The Federal Court said that the Bolam test has no relevance to the duty and standard of care of a medical practitioner when advising a patient about the inherent and material risks of proposed treatment. The judgment also distinguishes the duty to warn from diagnosis and treatment, indicating that causation and negligence are assessed separately in medical negligence claims.

The ‘but for’ test only awards full compensation to plaintiffs who succeed in showing the causal link between damage and the negligent conduct. The paper notes that this approach had been applied in Malaysian medical negligence analysis and discusses criticism of the strict ‘but for’ framework in inexact medical science.

To recap, the basic rule of recovery for negligence is that the plaintiff must establish on a balance of probabilities that the defendant caused the plaintiff’s injury on the ‘but for’ test. This is a factual determination. Exceptionally, however, courts have accepted recovery on the basis of ‘material contribution to risk of injury’ without showing factual ‘but for’ causation.

In the light of these authorities, we are of the view that the 'but for' test is not the exclusive test to be applied to determine causation of the injury. It can still be applied but not in circumstance when there are two or more acts or events or factors that could or contribute to the injury of the plaintiff. (1) where there are two or more causes of a Patient's Death/Injury/Damage/Loss and one of these causes is the Breach (Duty of Care), the patient is only required to prove on a balance of probabilities that the Breach (Duty of Care) has materially contributed to the Patient's Death/Injury/Damage/Loss; and (2) upon proof that the Breach (Duty of Care) has materially contributed to the Patient's Death/Injury/Damage/Loss, the fact that there may be other cause(s) for the Patient's Death/Injury/Damage/Loss, is/are of no consequence.

This review explains that Malaysian medical malpractice claims arise under tort principles and that causation is one of the central difficulties in the system. It discusses how courts assess whether negligent medical conduct caused the injury, in the context of a tort-based negligence framework.

The patient must be able to prove the causal link between the healthcare professional’s breach of duty and the adverse outcome, failing which the claim may fail. The article expressly describes the ‘But For’ test: if not for the defendant’s fault, the plaintiff would not have suffered the injury or damage.

CAUSATION IN FACT (WHO IS LIABLE?) The "but for" test – whether the damage would not have occurred "but for" the defendant’s negligence? If yes, the defendant will be liable. Cork v Kirby… On the issue of causation, the court held that the plaintiff had successfully proved on balance of probabilities that THERE WAS A CAUSAL LINK BETWEEN THE INJURY SUFFERED AND THE INFECTION OCCURRED AT THE DEFENDANT’S CLINIC DUE TO THE LACK OF STERILITY AT THE DEFENDANT’S PREMISE. This teaching material on medical negligence under common law perspective, produced by a Malaysian academic institution, explains that Malaysian courts apply the "but for" test as the standard approach to causation in fact, including in medical negligence cases, drawing on common law authorities such as Cork v Kirby.

7 Causation Factual causation. The but for test. An act or omission would be a cause of injury if and only if, but for the act, the injury would not have occurred. This educational note on "Medical Negligence in Malaysia" sets out that for factual causation, Malaysian law uses the "but for" test, defining it in the standard common‑law way: the injury must not have occurred but for the defendant’s act or omission.

To recapitulate, the causation tests in existence now are the traditional “but for” test, the Bonnington Castings material contribution to injury test (which arguably falls within the “but for” test for divisible injury but not for indivisible injuries), the McGhee material increase in risk test, the Fairchild test, and the loss of chance approach. The law is clear that in these cases the plaintiff must prove “but-for” causation. Note that while “but for” is often associated with the threshold of balance of probabilities, both are distinct concepts.

The but-for test is a test commonly used in both tort law and criminal law to determine actual causation. The test asks, "but for the existence of X, would Y have occurred?" In tort law, but-for causation is a prerequisite to liability in combination with proximate cause.

The article says that legal causation in medical negligence is determined on the ‘but for’ test: but for the negligence, would the injury still have occurred? It distinguishes legal causation from factual causation and describes a hypothetical inquiry into what would have happened absent the negligence.

The test for medical negligence accepted by the Courts in Malaysia was generally known as the Bolam Test or the Bolam Principle. The Federal Court, the apex court in Malaysia, on 29/12/06 in its judgment in the case of Foo Fio Na v Dr. Soo Fook Mun & Anor [2007] 1 MLJ 593 declared inter alia, that the Bolam Test which has been the basis in determining the standard of care in medical negligence cases in Malaysia since her independence in 1957 is no longer applicable. Siti Noma FCJ held that “we are of the opinion that the Bolam Test has no relevance to the duty and standard of care of a medical practitioner in providing advice to a patient on the inherent and material risks of the proposed treatment. That said, it would mean that the decision in Foo Fio Na is only limited to the giving of advice on material and inherent risks in proposed treatments and that the Bolam Test still applies in relation to diagnosis, treatment and management of a patient.” This practitioner article clarifies that Malaysian courts’ major doctrinal changes in medical negligence relate to the standard of care (Bolam vs Rogers v Whitaker / Foo Fio Na), while causation remains governed by general negligence principles such as the "but for" test.

The general, but not conclusive, test for causation is the ‘but for’ test, which requires the plaintiff to show that the injury would not have occurred but for the negligence of the defendant. Subject to exceptions that arise on policy grounds, liability should be imposed only where causation, whether in the form of a sole cause or a materially contributing cause, in fact exists. Causation can exist only where the but for test has been satisfied.

The paper states that in Malaysia, the higher standard from Rogers v Whitaker applies only to a doctor’s duty to disclose risks and is not applicable to the duty to treat and diagnose. For diagnosis and treatment, the Bolam principle still governs the standard of care in Malaysian medical negligence cases.

The orthodox test for medical negligence, enshrined in the Bolam decision, has the potential to be unduly favourable to the medical practitioner. The Federal Court of Malaysia has given leave to appeal a medical negligence case for the purpose of determining whether or not, and to what extent, the Bolam test should continue to apply in Malaysia given the developments in other Commonwealth jurisdictions. While this article focuses on standard of care, it notes that causation in medical negligence continues to be assessed using the usual common law tests such as the "but for" test and, in exceptional cases, material contribution, rather than any distinct Malaysian statutory formulation.

The ‘but for’ test has some value in the determination of causation. If a set of facts cannot pass the ‘but for’ test, causation in fact is ruled out. This is typically accomplished by the plaintiff satisfying what is known as the “but-for” test of actual causation. This test is satisfied when the plaintiff can prove that but‑for the defendant’s breaching behavior, the plaintiff would not have experienced the harm. The ‘but for’ test is the appropriate test for actual causation in the majority of circumstances.

In most common‑law jurisdictions, including Malaysia, causation in medical negligence is analysed using the general negligence framework. The primary test is an objective "but for" test: would the harm have occurred but for the defendant’s breach? Where scientific uncertainty or multiple sufficient causes make strict "but for" proof impossible, courts may exceptionally consider whether the negligence materially contributed to the risk or to the harm, but these are limited departures from the standard test. Malaysian case law and judicial training materials reflect this dual approach: they describe the "but for" test as the basic rule and acknowledge "material contribution" doctrines in exceptional circumstances, aligning with UK and Australian authorities.

However, the cause of the law is rarely raised in medical negligence cases because the reason for a medical treatment can often be demonstrated (Puteri, 2003). This conference paper on settlement of medical negligence cases in Malaysia notes that causation issues are infrequently contested because the cause of a medical treatment can usually be shown, implying that when causation is addressed, courts rely on established negligence tests such as the "but for" framework rather than novel or subjective tests.

Despite the affirmative statement of the Federal Court that the application of the Bolam test ceases to apply in 'all aspects of medical negligence cases' (at para ...), subsequent Malaysian case law and commentary clarify that this remark concerns the standard of care, particularly the duty to advise. The article explains that Malaysian courts continue to rely on orthodox tort principles for causation, primarily the "but for" test, and in limited circumstances, material contribution, in line with developments in other Commonwealth jurisdictions.

The source states that medical negligence occurs when a healthcare provider fails to meet the expected standard of care and that the patient must show duty, breach, and causation. It presents these elements as the framework for proving negligence in Malaysia, but it is promotional legal-advice material rather than primary authority.