Scottoline v. Women First, LLC: Delaware Supreme Court Clarifies the Distinction Between Diagnosis and Etiology Under Rule 702

Supreme Court of Delaware  |  Decided 18 June 2025  |  No. 48, 2024

1. Introduction

The Delaware Supreme Court, sitting en banc, has affirmed a Superior Court decision that excluded a plaintiff’s pediatric-neurology expert and, consequently, granted summary judgment in favour of the defendants in a medical-malpractice action concerning a birth-related brain injury. The litigation was brought by Lauren and Stephen Scottoline on behalf of their minor son, J.S.S., who sustained hypoxic-ischemic encephalopathy (“HIE”) at birth and was subsequently diagnosed with autism spectrum disorder (“ASD”) and other developmental impairments.

At stake was the admissibility of the causation testimony of Dr Daniel Adler, a paediatric neurologist. The trial court excluded his opinion that HIE caused all of J.S.S.’s later neurological, developmental, and behavioural deficits—including those meeting the criteria for ASD—because he lacked a reliable scientific basis and methodology under Delaware Rule of Evidence 702 (the Daubert standard). Without that opinion, the plaintiffs could not prove causation and the defendants prevailed on summary judgment.

On appeal, the plaintiffs argued that the Superior Court misapplied this Court’s earlier decisions in Norman v. All About Women (2018) and Wong v. Broughton (2019), which relaxed literature-based corroboration for medical experts. The Supreme Court rejected the argument, drawing a firm line between expert testimony on standard of care (diagnosis/procedure) and testimony on etiology (cause). The Court emphasized that credential-based clinical opinions are insufficient when an expert purports to identify the cause of a complex disorder with multiple potential origins.

2. Summary of the Judgment

• The Superior Court properly excluded Dr Adler’s causation opinion because it was not supported by reliable scientific evidence and employed no valid differential-etiology methodology.
• Norman and Wong remain good law but are limited to standard-of-care opinions; they do not dispense with Daubert reliability for causation opinions.
• Lacking admissible causation evidence, the plaintiffs’ claims failed as a matter of law and summary judgment for the hospital and obstetrical practice was affirmed.
• The Court upheld the discretionary refusal to hold an additional Daubert hearing and sustained the derivative exclusion of a life-care-planning expert whose opinions relied on Dr Adler.

3. Detailed Analysis

3.1 Precedents Cited and Their Influence

• Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579 (1993) – Underpins Delaware Rule 702’s reliability requirement. Adopted in Delaware via M.G. Bancorp.
• Kumho Tire v. Carmichael, 526 U.S. 137 (1999) – Extends Daubert to all expert testimony (not only science).
• Norman v. All About Women, P.A., 193 A.3d 726 (Del. 2018) – Held that a physician may, in some circumstances, rely on professional experience rather than literature for standard-of-care opinions. The Court distinguished, not repudiated, Norman.
• Wong v. Broughton, 204 A.3d 105 (Del. 2019) – Similar to Norman; reinforced that lack of literature does not automatically bar experiential testimony on standard of care.
• Minner v. American Mortgage & Guaranty Co., 791 A.2d 826 (Del. Super. 2000) – Established that experts must “rule in and rule out” causes when multiple plausible causes exist.
• Numerous medical-neurology articles were cited by Dr Adler; the Court held these showed association, not causation.

3.2 Legal Reasoning of the Court

1. Diagnosis ≠ Causation. The Court underscored that the ability to diagnose HIE and ASD does not automatically qualify a physician to opine that one causes the other. Etiological conclusions require “scientific exposition” beyond clinical observation.
2. Lack of Reliable Scientific Basis. Dr Adler acknowledged no peer-reviewed study linking HIE to ASD causally. At best, the literature showed correlations. Under Daubert, correlation alone cannot establish causation.
3. Flawed Differential Etiology. Where a disorder (ASD or broader neuro-developmental delays) has multiple independent causes—genetic, metabolic, infectious, environmental—the expert must employ a “rule in / rule out” process. Dr Adler did not address maternal history factors, genetic testing, or alternative explanations.
4. Norman/Wong Distinguished. Those cases dealt with standard-of-care breaches in procedures (laparoscopy, shoulder dystocia). Here, the question is specific causation; experiential testimony alone is insufficient.
5. Discretion on Hearings. The trial court had an ample record—three reports, a deposition, two rounds of briefing—to decide the motion. Delaware law gives judges broad latitude on whether to hold evidentiary hearings.

3.3 Anticipated Impact on Delaware Law

The opinion charts a clear doctrinal boundary:

• Physician experts in Delaware may continue to rely on clinical experience alone to testify about how a procedure should be performed (standard of care).
• However, when a physician seeks to testify about what caused a complex medical condition, Daubert’s full reliability arsenal applies. Experts must supply:
  • Empirical or peer-reviewed support indicating causation, or
  • A robust differential-etiology analysis that meaningfully rules out alternative causes.
• The ruling will likely encourage:
  • Earlier, more rigorous vetting of medical literature by plaintiffs’ counsel before filing suit;
  • Increased use of multidisciplinary expert teams (e.g., geneticists, epidemiologists) for causation in paediatric brain-injury cases;
  • More frequent Daubert motions where a plaintiff’s case hinges on novel or weak scientific links.
• The decision brings Delaware into line with federal circuits that demand heightened scrutiny of clinical ipse dixit opinions on causation (e.g., 6th Cir. Tamraz).

4. Complex Concepts Simplified

5. Conclusion

Scottoline v. Women First is now the leading Delaware authority on the admissibility of physician causation testimony. By affirming exclusion of an experienced paediatric neurologist’s opinion, the Supreme Court signals that Daubert rigor applies in full to medical causation—no matter how qualified the doctor or sympathetic the facts. The Court clarified that its earlier leniency in Norman and Wong does not extend beyond standard-of-care opinions. Litigants must marshal sound science, rigorous methodology, and explicit consideration of alternative causes when linking perinatal events to later neurodevelopmental outcomes.

The decision will reverberate through Delaware’s medical-malpractice bar, prompting more robust expert discovery, increasing the strategic importance of Rule 702 motions, and perhaps narrowing the circumstances in which plaintiffs can pursue birth-trauma claims that hinge on later-manifesting developmental disorders.