Document 10YX4r38o62RzwRjvLjwoJz5Z

Special Article Medicolegal Aspects of Asbestos for Pathologists c * i r nnn i c The t-o orincieal Itgtl femeOie* avails a to victim* ot atStcoi-ra'alaO Citeaia art m; etaimt fcr eanatitt undar w:-.at*' :ansantat.on !aw and (2) suita ter tini: `.rear tha liwi et sredueta T*? i-atieoia??! nua and tha ea.-t ot the cenjuiling paihoiogxt aa mad* ies.ajei eeny-ftant and aioart witnata in aaen et thssa legal oreeaae:e are rsentiarty tha jama. Urc/i Pttr.el L*i ye 1983:107:557sev fT^he 'era: remedies available to vieX time of asbestcx-rfiatcd disease art chiefly of two type*: ciaim.s for benefits under workers' compensation laws and suits for damages ur.dr tha law* of products liability. This report will examine both remedial systems of law, a? well as the role of the patholocirtexpert cor.juhr.rt and witness witr.-r. them. claims fcr benefits under V.'OF.ItERS' COMPENSATION LAWS compensation is the sys tem ': laws by which employees are compensated by their employers for r-cctyaticnaliv cause'! injury er dis- Traditional!", wrrkers' compensat.j.n fer asbestos-related disease has `ee.n the independent function of the individual states. Mow. however, several bills pcr.cir.j before Congress would ee*:bt:*h an important position for the fc ItrrI government within the A.! i-- ;u: "n;:>s .Vi.-i - J. l?il t:as a;sersr--~t-U*:* h.ine- tv.. 1 v nu! f -* --rrica* 0*7 Vr. r*i: 5x:t f C >i-*i Jtiar.i Enti. F.a. Ort 11. vAt fcrff-fj*.* r* : .*. *r- ??v*! r:-- r\ r::ii V- !(:frni-s >. system.'Eefore the 19.'0s. occupational lung disease as a cause of disability or death had been ignored by the nation ? workers' compensation sys tem. In 1932. the building of a tunnel through a mountain of quartz at Gau!ey Eridue. \Wa. brought death to hundreds of workers from, massive exposure to silica dust. Public shock over the Gauley Bridge disaster moti vated state legislatures to extend workers' compensation coverage to include total disability and death due to silicosis and other specific types of occupational lung disease, including asbestosis. In 196*. another West Vir ginia disaster, the mining explosion at Farmington, precipitated the Federal Black Lung Program. By 1978, every state had provided workers' compen sation for disability or death due to occupational lung disease. Coverage has so expanded that, according to Selikoff/ "Jnearlv] ail of the survivors of the asbestos insulators who filed workers' compensation death claims ultimately received benefits.'' Underlying workers' compensation is the concept of a "no-fault" liability insurance system by which employees trade off their common-law right to sue their employers for damages in exchange for income, and medical ben efits and rehabilitation services. The defenses of contributor-' negligence, assumption of risk, and the fellowservant rule (which often blocked employees' claims whenever a work er's injury had resulted from his own .negligence, from his voluntary taking a known risk, or from the actions of fellow workers) were abolished under workers* compensatk r. as part of the trade-off.' Importantly for asbestosrelated diseases, h:cs:i ef their long and latent periods of incubation, time limitations on institution of suit, callrd statutes o/ iimtta'ion. do not apply until there is reason to know that the employee's disability or death had in fact been due to occupa tional disease. I.n workers' compensation law the claimant is required to prove that the employee's disability or death arose out of his employment. Legal defini tions of "disability" may vary. but. with important exceptions, it usually means loss of earning power due to occupationally related injury or dis ease/ In most states, workers' com pensation equals two thirds of work ers' preinjury wages. By providing for less than complete compensation for wage loss, the system in theory cre ates incentives for healthy workers to avoid injury, -and for injured workers to return to work. However, it is doubtful that these socioeconomic objectives are attained in occupation al lung disease cases, because the pop ulation of occupational lung disease claimants disproportionately com prises retired workers or their survi vors ar.d avoidance of toxic exposures would be difficult when the toxicity risked involves either unperceived exposure to long-term conditions or unanticipated episodes of short-term exposure.*'"*' The average value of disability benefits for occupational lung disease under Pennsylvania's workers' compensation law is re portedly 8200,000/ However, in asbes tos-related case*, because calculation of th* preinjury wage is often based on the wage received by the worker at the time of exposure to asbestos, many years before disease appeared rlinirsily.* the ben-.-fit rate may prove to in; /-. hv current standard*. Thus. ~rzm FW U r *.<*--voi 1C7. NO* )U t/ss-coiega: Accte's --Rieftman 557 DOW 07244 a World War II shipbuildtr, presently facing many asbestos-related claims attributable to employment daring the 1940s, has computed 112,000 as the average value for them. In the United States, disputed ques tions, including formidable ones of diagnosis, etiology, and cause of death or disability*, are tried and decided by litigation in an adversary* proceeding. Evidence from lay and expert wit nesses is presented, subject to crossexamination, to adjudicators em ployed by the compensation agency. Because respiratory problems in par ticular are often unrelated etiologically to toxic exposures and frequently resuit from **ordir.ary diseases of life." social habits, or the aging pro cess. X"* of respiratory disease claims are litigated.1 In over 75% of the litigated cases, causation is a con troverted issue, often involving com plex scientific testimony and a costly battle of experts.' SUITS FCR DAMAGES UNDER PRODUCTS LIABILITY LAWS The chief means by which victims are compensated by the seller (or manufacturer) of a defective and unreasonably dangerous product is a civil suit for damages based on the law of products liability. If the harm had befallen the victim because of his employment and if the seller (or man ufacturer) had not been the victim's employer, the seller (or manufactur er) is sometimes called a third party, and the suit against it is sometimes referred to as a third-party claim. The law of products liability it grounded on a codification of the com mon law of torts as reported in section 402A of the Restatement (Second) of Torts. By it. "strict liability" at taches to the person who markets a product that, though useful and desir able. is inherently unsafe if its user or mnsnmrr is noi given proper warning of the product's dangers. The "strict" liability of the seller-manufacturer to the victim ir justified by the public policy belief that the burden of harm caused by the product should be placed on those who market it and should bo treated as a cost of doing business against which liability insur ance can be obtained.' Under the law of products liability, a manufacturer (or seller) of asbestos materials is required to warn of dan gers involved in handling the materials, and the failure to give ade quate warning renders the material unreasonably dangerous and its man ufacturer i or seller) liable in damages to the unwarned victim harmed by the material.1* In asbestos-related law suits, most plaintiffs allege that the manufacturer (or seller) had failed in this duty to warn of the hazards from inhalation of asbestos fiber originat ing from asbestos-containing prod ucts." In cases against Manviile Carp, a leading producer of asbestos, i: has been conclusively determined in the courts that asbestos materials art unreasonably dangerous as a natter of law because asbestos fibers cause ssbestosis and mesothelioma and because adequate warning had not been given by Manviile Corp.-4 The asbestos-related products lia bility claim is usually adjudicated at a trial in which the issues are decided by a judge and jury. Once the products liability issue of adequate warning is reached and passed, the remaining disputed questions art the same as those tried and decided in the work ers' compensation proceeding: the for midable ones of diagnosis, etiology, and cause of death or disability. As previously stated, these issues involve complex scientific testimony ar.d s costly battle of experts. The nationwide asbestos products liability caseload was recently esti mated to be 16,000 pending suits and growing by 400 to 500 cases per month." Manviile Corp reported that 16.500 lawsuits related to the health effects of asbestos have been brought against it1' According to a Manviile Corp official, the majority of cases have been brought by former insula tion workers employed in World War II shipyards.1"'"*** During liisO. the average amount of damages paid by Manviile Corp, as the result of settle ment or judgment in an asbestos products liability ease, had been J23.000.1"*"1 Through the first half of 19S2, Manviile Corp had settled approximately 300 asbestos-related claims for an average payment of $16,600 per claim.1* THE PATHOLOGIST'S ROLE AS MEDICOLEGAL CONSULTANT The pathologist's involvement with either a workers' compensation claim or a products liability lawsuit may originate because he has examined biopsy specimens or because he has performed autopsies. One interested pathologist has said that since as many, as 10T: of all iung cancer deaths may be related to asbestos exposure, failure of the autopsy prose cutor or surgical pathologist to take and retain adequate histologic sec tions for exclusion or establishment of asbestos exposure may be profession al negligence, thatis, malpractice (M. R. Hales. MD. written communi cation. Aug IS, 1952). The pathologist's involvement in a law case may also originate because of an attorney's request for consultation as to pathologic studies done by another pathologist.' Regardless of type of legal proceed ing or origin of case involvement, the principal role of the pathologist, as a mecicolegai consultant, is (1) to describe ar.d diagnose all important pathologic findings. (2) to prove or disprove a causal relationship be tween the important findings and impairment or death, and 12) to iden tify ar.d explain the etiology of the pathologic findings. To perform with competence his function as medicolegal consultant. **? the pathologist should be more thar*/) prosector and histologist. He mui'H study and evaluate the available evi-Q cence of elinica! history, occupational history, environmental history, ando the history of smoking and othexsi social habits/'" ">i It is the pathologist's duty* to make* the referring attorney aware of his^* information requirements. It is the duty of the referring attorney, who has access to legal processes for path- . cring farts, id furnish to his patholog ic consultant all needed data. Staling opinions as to the causes of death or disability and as to etiology without - acquiring knowledge of a victim's clin ical. occupations!, social, and environ mental history is, by my personal observations, a frequent and unfortu nate practice followed by some pathologists who. notwithstanding ssa i.-cn pwoi Lae Mtu--vt tor. Nov tees MMiCOttesI Aspects--P'e.snun DOW 07245 their obligation* u medicolegal con conflict with accepted medical defini bestosis, and severe coronary artery sul usa. ignore available vital data tions and standards. For example, disease with congestive heart failure. and base their opinions exclusively on because "anthracosis" is a disease of In formulating his opinion, should the the pathologic materials. the lung according to Federal Black pathologist merely list all of the In his study of the dinieal history, Lung Regulation.3* if the pathologist pathologic diagnoses as identified the pathologist should include the intends only to describe a condition of causes of death and thereby ignore the reported interpretations of chest carbonaceous pigmentation and not to relative fatal contribution of each? Or roentsenegrams. ECG records, tests diagnose a ditcast, he should avoid should he rank the conditions accord of pulmrnary function, and other rele the term anthrocosis and instead pro ing to their order of contributing vant laboratory data. If he considers vide a verba) description of the condi importance, and perhaps even quanti his knowledge of these matters want tion of anthracosis. In one of the fy by estimate the contribution made ing. the pathologist should candidly asbestos statutes introduced in Con by each? The medicolegal consultant acknowledge his limitations to tht gress, "bronchogenic cancer" and must be made aware of and conform referring attorney and request addi "gastrointestinal cancer" are both to the applicable legal standard of tional consultations with appropriate defined to be "asbestos-related dis-^ causation. In workers' compensation radical specialists (eg. in radiology, ease'"'; thus, if the pathologist proceedings, i: has been held that the cardiology, or pulmonology). In cases intends a pathologic diagnosis of can identification of a disease as the oi survivors' claims brought under the cer that is not asbestos related, he "most significant cause" or "primary Federal 3!ack Lung Law.1' where enti should, on enactment of this statute, cause" of death or disability does meet tlement may be based on either death choose another term. the required legal standard of causa or disability due to pneumoconiosis, Assuming that "bronchogenic car tion, but expressions such as "major my own iaw firm retains as medicole cinoma" is the correct pathologic contributing factor" or "contributed gal consultants both a pathologist and diagnosis in the case of a person who in a substantial or significant man a puimmoiogist. and we request their * had been both a heavy smoker and ner" or "contributed to and accelerat mutual consultation. If the patholo exposed to asbestos products as well ed" are ir.suir.cien: and do nor meet gist is asked to render an opinion as to as other carcinogens, unresolved sci the legal standard required for proof disability, additional consultation entific questions may preclude the of causation.3-' (However, another may indeed be obligatory to allow the expression of opinion as to etiology case3' indicates that the occupational patholcgi3t to feci qualified and com with reasonable medical certainty.11 disease need only be causally related fortable with the principles of physi Some contend that, in such cases, any to death without specifying the degree ology required for competent expres asbestos exposure (no matter how of contribution or cause. A Petition sions of opinion on impairment and trivial) should by law be ecologically for Allowance of Appeal to the , disability. la performing his investi presumed unless a contrary cause is Supreme Court of Pennsylvania is gation. the pathologist should acquire proven with reasonable medical cer presently pending.) In a products lia familiarity with the reported studies tainty. A legal presumption of this bility- lawsuit, however, the legal stan- * that correlate pathologic findings, typ* is proposed in another of the dard of causation is whether the iden- radiologic appearances, and measured asbestos statutes introduced in Con tided pathologic finding had been "a ^ puimonary function. He should also gress.31 According to Weill,1* 'tit) is substantial factor" in causing death ^ become informed about the preva not possible... to conclude that or disabilityor is a competent _ lences and etioiogic associations of any... [asbestos] exposure, no matter producing cause of death or disabili- ^ diseases established by epidemiology. how trivial, is causally associated ty.ia**-*. Qnt questionable way of set- t In his study of the occupational and with the development of [bronchogen ting the legal standard of causation is environmental history, the patholo ic carcinoma)... .":* Because of scien embodied in the Federal Black Lung gist should identify and comprehend tific uncertainty regarding the etiolo Law. In the case of s person who had the importance of relevant exposures gy of bronchogenic carcinoma, the worked ten years as a coal miner and to toxic substance pollution. For such proposed statute's enactment could who had a respiratory disease wherry knowledge, consultation with a chem- result in unfairly blaming asbestos he died of multiple causes, the Federal ' 1st. toxicologist, or industrial hygien for bronchogenic carcinoma even Black Lung Law presuma that death ist may sc required, and the patholo when asbestos exposurt had been had been due to pneumoconiosis if it is gist shouid make the need known to insignificant relative to exposure to not medically feasible to distinguish the referring attorney. other known carcinogens. which disease caused death or how From di of the collected informa The consulting pathologist might be much each disease had contributed to . tion. the pathologist prepares his asked his opinion as to cause of death causing death.3* opinions as to diagnosis, etiology, and when multiple diseases art present After completing all consultations causation. In formulating his opin concomitantly. Consider, for example, and studying ail records and ions. the pathologist must take into the extremely dyspneic, cigarette- materials, tht pathologist is able to seeount Ityal definitions and stan smoking insulator whose diagnoses at compose his report. Tht report should dards. which are provided to him by the referring attorney. These may necropsy included bronchogenic carci noma. ecntriiobular emphysema, as- identify all in vivo and postmortem records and materials that were stud- r-r tv** ua m#c--V91 ior. No* tens Mrtieolffal Atoects--Aiehman SS9 DOW 07246 fed or considered. It should describe histologic findings with measured preciseness and in deuiL Photomicro graphs. especially when a standard or control photograph ia available for comparison, can be an effective way to present pathologic findings and con clusions. The report might cite appro priate references of authorities to support the conclusions reached. Tha ultimate conclusions as to diagnosis, etiology*, and cause of death or disabil ity should be opinions expressed with reasonable medical certainty, which must include lineal deduction from the data available and a comparison with the known literature on the sub ject. This important point ia illus trated by X. L Lapp, MD, who has written in criticism: "You and I have both seen pathologists who... have described minimal, if any, changes typical of coal workers' pneumoconio sis and from tha: have made an extraordinary leap of logic to a totally disabling disease.. (written commu nication. Aug IS, 10S2). V.'here dis agreement exists between the report ing pathologist and another physi cian. that disagreement should be forthrightly stated and the reason for it supported. The report is not confidential and is available to all parties to the proceed ing. It may become admitted into evi dence and. unsupplemented by oral testimony, constitute the plenary statement of the physician. If the author of the report does give oral testimony at deposition or hearing, any ambiguities or errors in the report will be used to discredit its author's opinions. Therefore, special attention must be given to prepara tion of the report. Requests from tha referring attorney for amplification are common and should not ba regarded as slighting or offensive. Tha importance of completeness, accuracy, and unequivoeality in a report in tended for use in a legal proceeding ia absolutely cssentiaL THE PATHOLOGISTS ROLE AS EXPERT WITNESS In workers' compensation and in products liability cases, much of the scientific evidence is greatly beyond the ken of most adjudicators. There fore, litigants must employ expert witnesses who know and who are able to explain the ease in an understand able way. Under the Federal Rules of Evidence. "II scientific, technical or other specialized knowledge will assist the trier of fact to understand the evidence or t) determine a fact in issue, a witness qualified as an expert by knowledge, skill, txperience. train ing or education may testify thereto ia the form of an opinion or other wise."3 The "battle of experts" has in consequence become a standard part of asbestos litigation. Only through expert testimony can a litigant suc cessfully present his contention with respect to the issues of diagnosis, eti ology, or causation. The testimony of tha pathologist as expert witness, will be presented oral ly under oath. The opposing party will have a full right to cross-examine the expert witness as to ail matters cov ered in direct examination. The set ting for testimony may be the court room in the presence of judge and jury, or it may be the pathologist's own office by way of stenographic or videotape deposition which is later read or shown to the judge and jury' in the courtroom. Because a decision in a case is often reached by adopting a particular expert's opinion, it is important that the trier of fact be informed as to the professional qualifications of the expert. According to Belli,3 a famous trial lawyer, one must impress the jury w*ith and by the witness' creden tials: "The more experience the expert has and the more widely recognized he or she is as an authority in the field, tha more impressed the members of the jury will be: they will then accord such testimony more weight" There fore, the expert witness should be prepared to provide, without modesty or exaggeration, an accurate and com plete description of his professional qualifications. The opinion sxpressed by an expert witness may be based on any source, including hearsay sources such as hos pital records, reports of other physi cians, statements elicited from the disease'* victim, and acknowledged scientific treatises, provided the source is inherently reliable and of the kind customarily relied on by experts in forming their opinions. Either in his preparation for trial or during the presentation of his testi mony at trial, the expert witness may desire to review the information on which his opinions were basic. He is permitted to refer to any matters, including pathologic materials or even his ow*n report, to refresh his memory. However, once referenced, the infor mation becomes subject to the cross examiner's full right to examine and use it. Occasionally, embarrassment occurs when inspection at trial of the expert's file disclose* forgotten con tents that ths witness would have preferred to keep private. References to learned treatises are often invoked to corroborate or to impeach the expert's attested opin ions. The Federal Rules of Evidence provide: "To the extent called to the attention of ar. expert witness upon\ cross-examination or relied upon by ' him in direct examination, sutements \ contained in published treatises, peri odicals. or pamphlets on a subject of history, medicine or other science or ` art, established as a reliable authority / by the testimony or admission of the \ witness... may be read into evidence... The expert should, if he can, declare that he holds his opinion with a rmscnablc decree of medical certainty "I think" and "I believe" are accept able as shorthand recitals of th< "rea sonable medical certainty" standard." However, opinions given as " proba bly," "might be," or "could be" are not competent expressions because they are too equivocal and conjectural.'1-" An opinion based on mere possibility is dearly improper.1' The traditional legal formulations may not harmonize with the new for mulations of epidemiology. The point it well illustrated in a smoking asbes tos worker with lung cancer who had been exposed to other carcinogens. According to Enterline.1** an opinion about tha tumor's etiology cannot be stated with certainty, because to attribute lung cancer vith certainty to asbestos would falsely imply that tha asbestos exposure somehow blocked the possible effects of all oth er cancer-causir.; agents. However, an Sto Aren Aatfttf Lae Lite--Vol 107. Nov 1903 /ea^sieqai Ate*e:i-- 9US0Q 01S j 072^7 DOU opinion can be expressed rtlaiivtly as a mathematie probability for each carcinogenic agent to which the work* er had heen exposed.21* At what point medicine's probability becomes equiv alent to law's reasonable medical ear* tainty is yet to be addressed by the courts. Until it is, the problem will certainly perplex the knowing and conscientious medical expert. '.Vhen his opinions are informed, honest, and forthright, the patholo gist who has properly prepared should not lie apprehensive about serving as expert witness and giving oral testi mony. N'er should he be timid in his criticism o: other physicians when he knows that their opinions arc not informed, honest, or forthright. A prominent pulmonologist, with wide experience as an expert witness, has offered some advice that I will pass on: On cross-examination, do not be misled by hypothetieais: stick to wha: is known medically; be not per suaded 'ey "what might be" or "what could be"; stay with "what is": avoid the :att of the unwary physician led by the cur.r.ing cross-examiner down the path to an improbable disease state (C L Anderson, MD. written communication, July 21, 1982). Keep ing in mind the specific medicolegal issues about which he has been con sulted, the pathologist, tn giving testi mony, should avoid digression, remain relevant, and explicate his points com prehensibly--and be convincing! "However learned and honest the per son may be, it must always be remem bered that it is not just what the expert knows, it is also what the [ref eree, judge, or] jury understands and believes the expert knows."'*"'' CONCLUSIONS The outcome of asbestos-related lit igation is determined more by medical points than legal points. The attorney who is an experienced and successful litigator of asbestos cases will know generally the medical facts of asbes tos and be particularly familiar with the medical aspects of the case with which he is immediately involved. Because the role of the expert witness is so important to the result, the pathologist who would be medical consultant should anticipate crossexamination by an informed attorney. For tht pathologist who is himself informed about the subject of his tes timony, being an expert witness should not create concern because the training of a pathologist gives him enormous advantage over an adver sary trained in law. Asbestos-related disease is a signif icant public health concern. At the 1932 annual meeting of the American Thoracic Society, the extent of this concern was manifested by the many scientific papers devoted to asbestos and other occupational lung diseases, and by the exclusive dedication of an entire evening to a "public policy forum" that discussed the medico!egai problems of compensation for occupa tional lung disease. The full morning's program of the College of American Pathologists/American Society of Clinical Pathologists, at their 19S2 annual meeting, further underscored the special relevance of asbestosrelated disease. The pathologist who becomes medicolegal consultant en ters into a very topical, socially sensi tive. and intellectually stimulating professional activity. References L $ 1A4X. St-.h Const. l*t Motion; HR 5224, 97ik Corst. If. tMoton: HR 5725. 97tk Conft, 2nd w-tio-: HR t:TJ. 9-.h Concr. lot tctoien. 1 1J. -e$:lilp Corpromnoo /ot A.-Ixi<--id Dirrrte i ('. Lolled Si- ;. : ike CS Oral of Labor. 19*2. I.. -.ms Si. Why ciinnstt A iouk at ih ruT-i -; ef durability determination and . ir.r motion for om.p;r:o*a iunsdii.w ,V- -- Mrk 12.S:.*'J.SU. ? -r.;.r ?!. M-astre* of Impairment and Tbe ccthirnt.s wet! ohjtotvo* -- *c :*e conf.rion. CAer* :JM;75(|upp|i: V.-i-m-vr- CE fw of the Biark Lone '*--.t-a-i. -' C--.*- J 1 PSI .47.74-75. . ;* r- 5` ,--jenfs Cay. 13 ERRS *47 t. iV "(t ,, tft' H'e#t Prpert 'rtf Prrtr i. o" -r* C.-ro-ffa. ln`.rdaanrnnul Work* ,rv-;..-.s:;- r Talk forto. L'S Oort of Labor, 77. ; ]; s v,-..r Stt. Wr-lm' rrmpewatipii aod r*..i * m*,!--1 fnrrniin* fit prfwtlwt, in pi-'-v i.*. ii. ilrnahraJ Ml, Mu'.5 RJ. ot al Mi\t Con.rtrtnro Il'erkerp* C .a -if Ifirlrptecr LiWf|r. National Usnl for ihe Public lsierrtt. 1WL pp .? -o-. r tfero.-tl< n>` Taft. I45JA. com- nn k. 10. Borrt x Fibrtbeer* Piper PraAutu Cory. 493 F2d I0TC (Jib Cir 1ST3I. 11. Parker G Occur aiienal diatitr. Tkt iiViiw -xperitnrt. .Vi*:7 CraprJ, May 1991 pp 19-24. 11 Plan v ./o**e-.'faiY.' Salts Carp, 4tf FSup? (it (ZD T 19S0*. 11 S-'-'-ond r Jeias.'iaanUr Saks Cary 529 FSupp 339 (0 Mina 1M2i. 14. Aibertoaleml'tidal ra* iiclesiatia.Am Bar Aster 19i2;SS39T-3?S. !5. AW York Timet. Auf 2T, ISfZ p 01 11 Vail Street Jo*reel. Am Z7, 1951 p 10. IT. Autopsy -VaauaL US Otpta ef tbt Artsy, .Vary, and Air Fertt. 19<*. lection 1. 11 Kattcnttein AA. Atkin FI: Surpital Path- akrjp ef Sou-Sroptorue i-.rp Oiacatt. Philadel phia. WB Saundt.-a Co. 1W19 101 15. Ftiml CooI Ilia* HttlA and Safety Alt at tM*. PL 91-1TX title >V. (S3 auuia 791 cediAad Is 30 CSC fl-:s (1970k amarstd b>Rath l*9 troafts Art of 7i. PL 92-301 9S la:atr I.vi. red-Prd in CVl'SC >901-41 i197K amrihiad br Reek Larp < tin Refer* Art ef 1177. PL 95-239.92 atatut* 95. ndiSad ia 3T CSC >901-43 (tnppl II. 1979): amrsead by Rcrk l*i Btarr.'a Ameaimtait of .'.V.'. PL 97-119. 95 Utsta 1(43 (19S2L s& 20 CFR >711201. 21. HR 5221. >102(3). 22 Er.'.rrlinr PE Att.-ibutability in :h* fact of uiwonainiv. Cheat 1990: 7J(appll;377.379. 23. HR $735. t*b<3/. 24. Weill H: Bali* for clinical <iecia:on making. Clrrt 19*0: 7(up9l):3J2-.1S1. 25. Cnribt* Steel lac x H CaB. 442 A2d 11M. 1291 (Pa Comm 1992'. 21 rtm x H'CAB. 4-53 A2A 55 I Pa Comm 1992'. 27. 20 CFR >711202 (Tiia Mctien it not appii- eat'l* ia any claim Sled on or afur Jan 1. 1SS2.) ZS. Fed Role of Evidence 701 21. Belli MM; Tbe expert witnen. Trial. July 1991 pp 35-37. 30. Frd Rule of Evidence 903 (IS), a. .Voder* 7VooVr r tl'CA.8,40S A2d 900 (Pa Comm 19791. 31 Httatr x Alaa ll'ood Steel C, 233 A2d 923 (Pa Superior Ct 1907V 31 Xktiargi r Il'CAg. 3X3 A2d 571 (Pa Comm 197*:. 34. I'iW* r MrCuliotk Oil Cory iBnstak Cor,-i, 4 BLR 1-705119J2V 33. Baoortno r Il'CAg. 409 A2d 529 <Pa Comm 19501. 31 TirHrtllk Caasrearam atSmehap. Com- txr. report of iho Sarveos Ctaeral. US ?ert oI Heoit.'i and Human Forrim, 1921 pp 17-15.' 2;a Atn Psno( US A*e--vol 1C7. Nov 1993 Mece:toii Aaoeeta--Rierman SSI DU 724S