“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 that a plaintiff may be able to recover on the basis of 'material contribution to risk of injury', without showing factual 'but for' causation.”

“Under the law of torts claims cannot be brought after a lapse of six years from the date on which the cause of action occurred (Limitation Act 1953). In torts actionable per se, such as trespass to the person, the cause of action normally accrues at the date of defendant’s wrong, whereas with tort actionable only on proof of damage, such as negligence, the action accrues when the damage occurs (Kassim, 2008) and this is usually not the same time with the defendant’s breach of duty but later. … Another critical element in medical negligence actions is obtaining expert medical witness opinions on whether the particular act or omission concerned constituted a breach of duty.”

In a section on causation in medical negligence, the author (a Malaysian law academic) writes: "Far more complicated is the proof of causation. The 'but for' test only award full compensation to plaintiffs who are successful in showing the causal link between the defendant’s breach of duty and the damage suffered." The paper explains that causation in Malaysian medical negligence follows common law principles, and discusses limits of the 'but for' test and situations where courts may adopt different approaches.

The article explains that the Federal Court of Malaysia had given leave to appeal a medical negligence case to determine whether, and to what extent, the Bolam test should continue to apply in Malaysia. It discusses the standard of care framework, but it does not state that Malaysian courts establish medical causation by an objective "but-for" test.

“The patient must be able prove the causal link between the defendant’s breach of his duty of care and the adverse outcome suffered by him failing which, a claim in Court may fail. **The ‘But For’ Test**. The ‘But For’ test means that if it was not for fault of the defendant, the plaintiff would have not suffered any injury, losses or damage. If, however, the adverse result would have happened just the same, fault or no fault, the defendant will not be found to have been the cause of the plaintiff’s plight (Cork v Kirby Maclean Ltd [1952] 2 All ER 402). … It can be even a minor cause. A 25% contribution can be a material contribution (Athey v Leonati [1999] Lloyd’s Law Reports Med 458). As long as the defendant is part of the cause of an injury, he can be held liable, even though his act alone was not enough to create the injury.”

“In order to succeed in a medical negligence action, the plaintiff must prove on the balance of probabilities that the doctor’s breach of duty caused the injury complained of. The usual ‘but for’ test of causation will apply. In some instances, however, the courts have recognised that where the defendant’s negligence has materially contributed to the damage, strict proof of ‘but for’ causation may not be necessary.”

Under the heading "How Can Patients Prove Medical Negligence?", the article explains: "To prove medical negligence in Malaysia, patients must show clear evidence that: – The healthcare provider had a duty to care for them – That duty was breached through unreasonable actions or omissions – **The breach directly caused injury or harm**." The firm stresses that: "Evidence is everything, and that’s where documentation plays a vital role." While this overview does not name the "but-for" test expressly, it describes the need to establish that the breach was a cause of the injury in Malaysian medical negligence cases.

Analysing the Court of Appeal decision in *SAJ Ranhill Sdn Bhd v SWM Greentech Sdn Bhd & Anor* [2023] 1 LN 881, the article notes: "Following the case of *Chua Seng Sam Realty v. Say Chong Sdn Bhd* [2013] 2 MLJ 29, the High Court applied the ‘but for’ test to determine whether the damage would not have been caused but for the Respondents’ conduct/omission." It then explains the Court of Appeal’s view: "The Court of Appeal held that the **‘but for’ test was an inquiry into the facts of the case and was the first step** to determine the *cause sine qua non* factors. **However, a further determination must be carried out, which was a legal inquiry in order to establish the causa causans i.e. the effective factor.**" The piece concludes: "This decision … is vital as it serves as an important reminder that the ‘but for’ test is only the first step … courts must also undertake a legal inquiry in order to determine the proximate or effective cause of a breach of duty. Therefore, both the ‘but for’ test and the proximate cause test must be applied hand in hand." This shows Malaysian courts use the but‑for test as an initial factual causation tool, not the sole or complete legal test.

“The elements of negligence: (1) Duty of care; (2) Breach of duty; (3) Causation; (4) Damage. … Causation is generally determined using the ‘but for’ test – i.e. but for the defendant’s breach, would the plaintiff have suffered the injury? However, Malaysian courts have also considered principles of ‘material contribution’ and ‘material increase in risk’ in complex medical cases where strict ‘but for’ proof is difficult.”

“In medical negligence, the plaintiff must prove on a balance of probabilities that the doctor’s breach caused the injury. The primary test of causation is the ‘but for’ test: would the harm have occurred but for the defendant’s negligence? Yet, Malaysian courts, following common law developments, have in some cases accepted a ‘material contribution’ approach when scientific uncertainty makes strict ‘but for’ causation impossible to establish.”

The article describes the Bolam test and the Malaysian courts’ approach to professional negligence in medicine. It is about the standard of care and the impact of Foo Fio Na, but it does not provide authority for the proposition that causation in medical negligence is established by an objective "but-for" test.

In Foo Fio Na v Dr Soo Fook Mun & Anor, the Federal Court clarified the test for causation in medical negligence, affirming that factual causation is generally assessed using the orthodox ‘but for’ test on the balance of probabilities. However, the judgment also discussed the need to consider broader common law developments, signalling that rigid adherence to ‘but for’ may be inappropriate in some complex medical contexts.