Dillard, Presiding Judge. Pneumo Abex, LLC and Genuine Parts Company[1] appeal the trial court’s partial grant of summary judgment to Sheila Long—individually and as personal representative of her late husband’s estate[2]—in her toxic-tort action, alleging that Ron died from lung cancer as a result of exposure to asbestos contained in certain products. Long sought summary judgment on affirmative defenses that she anticipated the appellants might pursue. Now, the appellants argue that the trial court erred in granting summary judgment to Long as to their non-party fault defense and on “alternative carcinogens.” For the reasons set forth infra, we affirm. Viewing the evidence in the light most favorable to the appellants (i.e., the nonmoving parties),[3] the record shows that from 1977 until 1999, Ron worked as a truck and automobile mechanic for various companies and then at his own automobile repair shop. During his career, Ron performed numerous brake, clutch, and gasket replacements; and some of the equipment and materials he used in the course of his work were manufactured by the appellants and contained asbestos. On November 11, 2014, Ron was diagnosed with pulmonary adenocarcinoma, a form of lung cancer. According to one of his treating physicians, Ron was exposed to asbestos in the course of his work, and in the doctor’s professional opinion, Ron’s exposure to asbestos was “a substantial contributing factor in causing his lung cancer.” On September 16, 2016, prior to Ron’s death, the Longs filed a negligence complaint against numerous defendants, alleging, inter alia, that Ron’s lung cancer was a direct result of exposure to asbestos contained in their products.[4] Discovery ensued, and over a year later (after Ron died from his lung cancer), Long filed a motion to substitute herself—in her capacity as the executor of Ron’s estate—in place of Ron as a plaintiff. Long also sought to file an amended complaint, which, inter alia, added a wrongful-death claim. The trial court granted both requests, and so, Long proceeded with the case in her individual capacity, as well as in her capacity as executor of Ron’s estate. Thereafter, several parties filed motions for summary judgment. But this appeal concerns Long’s motion for partial summary judgment “regarding various affirmative defenses and alternative causation.” Specifically, Long argued that, during discovery, the appellants attempted to “assign liability” for Ron’s lung cancer to other causes, such as exposure to second-hand smoke, radon, or diesel exhaust (i.e., “alternative carcinogens”), but for purposes of apportionment, they failed to satisfy their burden of presenting any competent evidence that Ron was exposed to such alternative carcinogens. Furthermore, Long contended that she had “reason to believe” the appellants intended to assign liability for Ron’s death to the alleged medical malpractice of his doctors, who are not parties to this case; but according to Long, there was no evidence that any such malpractice occurred. As a result, Long maintained that she was entitled to summary judgment as to these potential defenses, or, alternatively, the trial court should exclude any evidence related to them. Following the appellants’ response and Long’s reply, which are discussed infra, the trial court ultimately granted Long’s motion.[5] As to the issue of alternative carcinogens, the trial court found that no expert witness in the case—either for Long or the appellants—testified that exposure to second-hand smoke, diesel exhaust, or radon could have caused Ron’s cancer, and certain arguments they made were inconsistent with the burden of proof required by the apportionment statute. Furthermore, the court found that the affidavit of the appellants’ expert (Dr. Allan Feingold)—in which he detailed his opinion regarding the alleged medical malpractice of Ron’s physicians—did not meet the required causation standard of expressing his opinion with “a reasonable degree of medical certainty.” Regardless, the court also found that Feingold was not qualified to testify as an expert because he did not have the requisite experience as a practicing medical doctor in the area of concern. Lastly, the court found that any injuries resulting from improper or unskilled medical treatment by a physician were a foreseeable part of the damages resulting from Ron’s lung cancer. This appeal from the trial court’s partial grant of summary judgment in favor of Long follows. Summary judgment is proper when “there is no genuine issue as to any material fact and the moving party is entitled to a judgment as a matter of law.”[6] Furthermore, a de novo standard of review “applies to an appeal from a grant or denial of summary judgment, and we view the evidence, and all reasonable conclusions and inferences drawn from it, in the light most favorable to the nonmovant.”[7] And at the summary-judgment stage, “[w]e do not resolve disputed facts, reconcile the issues, weigh the evidence, or determine its credibility, as those matters must be submitted to a jury for resolution.”[8] Nevertheless, if there is no evidence sufficient to “create a genuine issue as to any essential element of [the] plaintiff’s claim, that claim tumbles like a house of cards[,]” and all other factual disputes are rendered immaterial.[9] With these guiding principles in mind, we now address the appellants’ specific claims of error. 1. The appellants argue that the trial court erred in granting summary judgment to Long as to their “non[-]party fault defense” that Ron’s treating physicians committed malpractice, which contributed to his “injuries or damages.” We disagree. Under OCGA § 511233 (c), “in assessing percentages of fault, the trier of fact shall consider the fault of all persons or entities who contributed to the alleged injury or damages, regardless of whether the person or entity was, or could have been, named as a party to the suit.”[10] Indeed, the statute is designed to apportion damages “among all persons or entities who contributed to the alleged injury or damages—even persons who are not and could not be made parties to the lawsuit[.]“[11] But significantly, the fault of a nonparty “cannot be considered for the purposes of apportioning damages without some competent evidence that the non[-]party in fact contributed to the alleged injury or damages.”[12] Suffice it to say, were it otherwise, there would be “no limitation on the number of potential non[-]parties that a trial court would be required to include on the verdict form for purposes of assessing fault under OCGA § 511233 (c).”[13] The Supreme Court of Georgia has held that under OCGA § 51-12-33 (c), a person or entity who has contributed to the alleged injury or damages means “all persons or entities who have breached a legal duty in tort that is owed with respect to the plaintiff, the breach of which is a proximate cause of the injury sustained by the plaintiff.”[14] And that includes not only the plaintiff and defendants with liability to the plaintiff, but also “every other tortfeasor whose commission of a tort as against the plaintiff was a proximate cause of his injury, regardless of whether such tortfeasor would have actual liability in tort to the plaintiff.”[15] Finally, while it is the defendant’s burden to establish a “rational basis for apportioning fault to a nonparty, whether the nonparty contributed to the alleged injury is a question of fact for a jury to decide.”[16] So, because the appellants alleged that the non-party tortfeasors—i.e., Ron’s treating physicians—committed the tort of medical malpractice, they can only be included on the verdict form for purposes of apportionment if there is some competent evidence that they did, in fact, commit such malpractice and it proximately caused or contributed to causing Ron’s injuries and damages.[17] (a) Medical Malpractice. To recover in a medical-malpractice case, a plaintiff must “show not only a violation of the applicable medical standard of care but also that the purported violation or deviation from the proper standard of care is the proximate cause of the injury sustained.”[18] Indeed, a mere showing of negligence “without proof of causation is insufficient to withstand summary judgment.”[19] Additionally, to meet this burden, the plaintiff must “use expert testimony because the question of whether the alleged professional negligence caused the plaintiff’s injury is generally one for specialized expert knowledge beyond the ken of the average layperson.”[20] Nevertheless, questions regarding causation are “peculiarly questions for the jury except in clear, plain, palpable and undisputed cases.”[21] In Georgia, medical causation must be proved to a “reasonable degree of medical certainty and cannot be based on mere speculation[,]“[22] and the evidence must provide more than a “mere or bare possibility that the alleged negligence caused the plaintiff’s injury.”[23] Indeed, the expert’s testimony must show as an evidentiary threshold that “the expert’s opinion regarding causation is based, at the least, on the determination that there was a reasonable probability that the negligence caused the injury.”[24] Of course, a “reasonable degree of medical certainty,” while an acceptable means by which “an expert may express the confidence [he or she] has in the conclusion formed and the probability that it is accurate, is not the required standard.”[25] To the contrary, Georgia law requires only that “an expert state an opinion regarding proximate causation in terms stronger than that of medical possibility, i.e., reasonable medical probability or reasonable medical certainty.”[26] Turning to the alleged medical malpractice in this case, the appellants submitted an affidavit by Feingold, their proposed expert on Ron’s form of lung cancer, alleging that certain negligence by Ron’s treating physicians contributed to his pain and suffering and decline in his quality of life. In addition to his affidavit, Feingold issued a report regarding his review of Ron’s medical records and treatment. And as to the standard of care for pulmonary adenocarcinoma, Feingold averred that “it is currently routine to submit samples of newly diagnosed pulmonary adenocarcinoma for DNA mutation analysis.” According to Feingold, “EGFR-mutated adenocarcinoma . . . are usually susceptible to treatment with a new class of therapeutic agents named tyrosine kinasc inhibitors (“TKIs”) and that patients with EGFR mutations often experience dramatic therapeutic response to TKI treatment characterized by resolution or near resolution of pulmonary parenchymal masses and even resolution of mestatic foci.”[27] He further averred that in 2014, when Ron was diagnosed with cancer, “the possibility of adding TKI to chemotherapy was routinely considered by oncologists and pulmonologists . . . who were treating patients with EGFR-mutated lung cancers.”[28] As a caveat to his opinion, Feingold noted that the medical records available to him in this case were incomplete.[29] But a review of the records that were available to him at that time suggested Ron “was not treated with a TKI (if at all) until at least two years after his original diagnosis[,] . . . but instead was treated with traditional chemotherapy.” So, Feingold could tell from Ron’s records that a DNA-mutation analysis was not performed on his tumor until December 2016—two years after his diagnosis. And according to Feingold, when this testing was performed, it revealed a treatable EGFR mutation. Feingold noted that, initially, he could not determine from the records available to him whether or when Ron was treated with TKIs. But he later explained that Ron received TKI treatments in late 2016 or early 2017. According to Feingold’s report, Ron had a CT Scan on November 25, 2016, and after receiving additional medical records, Feingold was able to confirm that Ron received a TKI treatment in the six months following that scan. Feingold’s report further noted that on May 24, 2017, Ron had another CT scan; and while Feingold did not have access to a copy of that scan, it “reportedly revealed significant improvement[,] which implies that at some point in the six months after the CT of 11/25/2016[,] [Ron] was finally treated with a TKI for his EGFR mutated adenocarcinoma.”[30] But then, after receiving a report from another doctor, Feingold was able to confirm that Ron had been treated with a TKI following his November 25, 2016 CT scan, but before his May 24, 2017 CT scan, which Feingold still did not have a copy of for his records. In sum, Feingold concluded that “the more than two-year delay in the identification and proper treatment of [Ron's] EGFR mutation deprived him of the potential benefits of early TKI treatment and probably meaningfully contributed to his pain and suffering and a decrease in his quality of life during the period after November 2014 until his death.” Nevertheless, Feingold maintained that he still did not have a complete copy of Ron’s medical records, and he reserved the right to “supplement [his] opinion upon receipt of additional materials.” In providing an opinion in a medical-malpractice case, an expert need not use the magic words “reasonable degree of medical certainty,” but the facts in the record “must be sufficient to meet the legal standard embodied in those ‘magic words.’”[31] Nevertheless, in presenting an opinion on causation, the expert is “required to express some basis for both the confidence with which his conclusion is formed, and the probability that his conclusion is accurate.”[32] Put another way, there must be a “realistic assessment of the likelihood that the alleged negligence caused the injury or death.”[33] Indeed, perhaps nothing in medicine is absolutely certain, but “the law intends that if the plaintiff’s medical expert cannot form an opinion with sufficient certainty so as to make a medical judgment, there is nothing on the record with which a jury can make a decision with sufficient certainty so as to make a legal judgment.”[34] Applying these well-established principles in this case, we conclude that Feingold’s medical testimony was simply too vague to express the kind of reasonable degree of medical certainty or probability necessary to establish causation for a medical-malpractice claim. Significantly, Feingold admits that he never had Ron’s complete medical records, and he reserved the right to supplement his opinion if more records were received, which suggests that the opinion expressed in his affidavit might not even be final. Feingold also averred that in 2014, when Ron was diagnosed with lung cancer, “the possibility of adding TKI treatments to chemotherapy was routinely considered by oncologists and pulmonologists . . . who were treating patients with EGFR-mutated lung cancers.” Needless to say, testimony that cancer specialists only considered the possibility of administering TKI treatments in addition to chemotherapy when a patient has a EGFR mutation does not indicate how often TKI treatments were actually administered in such cases. And while Feingold’s report indicated that Ron received TKI treatments in the six months following his November 2016 CT scan, Feingold never saw the CT scan that was allegedly taken six months after the treatments, and thus, he had no first-hand knowledge of whether the treatment even benefitted Ron or how it was beneficial. Moreover, Feingold never specified the type of pain and suffering the TKI treatments would have reduced or the percentage of likelihood that they would have reduced such pain,[35] and he certainly did not claim that TKI treatments could have prevented Ron’s death. Simply put, Feingold’s summary conclusion that the “delay in the identification and proper treatment of [Ron's] EGFR mutation deprived him of the potential benefits of early TKI treatment and probably meaningfully contributed to his pain and suffering and a decrease in his quality of life . . .”[36] fails to “express some basis for both the confidence with which his conclusion is formed, and the probability that his conclusion is accurate.”[37] Thus, the appellants failed to present competent evidence to show that Ron’s doctors were “tortfeasors” who committed malpractice, and thus, the trial court did not err in finding that they should not be included on the verdict form for apportionment of fault.[38] (b) Feingold’s qualifications. The parties disagree as to whether Feingold is qualified to testify as an expert regarding the alleged medical malpractice. Further, the appellants challenge the trial court’s finding that their non-party fault defense fails because any medical malpractice resulting from Ron’s lung cancer was foreseeable to them. But because we hold in Division (1) (a) supra that Feingold’s testimony was insufficient to establish the causation element of a medical-malpractice claim against Ron’s physicians for purposes of apportionment, we need not separately address the trial court’s other alternative bases for granting summary judgment as to the appellants’ non-party fault defense. 2. Next, the appellants argues that the trial court erred in granting summary judgment on “alternative carcinogens.” But, in substance, their arguments relate to matters that were not actually ruled upon by the trial court, which leaves us with nothing to review. Because there seems to be some confusion among the parties as to what exactly the trial court granted summary judgment on with respect to alternative carcinogens, it is helpful to briefly review the procedural history of that claim. In moving for summary judgment, Long alleged that, during discovery, the appellants attempted to “assign liability” for Ron’s lung cancer to his exposure to alternative carcinogens, such as second-hand smoke, radon, and diesel exhaust. Specifically, Long claimed that “[i]n the apportionment of liability,”[39] the appellants bear the same burden that she does in assigning liability,[40] and they cannot prove that Ron had exposure to any of those substances. Then, in the argument section of Long’s summary-judgment motion, she contended that, as to alternative carcinogens, the appellants “must present actual evidence that a non-party was at fault.“[41] But Long also argued that, alternatively, if the trial court found that she was not entitled to summary judgment, it should exclude any evidence that Ron was exposed to alternative carcinogens under OCGA § 24-4-403 (“Rule 403″).[42] In their response, the appellants explained that Long “mistakenly” believed that they sought “to ‘assign liability’ to these alternative exposures . . . .” Indeed, they claim that Long simply misunderstood their intentions. Nevertheless, the appellants argued that it was Long’s burden to prove causation as an essential element of her toxic-tort claim. And after further discussing Long’s burden of proof, the appellants contended that they are “entitled to show the jury through cross-examination of [Long's] experts that those experts failed to investigate and appropriately rule out alternative causes of [Ron's] injury and death.”[43] Lastly, the appellants contended that any ruling to exclude all evidence of alternative carcinogens was premature, as discovery was still ongoing and responses to certain pre-trial motions were not yet due. In her reply, disregarding the appellants’ clarification that they were not intending to present evidence of alternative carcinogens for purposes of assigning liability to a non-party, Long reiterated her argument that, as to alternative carcinogens, the appellants must satisfy the requirements of the apportionment statute and present “actual evidence that [a] non-party was at fault.” Long also reasserted her claim that, alternatively, the court should exclude evidence of alternative carcinogens because it had the potential to mislead or prejudice the jury. In the trial court’s four-sentence ruling related to alternative carcinogens, it addressed the sole issue for which Long sought summary judgment—her claim that the appellants failed to present sufficient evidence to satisfy the causation requirement of the apportionment statute. Specifically, in its summary ruling, the court agreed with Long, citing only OCGA § 51-12-33 (c) and a case that addresses a trial court’s rulings on apportionment issues.[44] Presumably, because the court found that Long was entitled to summary judgment, it did not address her alternative evidentiary arguments. Turning to this appeal, the appellants explain, yet again, that they “do not seek to apportion fault to any non[-]party with respect to these alternative carcinogens.”[45] So, the appellants present no arguments that challenge the trial court’s apportionment ruling as to alternative carcinogens, and as a result, they have affirmatively abandoned any such challenge on appeal.[46] Nevertheless, the appellants maintain that the trial court erred in “granting summary judgment on ‘alternative carcinogens.’” Then, the appellants argue that they should be permitted to present evidence of alternative potential causes for Ron’s lung cancer during its case-in-chief and through cross-examination of Long’s experts. But despite the parties’ lengthy arguments as to the admissibility of this evidence for purposes other than apportionment, their arguments bear no relation to the order being appealed.[47] As we have repeatedly explained, this is a Court for the correction of errors of law, and “if the trial court has not ruled on an issue, we will not address it.”[48] Indeed, without a ruling by the trial court on a particular issue, there is “nothing for this Court to review upon appeal.”[49] Here, as evidenced supra, Long’s motion for summary judgment as to alternative carcinogens was based solely on preventing the appellants from pursuing an apportionment defense, and the appellants acknowledge that the trial court’s sole basis for granting summary judgment was their failure to meet the causation requirement of the apportionment statute. And while they never had any intention of seeking to apportion fault with respect to alternative carcinogens, the trial court granted Long’s motion for partial summary judgment, which alleged that the appellants did so. Simply put, the court’s order involved the grant of summary judgment on an apportionment defense, not any evidentiary rulings unrelated to apportionment, which makes sense if, as the appellants contend, discovery is not over and responses to motions in limine are not yet due.[50] Thus, the appellants’ claims of error relate to purely evidentiary matters that have not yet been resolved by the trial court, and under such circumstances, they present no error for this Court to review.[51] For all these reasons, we affirm the trial court’s grant of partial summary judgment to Long. Judgment affirmed. Rickman and Brown, JJ., concur.
