about    polypropylene
    being     used    in       the    Avaulta    Plus     after     Phillips        added   the
    implantation warning to the MSDS in 2007.                       Again, this evidence
    tended     to    show       that    Bard’s        reaction     to   the       warning   was
    unreasonable, not that polypropylene caused Cisson’s injuries.
    The MSDS simply was not being used for its truth.                             The same is
    30
    true of all Bard’s citations to the record on this point, with
    the exception of the one statement we have noted.                         The fact that
    there was only one such instance during ten days of evidence
    cuts strongly in favor of finding the alleged error harmless.
    Second, Cisson presented substantive evidence showing that
    the polypropylene implanted in her body was degraded, providing
    the jury with a much more compelling reason to conclude that
    polypropylene contributed to her injuries than simple reliance
    on a warning in a MSDS.               Had Cisson’s “dismiss all the experts”
    statement been repeated, particularly on separate occasions and
    thereby developed into a theme, we might be more persuaded that
    there was error and that it was not harmless.                        After all, taken
    on   its   face     and     without       context,      the        statement     can     be
    interpreted    to    tell       the    jurors    that       they    can    ignore      both
    Cisson’s experts, who testified that polypropylene can degrade
    in   the   body     and    cause       injuries,     and     Bard’s       experts,      who
    testified this was undemonstrated and unlikely.
    However, the jury in this case heard substantial evidence
    to support the conclusion that the polypropylene in Cisson’s
    Avaulta Plus degraded and harmed her.                       Cisson presented three
    separate   experts        who   testified       on   this    point:        Dr.   Anthony
    Brennan,   a   biomedical         engineer;      Dr.    Bernd       Klosterhalfen,       a
    pathologist; and Dr. Brian Raybon, the physician who implanted
    the Avaulta Plus into Cisson’s body.                    Dr. Brennan provided the
    31
    jury with an opinion that fluids in the human body can degrade
    polypropylene, Dr. Raybon testified that the polypropylene in
    Cisson’s implant had degraded, and Dr. Klosterhalfen reviewed
    Cisson’s pathology and told the jury she had an inflammatory
    reaction and scar plate, symptoms consistent with polypropylene
    degradation.        In order for us to reverse the district court,
    Bard   must   show    that    its    “substantial        rights”    were   affected,
    
    Greenwood, 464 U.S. at 553-54
    ,     or     that     the     jury      was
    “substantially swayed by the error,” 
    Heater, 63 F.3d at 325
    , but
    the fact that the jury had substantial expert testimony on one
    side and a single stray comment by Cisson’s attorney on the
    other again cuts strongly in favor of finding the alleged error
    harmless.
    Finally,    Cisson’s     causation     evidence      linked       three      other
    design    defects    to   her      injuries   in    addition       to    the    alleged
    polypropylene defect.           Bard therefore cannot meet its burden
    without   some     showing    that    the   jury   was     unpersuaded         by   these
    alternative       theories    of     causation,     or     at     least    that      the
    polypropylene      theory    was     sufficiently       central    to    its    damages
    award that Bard’s substantial rights were affected.                             See 
    id. (assuming an
        evidentiary       ruling      was     erroneous       and       then
    considering all of the evidence adduced at trial to determine
    the likelihood of prejudice).               Specifically, Cisson’s evidence
    included expert testimony to the effect that the mesh in the
    32
    Avaulta Plus was subject to shrinking post-implantation, that
    the pores in the mesh were too small and therefore likely to
    result in the formation of rigid scar tissue, and that the arms
    used   to   hold    the   Avaulta   Plus     in   place   in    the    body    were
    defectively designed and contributed to Cisson’s pain.                         Bard
    fails to demonstrate, or even argue, that the jury based its
    conclusions    on   the   polypropylene       degradation      evidence    rather
    than these theories, which were central to her case.                   Cisson, on
    the other hand, presented multiple experts in support of each
    causation theory and linked them to her injuries.
    Bard has failed to demonstrate that the one problematic
    statement regarding the MSDS it has managed to identify in the
    record had a significant effect on the jury’s decision.                       Given
    the very significant evidence Cisson presented on causation, and
    given that the problematic statement was, at most, addressed to
    one of Cisson’s four theories of causation, we cannot find that
    Bard’s substantial rights were affected.             We therefore find the
    alleged error harmless and affirm the district court’s admission
    of the MSDS.
    IV.
    The third issue raised by Bard on appeal is whether the
    district    court    erred    in    its     instruction    to    the    jury    on
    causation, as well as in its subsequent ruling upholding the
    33
    jury’s    causation     finding       pursuant     to    its        denial      of   Bard’s
    renewed motion for judgment as a matter of law.                            Bard charges
    that it was prejudiced because the court’s causation instruction
    did not reflect Georgia law.
    Rulings    on    jury     instructions      are    reviewed       for      abuse    of
    discretion, but where there is an error of law we review de
    novo.     Emergency One, Inc. v. Am. Fireeagle, Ltd., 
    228 F.3d 531
    ,
    538 (4th Cir. 2000).          We review to ensure that the “charge [was]
    accurate on the law and [did] not confuse or mislead the jury.”
    Hardin    v.   Ski    Ventures,      Inc.,   
    50 F.3d 1291
    ,       1294      (4th    Cir.
    1995).     Because the court’s instruction met this standard, and
    because    the   jury     had    ample    evidence       on    which       to    base    its
    causation finding, we affirm the district court.
    Bard’s     position       is    that     Georgia        law    requires        injury
    causation be proved by “expert testimony stated to a reasonable
    degree of medical probability or certainty,” that the court was
    wrong to deny its request for an instruction reflecting that
    standard, and that Cisson failed to offer expert testimony on
    two   alleged    design    defects       sufficient      under       the     standard     to
    prove they caused her injuries.                But Bard’s characterization of
    Georgia law incorrectly states the standard of proof applicable
    here, inserting the standard for medical malpractice cases into
    this product liability case.
    34
    The district court charged the jury using Georgia’s pattern
    jury instructions for strict liability tort cases, which defines
    the burden of proof for proximate cause as a preponderance of
    the evidence.    See Ga. Suggested Pattern Jury Instructions, Vol.
    I:     Civil Cases §§ 60.200 & 62.610 (5th ed. 2015).             It is also
    established under Georgia law that plaintiffs in medical implant
    cases “may present medical as well as non-medical evidence to
    show causation.”       Allison v. McGhan Med. Corp., 
    184 F.3d 1300
    ,
    1320 (11th Cir. 1999).
    Bard cannot point to a single Georgia case (or any case
    applying Georgia law) stating that the standard in the pattern
    jury    instruction    is   incorrect.     Instead,   Bard   points   to    an
    inapposite Georgia Supreme Court case, Zwiren v. Thompson, 
    578 S.E.2d 862
    (Ga. 2003), a comparison that suffers from multiple
    problems.    First, Zwiren was a medical malpractice case, not a
    product    liability   case.     Second,   while   the   Zwiren   court    did
    indeed adopt the “reasonable medical probability or certainty”
    standard Bard advocates, the thrust of the opinion was to reduce
    the standard from “reasonable medical certainty” to “reasonable
    medical probability.”        
    Id. at 867.
       This lower standard “is the
    functional equivalent of preponderance of the evidence”—the same
    standard expressed by the pattern jury instruction.                 
    Allison, 184 F.3d at 1320
    .           Thus, even in malpractice cases, “Georgia
    case law requires only that an expert state an opinion regarding
    35
    proximate       causation      in    terms     stronger       than       that     of    medical
    possibility.”           
    Zwiren, 578 S.E.2d at 867
    .                      In medical implant
    cases the need for exclusively medical evidence is abrogated.
    
    Allison, 184 F.3d at 1320
    .
    Cisson presented ample expert and non-expert testimony for
    a jury to find that the design defects caused her injuries.                                    In
    addition to the evidence already described in Part III of this
    opinion, Cisson presented the following testimony to the jury:
    Dr. Lennox Hoyte, a urogynecologist, and Dr. John Miklos, one of
    Cisson’s    treating         physicians,      respectively           testified         that   the
    arms on the Avaulta Plus constituted a design defect and caused
    Cisson’s       pain;     Dr.   Bernd       Klosterhalfen,           a    pathologist,         and
    Dr. Jim Ross testified that inadequate pore size can cause the
    implanted mesh to shrink and can lead to inflammatory reactions
    and     rigid       scarification         inside    the      body;       and    Dr.     Anthony
    Brennan,        a    professor      and     expert      in    material          sciences      and
    biomedical engineering, Dr. Klosterhalfen, and Dr. Brian Raybon,
    another     of        Cisson’s       treating        physicians,           testified          that
    polypropylene can degrade in the human body, degradation can
    cause    internal        inflammation,       and     that     Ms.       Cisson’s       mesh    was
    degraded.           This and the other evidence presented at trial was
    more    than        enough   for    the    jury    to   conclude         that    the    alleged
    defects caused Cisson’s injuries.                       Although Bard argues that
    Cisson’s burden was to show precisely how each alleged defect
    36
    caused particular injuries, under Georgia product liability case
    law “it is not necessary for the plaintiff to specify precisely
    the nature of the defect”; a plaintiff need only show that “the
    device did not operate as intended and this was the proximate
    cause    of   [the   plaintiff’s]   injuries.”       Trickett    v.    Advanced
    Neuromodulation Sys., Inc., 
    542 F. Supp. 2d 1338
    , 1345 (S.D. Ga.
    2008) (emphasis removed) (quoting Williams v. Am. Med. Sys., 
    548 S.E.2d 371
    , 373 (2001)) (quotation marks omitted).
    We therefore find that the district court did not err in
    giving the Georgia pattern jury instruction, in denying Bard’s
    request for a modified instruction, or in upholding the jury’s
    causation finding.
    V.
    The jury awarded Cisson $250,000 in compensatory damages
    and $1.75 million in punitive damages. 4         “The Due Process Clause
    of the Fourteenth Amendment prohibits the imposition of grossly
    excessive or arbitrary punishments on a tortfeasor” in the form
    of   punitive    damages.     State    Farm   Mut.    Auto.     Ins.   Co.   v.
    Campbell, 
    538 U.S. 408
    , 416 (2003).           As such, Bard argues that
    4 The punitive damages were subject to a split-recovery
    statute, dividing the award between the plaintiff and the State
    of Georgia.    As a result, Cisson only received twenty-five
    percent of the award, while Georgia received the remaining
    seventy-five percent. See Part VI. infra.
    37
    the punitive award in this case was constitutionally excessive.
    We review this constitutional question de novo, 
    id. at 418,
    and
    affirm the award.
    The Supreme Court has articulated three “guideposts” for
    reviewing     the   constitutionality           of   a     punitive         damages     award:
    “(1)    the     degree     or     reprehensibility              of      the      defendant’s
    misconduct, (2) the disparity between the harm (or potential
    harm) suffered by the plaintiff and the punitive damages award,
    and (3) the difference between the punitive damages awarded by
    the    jury   and   the    civil     penalties       authorized             or   imposed     in
    comparable      cases.”        Cooper     Indus.,        Inc.     v.    Leatherman          Tool
    Group, Inc., 
    532 U.S. 424
    , 440 (2001)) (citing BMW of N. Am.,
    Inc. v. Gore, 
    517 U.S. 559
    , 574-75 (1996)).                                 The Court also
    noted that the first of these factors, reprehensibility, is the
    most important.          
    Campbell, 538 U.S. at 419
    (quoting 
    Gore, 517 U.S. at 575
    ).       Bard, however rests its challenge entirely on the
    second guidepost, asserting only that the punitive award “is
    constitutionally         impermissible,         as    it     is        seven     times      the
    $250,000 compensatory damages award.”                    Appellant’s Br. 58.
    Bard’s    argument       is   based      principally            on     the     Campbell
    Court’s observation that “an award of more than four times the
    amount of compensatory damages might be close to the line of
    constitutional 
    impropriety.” 538 U.S. at 425
    .                    However, Bard
    apparently      failed    to    realize    that      the    Court       went     on    to   say
    38
    “these ratios are not binding” and to conclude that “[s]ingle-
    digit    multipliers       are     more     likely      to   comport       with       due
    process . . . than awards with ratios in range of 500 to 1.”
    
    Id. Bard effectively
    urges this court to adopt a bright line
    rule against punitive damages exceeding a ratio of four-to-one,
    despite the Supreme Court itself “declin[ing] again to impose a
    bright-line ratio which a punitive damages award cannot exceed”
    in Campbell.       
    Id. The district
    court found that “here, the
    compensatory     damages     and    punitive      damages    against       Bard      both
    arose    from    its     misconduct       that    resulted    in     Ms.       Cisson’s
    injuries,” JA 7139-40 n.8, and grounded its refusal to overturn
    the award in reprehensibility of Bard’s conduct, JA 7138-43.                           We
    therefore       find     that      the     seven-to-one       ratio        was        not
    constitutionally excessive in this case and affirm the district
    court.
    VI.
    The final issue before us comes from Cisson who challenges,
    by    cross-appeal,    the    district      court’s     ruling     that    a    Georgia
    split-recovery     statute       garnishing      seventy-five      percent      of    any
    punitive    damages       award    arising       from    a   product       liability
    judgment, O.C.G.A. § 51-12-5.1(e), does not violate the Takings
    Clause of the Fifth Amendment of the United States Constitution.
    39
    Cisson asserts that Georgia created a property interest in such
    punitive damages awards when it codified them in O.C.G.A. § 51-
    12-5.1, and that enforcement of the state’s subsequently enacted
    split-recovery     statute     violates     the   Takings    Clause.         The
    district   court    rejected    that    argument,    and     we    review    its
    decision de novo.     To succeed, Cisson must first show she has “a
    constitutionally    protected    property     interest”     in    the   punitive
    damages award at issue.         See Washlefske v. Winston, 
    234 F.3d 179
    , 184 (4th Cir. 2000).       Cisson contends that she has a vested
    property interest in the entire punitive damages award, but, in
    the scant briefing she has provided to this Court on the issue,
    she has failed to articulate a viable theory in support of that
    contention.
    Cisson makes no claim that her right to punitive damages
    arises from the common law or is otherwise fundamental, so we
    need not address the opinions of some courts which have found
    that no such right is cognizable under the Takings Clause.                  E.g.
    Enquist v. Oregon Dep’t of Agric., 
    478 F.3d 985
    , 1002-04 (9th
    Cir. 2007).   Instead she argues that her property interest was
    created by Georgia statute.       Appellee’s Br. 92.         But Cisson does
    not explain how Georgia exceeds its authority by defining the
    contours of the right it has allegedly created.              
    Washlefske, 234 F.3d at 184
    ; see Cheatham v. Pohle, 
    789 N.E.2d 467
    , 473 (Ind.
    2003) (holding that the legislature could define a plaintiff’s
    40
    interest     in   a   statutorily    created    property   right).    “[I]f   a
    statute creates a property right . . . , the property interest
    so created is defined by the statute . . . .”                
    Washlefske, 234 F.3d at 184
    .       As   such,    under     Cisson’s   own   theory   “the
    legislature may lawfully regulate the amount of punitive damages
    which can be awarded,” Mack Trucks, Inc. v. Conkle, 
    436 S.E.2d 635
    , 639 (Ga. 1993), and she has therefore provided no basis for
    us to find the state’s actions unconstitutional.
    As such, we affirm the judgment of the district court.
    VII.
    For the foregoing reasons, the judgment of the district
    court on all issues raised in this appeal is
    AFFIRMED.
    41
    

Document Info

Docket Number: 15-1102, 15-1137

Citation Numbers: 810 F.3d 913

Judges: Gregory, Agee, Diaz

Filed Date: 1/14/2016

Precedential Status: Precedential

Modified Date: 11/5/2024

Authorities (26)

anup-engquist-v-oregon-department-of-agriculture-joseph-jeff-hyatt-john , 478 F.3d 985 ( 2007 )

No. 98-1884 , 179 F.3d 154 ( 1999 )

Williams v. American Medical Systems , 248 Ga. App. 682 ( 2001 )

eugene-duvall-patricia-sue-duvall-v-bristol-myers-squibb-company-a , 103 F.3d 324 ( 1996 )

Circuit City Stores, Inc. v. Adams , 121 S. Ct. 1302 ( 2001 )

Trickett v. Advanced Neuromodulation Systems, Inc. , 542 F. Supp. 2d 1338 ( 2008 )

Barger v. Garden Way, Inc. , 231 Ga. App. 723 ( 1998 )

Cheatham v. Pohle , 2003 Ind. LEXIS 440 ( 2003 )

United States v. Thomas G. Heyward , 729 F.2d 297 ( 1984 )

Almy v. Sebelius , 679 F.3d 297 ( 2012 )

precision-piping-and-instruments-incorporated-a-west-virginia-corporation , 951 F.2d 613 ( 1991 )

Riegel v. Medtronic, Inc. , 128 S. Ct. 999 ( 2008 )

BMW of North America, Inc. v. Gore , 116 S. Ct. 1589 ( 1996 )

Medtronic, Inc. v. Lohr , 116 S. Ct. 2240 ( 1996 )

Allison v. McGhan Medical Corp. , 184 F.3d 1300 ( 1999 )

Henry L. Hardin v. Ski Venture, Incorporated, D/B/A ... , 50 F.3d 1291 ( 1995 )

United States v. Harald Olav Nyman , 649 F.2d 208 ( 1980 )

William F. Washlefske v. Andrew J. Winston Ronald J. ... , 234 F.3d 179 ( 2000 )

Rodriguez v. Stryker Corp. , 680 F.3d 568 ( 2012 )

sally-s-hottle-personal-representative-of-the-estate-of-douglas-a , 47 F.3d 106 ( 1995 )

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