Case Title: Donna L. Johnson v. Richard Kokemoor

Citation: 

Docket Number: 1993AP003099

State: wisconsin

Court: Wisconsin Supreme Court

Date: 1996-03-20T00:00:00Z

Document:
NOTICE 
This opinion is subject to further 
editing and modification.  The final 
version will appear in the bound 
volume of the official reports.   
 
 
 
 
No.  93-3099 
 
STATE OF WISCONSIN             :                IN SUPREME COURT 
                                                                   
 
 
Donna L. Johnson,  
by her Guardian ad Litem, Timothy J. Adler, 
 
 
Plaintiff-Respondent-Petitioner, 
 
 
v. 
 
Dr. Richard Kokemoor, 
Physicians Insurance Company of Wisconsin, 
and Wisconsin Patients Compensation Fund, 
 
 
 
Defendants-Appellants-Cross  
 
Petitioners, 
 
Sacred Heart Hospital, Wisconsin Healthcare 
Liability Plan, Wisconsin Department of 
Health and Social Services, and 
Healthcare Financing Administration, 
 
 
Defendants. 
 
 
FILED 
 
 MAR 20, 1996 
 
 
 Marilyn L. Graves 
  
Clerk of Supreme Court 
  
Madison, WI  
                                                                 
  
 
 
 
REVIEW of a decision of the Court of Appeals.  Reversed and 
cause remanded. 
 
SHIRLEY S. ABRAHAMSON, J.   This is a review of a published 
decision of the court of appeals, Johnson v. Kokemoor, 188 Wis. 2d 
202, 525 N.W.2d 71 (Ct. App. 1994), reversing an order of the 
circuit court for Chippewa County, Richard H. Stafford, judge.  We 
reverse the decision of the court of appeals and remand the cause 
 
No. 93-3099 
 
 
 
2 
to the circuit court for further proceedings on the question of 
damages.
1 
 
Donna Johnson (the plaintiff) brought an action against Dr. 
Richard Kokemoor (the defendant)
2 alleging his failure to obtain 
her informed consent to surgery as required by Wis. Stat. § 448.30 
(1993-94).
3  The jury found that the defendant failed to 
adequately inform the plaintiff regarding the risks associated 
with her surgery.  The jury also found that a reasonable person in 
the plaintiff's position would have refused to consent to surgery 
by the defendant if she had been fully informed of its attendant 
risks and advantages.
4   
                     
     
1  The trial was bifurcated at the circuit court.  The jury 
decided only the liability issue; the issue of damages has not 
been tried.   
     
2  While there are other defendants in this case, in the 
interest of clarity we refer only to Dr. Kokemoor as the 
defendant. 
     
3  All future statutory references are to the 1993-94 volume 
of the Wisconsin Statutes. 
     
4  The parties agreed to a special verdict form requiring the 
jury to answer the following two questions: 
 
(1) Did Dr. Richard Kokemoor fail to adequately inform Donna 
Johnson of the risks and advantages of her surgery? 
 
(2) If you have answered Question 1 "yes", then and then only 
answer this question:  Would a reasonable person in 
Donna Johnson's position have refused to consent to the 
surgery by Dr. Richard Kokemoor had she been informed of 
the risks and advantages of the surgery?  
 
The jury answered "yes" to both questions. 
 
No. 93-3099 
 
 
 
3 
 
The circuit court denied the defendant's motions to change 
the answers in the special verdict and, in the alternative, to 
order a new trial.  In a split decision, the court of appeals 
reversed the circuit court's order.   
 
This case presents the issue of whether the circuit court 
erred in admitting evidence that the defendant, in undertaking his 
duty to obtain the plaintiff's informed consent before operating 
to clip an aneurysm, failed (1) to divulge the extent of his 
experience in performing this type of operation; (2) to compare 
the morbidity and mortality rates
5 for this type of surgery among 
experienced surgeons and inexperienced surgeons like himself; and 
(3) to refer the plaintiff to a tertiary care center staffed by 
physicians more experienced in performing the same surgery.
6  The 
admissibility of such physician-specific evidence in a case 
involving the doctrine of informed consent raises an issue of 
first impression in this court and is an issue with which 
appellate courts have had little experience.   
                     
     
5  As used by the parties and in this opinion, morbidity and 
mortality rates refer to the prospect that surgery may result in 
serious impairment or death. 
     
6  In a motion brought prior to trial, the defendant 
attempted to bar testimony and argument relating to his personal 
experience with aneurysm surgery and to the relative experience of 
other surgeons available to perform such surgery.  The defendant 
argued that such disclosures are not material to the issue of 
informed consent.  The circuit court denied the defendant's motion 
and also ruled that the plaintiff could present expert testimony 
that the defendant should have advised her of and referred her to 
more experienced neurosurgeons.  
 
No. 93-3099 
 
 
 
4 
 
The court of appeals concluded that the first two evidentiary 
matters were admissible but that the third was not.  The court of 
appeals determined that evidence about the defendant's failure to 
refer the plaintiff to more experienced physicians was not 
relevant to a claim of failure to obtain the plaintiff's informed 
consent.  Johnson, 188 Wis. 2d at 223.  Furthermore, the court of 
appeals held that the circuit court committed prejudicial error in 
admitting evidence of the defendant's failure to refer, because 
such evidence allowed the jury to conclude that the defendant 
performed negligently simply because he was less experienced than 
other physicians, even though the defendant's negligence was not 
at issue in this case.  Johnson, 188 Wis. 2d at 224.
7  The court 
of appeals therefore remanded the cause to the circuit court for a 
new trial.
8   
 
The plaintiff's position is that the court of appeals erred 
in directing a new trial.  The defendant's position in his cross-
petition is that the circuit court and the court of appeals both 
erred in approving the admission of evidence referring to his 
experience with this type of surgery and to his and other 
                     
     
7  Prior to trial, the plaintiff had voluntarily dismissed a 
cause of action alleging that the defendant was negligent in 
performing the surgery.   
     
8  Given the "overwhelming" evidence "that Kokemoor did not 
adequately inform Johnson," Johnson v. Kokemoor, 188 Wis. 2d 202, 
227, 525 N.W.2d 71 (Ct. App. 1994), the court of appeals left to 
the circuit court's discretion whether it need retry the issue of 
the defendant's alleged failure to obtain the plaintiff's informed 
consent or whether it need retry only the causation issue.   
 
No. 93-3099 
 
 
 
5 
physicians' morbidity and mortality statistics in performing this 
type of surgery.   
 
We conclude that all three items of evidence were material to 
the issue of informed consent in this case.  As we stated in 
Martin v. Richards, 192 Wis. 2d 156, 174, 531 N.W.2d 70 (1995), "a 
patient cannot make an informed, intelligent decision to consent 
to a physician's suggested treatment unless the physician 
discloses what is material to the patient's decision, i.e., all of 
the viable alternatives and risks of the treatment proposed."  In 
this case information regarding a physician's experience in 
performing a particular procedure, a physician's risk statistics 
as compared with those of other physicians who perform that 
procedure, and the availability of other centers and physicians 
better able to perform that procedure would have facilitated the 
plaintiff's awareness of "all of the viable alternatives" 
available to her and thereby aided her exercise of informed 
consent.  We therefore conclude that under the circumstances of 
this case, the circuit court did not erroneously exercise its 
discretion in admitting the evidence. 
 
I. 
 
We first summarize the facts giving rise to this review, 
recognizing that the parties dispute whether several events 
occurred, as well as what inferences should be drawn from both the 
disputed and the undisputed historical facts.   
 
No. 93-3099 
 
 
 
6 
 
On the advice of her family physician, the plaintiff 
underwent a CT scan to determine the cause of her headaches.  
Following the scan, the family physician referred the plaintiff to 
the defendant, a neurosurgeon in the Chippewa Falls area.  The 
defendant diagnosed an enlarging aneurysm at the rear of the 
plaintiff's brain and recommended surgery to clip the aneurysm.
9  
The defendant performed the surgery in October of 1990.   
 
The defendant clipped the aneurysm, rendering the surgery a 
technical success.  But as a consequence of the surgery, the 
plaintiff, who had no neurological impairments prior to surgery, 
was rendered an incomplete quadriplegic.  She remains unable to 
walk or to control her bowel and bladder movements.  Furthermore, 
her vision, speech and upper body coordination are partially 
impaired.  
 
At trial, the plaintiff introduced evidence that the 
defendant overstated the urgency of her need for surgery and 
overstated his experience with performing the particular type of 
aneurysm surgery which she required.  According to testimony 
introduced during the plaintiff's case in chief, when the 
plaintiff questioned the defendant regarding his experience, he 
replied that he had performed the surgery she required "several" 
times; asked what he meant by "several," the defendant said 
"dozens" and "lots of times."   
                     
     
9  The defendant acknowledged at trial that the aneurysm was 
not the cause of the plaintiff's headaches. 
 
No. 93-3099 
 
 
 
7 
 
In fact, however, the defendant had relatively limited 
experience with aneurysm surgery.  He had performed thirty 
aneurysm surgeries during residency, but all of them involved 
anterior circulation aneurysms.  According to the plaintiff's 
experts, 
operations 
performed 
to 
clip 
anterior 
circulation 
aneurysms are significantly less complex than those necessary to 
clip posterior circulation aneurysms such as the plaintiff's.
10  
Following residency, the defendant had performed aneurysm surgery 
on six patients with a total of nine aneurysms.  He had operated 
on basilar bifurcation aneurysms only twice and had never operated 
on a large basilar bifurcation aneurysm such as the plaintiff's 
aneurysm.
11   
 
The plaintiff also presented evidence that the defendant 
understated the morbidity and mortality rate associated with 
basilar 
bifurcation 
aneurysm 
surgery. 
 
According 
to 
the 
plaintiff's witnesses, the defendant had told the plaintiff that 
her surgery carried a two percent risk of death or serious 
impairment and that it was less risky than the angiogram procedure 
she would have to undergo in preparation for surgery.  The 
                     
     
10  The plaintiff's aneurysm was located at the bifurcation of 
the basilar artery.  According to the plaintiff's experts, surgery 
on basilar bifurcation aneurysms is more difficult than any other 
type of aneurysm surgery. 
     
11  The defendant testified that he had failed to inform the 
plaintiff that he was not and never had been board certified in 
neurosurgery and that he was not a subspecialist in aneurysm 
surgery. 
 
No. 93-3099 
 
 
 
8 
plaintiff's witnesses also testified that the defendant had 
compared the risks associated with the plaintiff's surgery to 
those associated with routine procedures such as tonsillectomies, 
appendectomies and gall bladder surgeries.
12 
 
The plaintiff's neurosurgical experts testified that even the 
physician considered to be one of the world's best aneurysm 
surgeons, who had performed hundreds of posterior circulation 
aneurysm surgeries, had reported a morbidity and mortality rate of 
ten-and-seven-tenths 
percent 
when 
operating 
upon 
basilar 
bifurcation aneurysms comparable in size to the plaintiff's 
aneurysm.  Furthermore, information in treatises and articles 
which the defendant reviewed in preparation for the plaintiff's 
surgery set the morbidity and mortality rate at approximately 
fifteen percent for a basilar bifurcation aneurysm.  The plaintiff 
also introduced expert testimony that the morbidity and mortality 
rate for basilar bifurcation aneurysm operations performed by one 
with the defendant's relatively limited experience would be 
between twenty and thirty percent, and "closer to the thirty 
percent range."
13 
                     
     
12  The defendant testified at trial that he had informed the 
plaintiff that should she decide to forego surgery, the risk that 
her unclipped aneurysm might rupture was two percent per annum, 
cumulative.  Since he informed the plaintiff that the risk 
accompanying surgery was two percent, a reasonable person in the 
plaintiff's position might have concluded that proceeding with 
surgery was less risky than non-operative management.   
     
13  The plaintiff introduced into evidence as exhibits 
articles from the medical literature stating that there are few 
areas in neurosurgery where the difference in results between 
 
No. 93-3099 
 
 
 
9 
 
Finally, the plaintiff introduced into evidence testimony and 
exhibits stating that a reasonable physician in the defendant's 
position would have advised the plaintiff of the availability of 
more experienced surgeons and would have referred her to them.  
The plaintiff also introduced evidence stating that patients with 
basilar 
aneurysms 
should 
be 
referred 
to 
tertiary 
care 
centers--such as the Mayo Clinic, only 90 miles away--which 
contain 
the 
proper 
neurological 
intensive 
care 
unit 
and 
microsurgical facilities and which are staffed by neurosurgeons 
with the requisite training and experience to perform basilar 
bifurcation aneurysm surgeries. 
 
In his testimony at trial, the defendant denied having 
suggested to the plaintiff that her condition was urgent and 
required immediate care.  He also denied having stated that her 
risk was comparable to that associated with an angiogram or minor 
surgical procedures such as a tonsillectomy or appendectomy.  
While he acknowledged telling the plaintiff that the risk of death 
or serious impairment associated with clipping an aneurysm was two 
percent, he also claims to have told her that because of the 
location of her aneurysm, the risks attending her surgery would be 
greater, although he was unable to tell her precisely how much 
(..continued) 
surgeons is as evident as it is with aneurysms.  One of the 
plaintiff's neurosurgical experts testified that experience and 
skill with the operator is more important when performing basilar 
tip aneurysm surgery than with any other neurosurgical procedure.  
 
No. 93-3099 
 
 
 
10 
greater.
14  In short, the defendant testified that his disclosure 
to the plaintiff adequately informed her regarding the risks that 
she faced.  
 
The 
defendant's 
expert 
witnesses 
testified 
that 
the 
defendant's recommendation of surgery was appropriate, that this 
type of surgery is regularly undertaken in a community hospital 
setting, and that the risks attending anterior and posterior 
circulation aneurysm surgeries are comparable.  They placed the 
risk accompanying the plaintiff's surgery at between five and ten 
percent, although one of the defendant's experts also testified 
that such statistics can be misleading.  The defendant's expert 
witnesses also testified that when queried by a patient regarding 
their experience, they would divulge the extent of that experience 
and its relation to the experience of other physicians performing 
similar operations.
15   
                     
     
14  The defendant maintained that characterizing the risk as 
two percent was accurate because the aggregate morbidity and 
mortality rate for all aneurysms, anterior and posterior, is 
approximately two percent.  At the same time, however, the 
defendant conceded that in operating upon aneurysms comparable to 
the plaintiff's aneurysm, he could not achieve morbidity and 
mortality rates as low as the ten-and-seven-tenths percent rate 
reported by a physician reputed to be one of the world's best 
aneurysm surgeons.  
     
15  The defendant's expert witness Dr. Patrick R. Walsh 
testified: 
 
In my personal practice, I typically outline my understanding 
of the natural history of aneurysms, my understanding of 
the experience of the neurosurgical community in dealing 
with aneurysms and then respond to specific questions 
raised by the patient.  If a patient asks specifically 
what my experience is, I believe it is mandatory that I 
 
No. 93-3099 
 
 
 
11 
 
II. 
 
We now turn to a review of Wisconsin's law of informed 
consent.  The common-law doctrine of informed consent arises from 
and reflects the fundamental notion of the right to bodily 
integrity.  Originally, an action alleging that a physician had 
failed to obtain a patient's informed consent was pled as the 
intentional tort of assault and battery.  In the typical situation 
giving rise to an informed consent action, a patient-plaintiff 
consented to a certain type of operation but, in the course of 
that operation, was subjected to other, unauthorized operative 
procedures.  See, e.g., Paulsen v. Gundersen, 218 Wis. 578, 584, 
260 N.W. 448 (1935) (when a patient agrees to a "simple" operation 
and a physician performs a more extensive operation, the physician 
is "guilty of an assault and would be responsible for damages 
resulting therefrom"); Throne v. Wandell, 176 Wis. 97, 186 N.W. 
146 (1922) (dentist extracting six of the plaintiff's teeth 
without her consent has committed a technical assault).   
(..continued) 
outline that to him as carefully as possible. 
 
Dr. Walsh also stated that "[i]t certainly is reasonable for [the 
defendant] to explain to [the plaintiff] that other surgeons are 
available."   
 
 
Dr. Douglas E. Anderson, who also testified for the defense, 
stated that "if the patient is asking issues about prior 
experience, it is reasonable . . . to proceed with a discussion of 
your prior experience."  Dr. Anderson also stated that "if the 
patient asks a surgeon if there is someone who has performed more 
surgeries than he, it is reasonable to tell the truth."  
 
No. 93-3099 
 
 
 
12 
 
The court further developed the doctrine of informed consent 
in Trogun v. Fruchtman, 58 Wis. 2d 569, 207 N.W.2d 297 (1972), 
stating for the first time that a plaintiff-patient could bring an 
informed consent action based on negligence rather than as an 
intentional tort.
16  The court clarified Wisconsin's modern 
doctrine of informed consent in Scaria v. St. Paul Fire & Marine 
Ins. Co., 68 Wis. 2d 1, 227 N.W.2d 647 (1975).  Wis. Stat. 
§ 448.30 codifies the common law set forth in Scaria.
17  This 
                     
     
16  Although an action alleging a physician's failure to 
adequately inform is grounded in negligence, it is distinct from 
the negligence triggered by a physician's failure to provide 
treatment meeting the standard of reasonable care.  The doctrine 
of informed consent focuses upon the reasonableness of a 
physician's 
disclosures 
to 
a 
patient 
rather 
than 
the 
reasonableness of a physician's treatment of that patient.  
     
17  See Martin v. Richards, 192 Wis. 2d 156, 174, 531 N.W.2d 
70 (1995) (discussing the legislative history of Wis. Stat. 
§ 448.30). 
 
 
Wisconsin Stat. § 448.30 requires that a physician inform a 
patient about the availability of all alternate, viable medical 
modes of treatment and about the benefits and risks attending 
these treatments.  The informed consent statute reads as follows: 
 
448.30  Information on alternate modes of treatment.   
Any physician who treats a patient shall inform the patient 
about the availability of all alternate, viable medical 
modes of treatment and about the benefits and risks of 
these treatments.  The physician's duty to inform the 
patient under this section does not require disclosure 
of: 
 
(1) Information beyond what a reasonably well-qualified 
physician in a similar medical classification would 
know. 
 
(2) Detailed technical information that in all probability a 
patient would not understand. 
 
 
No. 93-3099 
 
 
 
13 
statute has recently been interpreted and applied in Martin, 192 
Wis. 2d 156.
18   
The concept of informed consent is based on the 
tenet that in order to make a rational and informed decision about 
undertaking a particular treatment or undergoing a particular 
surgical procedure, a patient has the right to know about 
significant potential risks involved in the proposed treatment or 
surgery.  Scaria, 68 Wis. 2d at 11.  In order to insure that a 
patient can give an informed consent, a "physician or surgeon is 
under the duty to provide the patient with such information as may 
be necessary under the circumstances then existing" to assess the 
significant potential risks which the patient confronts.  Id.   
 
The information that must be disclosed is that information 
which would be "material" to a patient's decision.  Martin, 192 
Wis. 2d at 174.  In the first of three seminal informed consent 
decisions relied upon by both the Trogun and Scaria courts,
19 the 
(..continued) 
 
(3) Risks apparent or known to the patient. 
 
(4) Extremely 
remote 
possibilities 
that 
might 
falsely 
or 
detrimentally alarm the patient. 
 
(5) Information in emergencies where failure to provide 
treatment would be more harmful to the patient than 
treatment. 
 
(6) Information in cases where the patient is incapable of 
consenting. 
     
18  See also Platta v. Flatley, 68 Wis. 2d 47, 227 N.W.2d 898 
(1975). 
     
19  Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972), cert. 
denied, 409 U.S. 1064 (1972); Cobbs v. Grant, 502 P.2d 1 (Cal. 
1972); Wilkinson v. Vesey, 295 A.2d 676 (R.I. 1972). 
 
No. 93-3099 
 
 
 
14 
federal court of appeals for the District of Columbia stated that 
information regarding risk is material when "a reasonable person, 
in what the physician knows or should know to be the patient's 
position, would be likely to attach significance to the risk or 
cluster of risks in deciding whether or not to forego the proposed 
therapy."  Canterbury v. Spence, 464 F.2d 772, 787 (D.C. Cir. 
1972), cert. denied, 409 U.S. 1064 (1972).  The Canterbury court 
defined as material and therefore "demanding a communication" from 
a physician to a patient all information regarding "the inherent 
and potential hazards of the proposed treatment, the alternatives 
to that treatment, if any, and the results likely if the patient 
remains untreated."  Id. at 787-88.
20   
 
According to both the Scaria and Martin courts, a physician's 
reasonable disclosure requires that a patient be informed 
regarding available options.  A "reasonable disclosure" of 
"significant risks," stated the Scaria court, requires an 
assessment of and communication regarding "the gravity of the 
patient's condition, the probabilities of success, and any 
alternative treatment or procedures if such are reasonably 
appropriate so that the patient has the information reasonably 
necessary to form the basis of an intelligent and informed consent 
                     
     
20  See also Miles J. Zaremski & Louis S. Goldstein, 1 Medical 
and Hospital Negligence § 15.05 at 17 (1988-90) (stating that 
"[m]ateriality is the touchstone for determining the adequacy of 
the disclosure . . . the crux of the issue is the effect of the 
nondisclosure on the patient's ability to make an intelligent 
choice"). 
 
No. 93-3099 
 
 
 
15 
to the proposed treatment or procedure."  Scaria, 68 Wis. 2d at 
11.
21  The Martin court, explicitly recognizing that the statutory 
doctrine of informed consent in Wisconsin is "based upon the 
standard expounded in Canterbury," Martin, 192 Wis. 2d at 173, 
explained that a patient cannot make an informed decision to 
consent to the suggested treatment "unless the physician discloses 
what is material to the patient's decision, i.e., all of the 
viable alternatives and risks of the treatment proposed."  Martin, 
192 Wis. 2d at 174.   
 
What constitutes informed consent in a given case emanates 
from what a reasonable person in the patient's position would want 
to know.  Scaria, 68 Wis. 2d at 13; Martin, 192 Wis. 2d at 174.  
This standard regarding what a physician must disclose is 
described as the prudent patient standard; it has been embraced by 
a growing number of jurisdictions since the Canterbury decision.
22 
                     
     
21  For a discussion of informed consent from the legal and 
medical perspectives, see also Paul S. Applebaum, Charles W. Lidz, 
& Alan Meisel, Informed Consent:  Legal Theory and Clinical 
Practice (1987).   
     
22  Wisconsin's adoption of this standard in Scaria is 
discussed in Medical Malpractice:  Concepts and Wisconsin Cases, 
Staff Paper #2 of the Medical Malpractice Committee,  Wisconsin 
Legislative Council Reports 1, 2 (1976); John S. Schliesmann, 
Torts, 59 Marq. L. Rev. 417, 417-19 (1976).  For a more general 
overview 
of 
the 
history 
of 
and 
distinctions 
between 
the 
traditional professional physician standard and the prudent 
patient standard, see Applebaum, supra, 41-49; David W. Louisell & 
Harold Williams, 2 Medical Malpractice § 22.05 (2d ed. 1987) 
(pointing out that the professional physician standard has been 
criticized for being vague and thereby conferring almost unlimited 
discretion on the treating physician); Zaremski & Goldstein, 
supra, § 15.03 & nn.18-20 (collecting cases).  
 
No. 93-3099 
 
 
 
16 
 
The Scaria court emphasized that those "disclosures which 
would be made by doctors of good standing, under the same or 
similar circumstances, are certainly relevant and material" in 
assessing what constitutes adequate disclosure, adding that 
physician disclosures conforming to such a standard "would be 
adequate to fulfill the doctor's duty of disclosure in most 
instances."  Scaria, 68 Wis. 2d at 12.  But the evidentiary value 
of what physicians of good standing consider adequate disclosure 
is not dispositive, for ultimately "the extent of the physician's 
disclosures is driven . . . by what a reasonable person under the 
circumstances then existing would want to know."  Martin, 192 
Wis. 2d at 174; see also Scaria, 68 Wis. 2d at 13.
23   
 
"The information that is reasonably necessary for a patient 
to make an informed decision regarding treatment will vary from 
                     
     
23  We recognize, as did the Scaria court, that there must be 
some limitation upon the doctor's duty to disclose risks involved. 
 In Scaria, we cautioned: 
 
A doctor should not be required to give a detailed technical 
medical explanation that in all probability the patient 
would not understand.  He should not be required to 
discuss risks that are apparent or known to the patient. 
 Nor should he be required to disclose extremely remote 
possibilities that at least in some instances might only 
serve to falsely or detrimentally alarm the particular 
patient.  Likewise, a doctor's duty to inform is further 
limited in cases of emergency or where the patient is a 
child, mentally incompetent or a person is emotionally 
distraught or susceptible to unreasonable fears.  
 
Scaria, 68 Wis. 2d at 12-13 (note omitted).  Similar limitations 
on a physician's duty to disclose were subsequently incorporated 
into Wis. Stat. § 448.30.  
 
No. 93-3099 
 
 
 
17 
case to case."  Martin, 192 Wis. 2d at 175.
24  The standard to 
which a physician is held is determined not by what the particular 
patient being treated would want to know, but rather by what a 
reasonable person in the patient's position would want to know.  
Scaria, 68 Wis. 2d at 13. 
 
III. 
 
Before addressing the substantive issues raised by the 
parties, we briefly outline the standards of review which we apply 
to the circuit court's evidentiary ruling admitting the three 
items of evidence in dispute in this case. 
 
The defendant argues that the circuit court erred in 
admitting the evidence.  He asks the court to declare that the 
three pieces of evidence at issue are not admissible as a matter 
of law in informed consent cases.
25 
                     
     
24  See also Zaremski & Goldstein, supra, § 15.01 at 3 ("the 
scope of the disclosure is to be viewed in conjunction with the 
circumstances of each individual case").  
     
25  Under Wisconsin's doctrine of informed consent, whenever 
the determination of what a reasonable person in the patient's 
position would want to know is open to debate by reasonable 
people, the issue of informed consent is a question for the jury. 
 Martin, 192 Wis. 2d at 172-73; Platta, 68 Wis. 2d at 60; see also 
Canterbury, 464 F.2d at 788.  
 
 
In Martin, we upheld that part of a court of appeals decision 
reversing the circuit court's exclusion as a matter of law of 
certain evidence relating to the physician's failure to disclose a 
one-to-three-percent chance that the plaintiff might suffer 
intracranial bleeding following a serious head injury.  The 
circuit court had determined that the disputed information 
involved "extremely remote possibilities" and was therefore not 
subject to disclosure under Wis. Stat. § 448.30(4) as a matter of 
law.  Instead, we noted that while the undisclosed risk may have 
been small, "such risk may be significant to a patient's decision 
 
No. 93-3099 
 
 
 
18 
 
The general rule is that a circuit court's decision with 
regard to the relevance of proffered evidence is a discretionary 
decision.  State v. Pittman, 174 Wis. 2d 255, 267, 496 N.W.2d 74 
(1993).  Evidence is relevant when it "tends 'to make the 
existence of [a material fact] more probable or less probable than 
it would be without the evidence.'"  In Interest of Michael R.B., 
175 Wis. 2d 713, 724, 499 N.W.2d 641 (1993) (quoting State v. 
Denny, 120 Wis. 2d 614, 623, 357 N.W.2d 12 (Ct. App. 1984)); Wis. 
Stat. § 904.01.
26  Material facts are those that are of consequence 
to the merits of the litigation.  In Interest of Michael R.B., 175 
Wis. 2d at 724. 
 
Evidence which is relevant may nevertheless be excluded if 
its probative value is substantially outweighed by the danger of 
unfair prejudice, confusion of the issues, or misleading the jury. 
 State v. Patricia A.M., 176 Wis. 2d 542, 554, 500 N.W.2d 289 
(1993); Wis. Stat. § 904.03.
27  It is not enough that the evidence 
(..continued) 
in light of the potentially severe consequences" and therefore 
should have been admitted.  Martin, 192 Wis. 2d at 168.  
     
26  Wis. Stat. § 904.01 provides as follows: 
 
Definition of "relevant evidence."  "Relevant evidence" means 
evidence having any tendency to make the existence of 
any fact that is of consequence to the determination of 
the action more probable or less probable than it would 
be without the evidence."    
     
27  Wis. Stat. § 904.03 provides as follows:  
 
Exclusion of relevant evidence on grounds of prejudice, 
confusion, or waste of time.  Although relevant, 
evidence may be excluded if its probative value is 
 
No. 93-3099 
 
 
 
19 
will be prejudicial; "exclusion is required only if the evidence 
is unfairly prejudicial."  Patricia A.M., 176 Wis. 2d at 554. 
 
The question of whether otherwise admissible evidence is 
nevertheless unfairly prejudicial rests with the discretion of the 
circuit court.  Featherly v. Continental Ins. Co., 73 Wis. 2d 273, 
243 N.W.2d 806 (1976).  This court will not conclude that a 
circuit court erroneously exercised its discretion when there is a 
reasonable basis for the circuit court's determination.   
 
Finally, if the circuit court erred in admitting the 
evidence, reversal or a new trial is required only if the improper 
admission of evidence has affected the substantial rights of the 
party seeking relief.  Wis. Stat. § 805.18(2).
28  
 
IV. 
 
The defendant contends that the circuit court erred in 
allowing the plaintiff to introduce evidence regarding the 
(..continued) 
substantially outweighed by the danger of unfair 
prejudice, confusion of the issues, or misleading the 
jury, or by considerations of undue delay, waste of 
time, or needless presentation of cumulative evidence.  
     
28  Wis. Stat. § 805.18(2) provides as follows: 
 
No judgment shall be reversed or set aside or new trial 
granted in any action or proceeding on the ground of 
drawing, selection or misdirection of jury, or the 
improper admission of evidence, or for error as to any 
matter of pleading or procedure, unless in the opinion 
of the court to which the application is made, after an 
examination of the entire action or proceeding, it shall 
appear that the error complained of has affected the 
substantial rights of the party seeking to reverse or 
set aside the judgment, or to secure a new trial.   
 
No. 93-3099 
 
 
 
20 
defendant's 
limited 
experience 
in 
operating 
upon aneurysms 
comparable to the plaintiff's aneurysm.  Wisconsin's law of 
informed consent, the defendant continues, requires a physician to 
reveal only those risks inherent in the treatment.  Everyone 
agrees, argues the defendant, that he advised the plaintiff 
regarding those risks:  the potential perils of death, a stroke or 
blindness associated with her surgery. 
 
The defendant argues that the circuit court's decision to 
admit evidence pertaining to his surgical experience confused 
relevant information relating to treatment risks with irrelevant 
and prejudicial information that the defendant did not possess the 
skill and experience of the very experienced aneurysm surgeons.  
Therefore, according to the defendant, the jury's attention was 
diverted from a consideration of whether the defendant made 
required disclosures regarding treatment to the question of who 
was performing the plaintiff's operation.  Thus, the defendant 
contends, the circuit court transformed a duty to reasonably 
inform into a duty to reasonably perform the surgery, even though 
the plaintiff was not alleging negligent treatment.   
 
The doctrine of informed consent should not, argues the 
defendant, be construed as a general right to information 
regarding possible alternative procedures, health care facilities 
and physicians.  Instead, urges the defendant, the doctrine of 
informed consent should be viewed as creating a "bright line" rule 
requiring physicians to disclose only significant complications 
 
No. 93-3099 
 
 
 
21 
intrinsic to the contemplated procedure.  The defendant interprets 
Wis. Stat. § 448.30 as an embodiment of this more modest 
definition of informed consent.  In sum, the defendant urges that 
the statutory provisions require disclosure of risks associated 
with particular "treatments" rather than the risks associated with 
particular physicians.
29   
                     
     
29  The defendant also argues that the plaintiff is trying to 
disguise what is actually a negligent misrepresentation claim as 
an informed consent claim so that she might bring before the jury 
otherwise 
inadmissible 
evidence 
regarding 
the 
defendant's 
experience and relative competence.   
 
 
The tort of negligent misrepresentation occurs when one 
person negligently gives false information to another who acts in 
reasonable reliance on the information and suffers physical harm 
as a consequence of the reliance.  Restatement (Second) of Torts, 
§ 311(1) (1965).  An overlap exists between a claim pleading this 
tort and one alleging a failure to provide informed consent.  As 
the commentary to § 311 of the Restatement points out: 
 
The rule stated in this Section finds particular application 
where it is a part of the actor's business or profession 
to give information upon which the safety of the 
recipient or a third person depends.  Thus it is as much 
a part of the professional duty of a physician to give 
correct information as to the character of the disease 
from which his plaintiff is suffering, where such 
knowledge is necessary to the safety of the patient or 
others, as it is to make a correct diagnosis or to 
prescribe the appropriate medicine.   
 
Restatement (Second) of Torts, § 311(1) cmt. b (1965). 
 
 
Because of this overlap between negligent misrepresentation 
and informed consent, it is not surprising that allegations made 
and 
evidence 
introduced 
by 
the 
plaintiff 
might 
have 
fit 
comfortably under either theory.  But this overlap does not 
preclude the plaintiff from making allegations and introducing 
evidence in an informed consent case which might also have been 
pled in a negligent misrepresentation case.  This case was pled 
and proved under the tort of failure to procure informed consent. 
 
No. 93-3099 
 
 
 
22 
 
We reject the defendant's proposed bright line rule that it 
is error as a matter of law to admit evidence in an informed 
consent case that the physician failed to inform the patient 
regarding the physician's experience with the surgery or treatment 
at issue.  The prudent patient standard adopted by Wisconsin in 
Scaria is incompatible with such a bright line rule.   
 
As Scaria states and as Martin confirms, what a physician 
must disclose is contingent upon what, under the circumstances of 
a given case, a reasonable person in the patient's position would 
need to know in order to make an intelligent and informed 
decision.  Scaria, 68 Wis. 2d at 13; Martin, 192 Wis. 2d at 174.  
The question of whether certain information is material to a 
patient's decision and therefore requires disclosure is rooted in 
the facts and circumstances of the particular case in which it 
arises.  Martin, 192 Wis. 2d at 175. 
 
The cases upon which the Trogun and Scaria courts relied in 
fashioning Wisconsin's current doctrine of informed consent 
rejected the concept of bright line rules.  The "scope of the 
disclosure required of physicians," stated the California Supreme 
Court, "defies simple definition" and must therefore "be measured 
by the patient's need, and that need is whatever information is 
material to the decision."  Cobbs v. Grant, 502 P.2d 1, 10, 11 
(Cal. 1972).  "The amount of disclosure can vary from one patient 
to another," stated the Rhode Island Supreme Court, because 
"[w]hat is reasonable disclosure in one instance may not be 
 
No. 93-3099 
 
 
 
23 
reasonable in another."  Wilkinson v. Vesey, 295 A.2d 676, 687-88 
(R.I. 1972).  Finally, the Canterbury court's decision--which, as 
the Martin court underscored last term, provides the basis for 
Wisconsin's doctrine of informed consent, Martin, 192 Wis. 2d at 
173--states explicitly that under the doctrine of informed 
consent, "[t]here is no bright line separating the significant 
from the insignificant."  Canterbury, 464 F.2d at 788. 
 
Wisconsin Stat. § 448.30 explicitly requires disclosure of 
more 
than 
just 
treatment 
complications 
associated 
with 
a 
particular procedure.  Physicians must, the statute declares, 
disclose "the availability of all alternate, viable medical modes 
of treatment" in addition to "the benefits and risks of these 
treatments."   
 
The Martin court rejected the argument that Wis. Stat. 
§ 448.30 was limited by its plain language to disclosures 
intrinsic to a proposed treatment regimen.  The Martin court 
stated that Wis. Stat. § 448.30 "should not be construed so as to 
unduly limit the physician's duty to provide information which is 
reasonably necessary under the circumstances."  Martin, 192 
Wis. 2d at 175.
30  "There can be no dispute," the Martin court 
                     
     
30  Ruling before the publication of Martin on the 
admissibility 
of 
evidence 
pertaining 
to 
the 
defendant's 
experience, the circuit court made a similar point: 
 
I've also looked at the informed consent instruction, 1023.2, 
and it says that the doctor or physician is under a duty 
to make such disclosures that will enable a reasonable 
person under the circumstances confronting the patient 
to exercise the patient's right to make a proper 
 
No. 93-3099 
 
 
 
24 
declared, "that the language in Scaria . . . requires that a 
physician disclose information necessary for a reasonable person 
to make an intelligent decision."  Id.   
 
In this case, the plaintiff introduced ample evidence that 
had a reasonable person in her position been aware of the 
defendant's relative lack of experience in performing basilar 
bifurcation aneurysm surgery, that person would not have undergone 
surgery with him.  According to the record the plaintiff had made 
inquiry of the defendant's experience with surgery like hers.  In 
response to her direct question about his experience he said that 
he had operated on aneurysms comparable to her aneurysm "dozens" 
of times.  The plaintiff also introduced evidence that surgery on 
basilar bifurcation aneurysms is more difficult than any other 
type of aneurysm surgery and among the most difficult in all of 
neurosurgery.  We conclude that the circuit court did not 
erroneously 
exercise 
its 
discretion 
in 
admitting 
evidence 
regarding the defendant's lack of experience and the difficulty of 
the proposed procedure.  A reasonable person in the plaintiff's 
(..continued) 
consent, so I don't think that--that we're limited to 
the references made in the statute.  I think that 
anything that's necessary to a reasonable person to 
arrive at an informed and reasonable consent is 
allowable evidence, so clearly the six times [i.e. the 
six 
post-residency 
aneurysm 
operations 
which 
the 
defendant had performed] is allowable evidence and the 
fact that he made a statement that he had done this lots 
of time, there's nothing wrong with that [being 
admitted].  
 
No. 93-3099 
 
 
 
25 
position would have considered such information material in making 
an intelligent and informed decision about the surgery.   
 
We also reject the defendant's claim that even if this 
information was material, it should have been excluded because its 
prejudicial effect outweighed its probative value.  The defendant 
contends that the admission of such evidence allowed the jury to 
infer that the plaintiff's partial paralysis was a product of the 
defendant's lack of experience and skill rather than a consequence 
of his alleged failure to inform.   
 
We disagree with the defendant's claim that evidence 
pertaining to the defendant's experience was unduly and unfairly 
prejudicial.  While a jury might confuse negligent failure to 
disclose with negligent treatment,
31 the likelihood of confusion is 
nonexistent or de minimis in this case.  The plaintiff dismissed 
her negligent treatment claim before trial.  It is thus unlikely 
that the jury would confuse an issue not even before it with the 
issue that was actually being tried.  We therefore conclude that 
the defendant was not unduly or unfairly prejudiced by the 
admission of evidence reflecting his failure to disclose his 
limited prior experience in operating on basilar bifurcation 
aneurysms.   
                     
     
31  See Marjorie Maguire Schultz, From Informed Consent to 
Patient Choice:  A New Protected Interest, 95 Yale L.J. 219, 228-
29 (1985).  One could only completely eliminate the potential that 
such confusion might arise by categorically prohibiting all 
actions predicated on an alleged failure to procure informed 
consent.   
 
No. 93-3099 
 
 
 
26 
 
V. 
 
The defendant next argues that the circuit court erred in 
allowing the plaintiff to introduce evidence of morbidity and 
mortality rates associated with the surgery at issue.  The 
defendant particularly objects to comparative risk statistics 
purporting to estimate and compare the morbidity and mortality 
rates when the surgery at issue is performed, respectively, by a 
physician of limited experience such as the defendant and by the 
acknowledged masters in the field.  Expert testimony introduced by 
the plaintiff indicated that the morbidity and mortality rate 
expected when a surgeon with the defendant's experience performed 
the surgery would be significantly higher than the rate expected 
when a more experienced physician performed the same surgery.   
 
The defendant asserts that admission of these morbidity and 
mortality rates would lead the jury to find him liable for failing 
to perform at the level of the masters rather than for failing to 
adequately inform the plaintiff regarding the risks associated 
with her surgery.  Furthermore, contends the defendant, statistics 
are notoriously inaccurate and misleading.  
 
As with evidence pertaining to the defendant's prior 
experience with similar surgery, the defendant requests that the 
court fashion a bright line rule as a matter of law that 
comparative risk evidence should not be admitted in an informed 
consent case.  For many of the same reasons which led us to 
conclude that such a bright line rule of exclusion would be 
 
No. 93-3099 
 
 
 
27 
inappropriate for evidence of a physician's prior experience, we 
also reject a bright line rule excluding evidence of comparative 
risk relating to the provider.   
 
The 
medical 
literature 
identifies 
basilar 
bifurcation 
aneurysm surgery as among the most difficult in neurosurgery.  As 
the plaintiff's evidence indicates, however, the defendant had 
told her that the risks associated with her surgery were 
comparable to the risks attending a tonsillectomy, appendectomy or 
gall bladder operation.  The plaintiff also introduced evidence 
that the defendant estimated the risk of death or serious 
impairment associated with her surgery at two percent.  At trial, 
however, the defendant conceded that because of his relative lack 
of experience, he could not hope to match the ten-and-seven-tenths 
percent morbidity and mortality rate reported for large basilar 
bifurcation aneurysm surgery by very experienced surgeons. 
 
The defendant also admitted at trial that he had not shared 
with the plaintiff information from articles he reviewed prior to 
surgery. 
 
These 
articles 
established 
that 
even 
the 
most 
accomplished posterior circulation aneurysm surgeons reported 
morbidity and mortality rates of fifteen percent for basilar 
bifurcation aneurysms.  Furthermore, the plaintiff introduced 
expert testimony indicating that the estimated morbidity and 
mortality rate one might expect when a physician with the 
defendant's relatively limited experience performed the surgery 
would be close to thirty percent. 
 
No. 93-3099 
 
 
 
28 
 
Had a reasonable person in the plaintiff's position been made 
aware that being operated upon by the defendant significantly 
increased the risk one would have faced in the hands of another 
surgeon performing the same operation, that person might well have 
elected to forego surgery with the defendant.  Had a reasonable 
person in the plaintiff's position been made aware that the risks 
associated with surgery were significantly greater than the risks 
that an unclipped aneurysm would rupture, that person might well 
have elected to forego surgery altogether.  In short, had a 
reasonable person in the plaintiff's position possessed such 
information before consenting to surgery, that person would have 
been better able to make an informed and intelligent decision.   
 
The defendant concedes that the duty to procure a patient's 
informed consent requires a physician to reveal the general risks 
associated with a particular surgery.  The defendant does not 
explain why the duty to inform about this general risk data should 
be interpreted to categorically exclude evidence relating to 
provider-specific risk information, even when that provider-
specific data is geared to a clearly delineated surgical procedure 
and identifies a particular provider as an independent risk 
factor.  When different physicians have substantially different 
success rates, whether surgery is performed by one rather than 
another represents a choice between "alternate, viable medical 
modes of treatment" under § 448.30.   
 
No. 93-3099 
 
 
 
29 
 
For example, while there may be a general risk of ten percent 
that a particular surgical procedure will result in paralysis or 
death, that risk may climb to forty percent when the particular 
procedure is performed by a relatively inexperienced surgeon.  It 
defies logic to interpret this statute as requiring that the 
first, almost meaningless statistic be divulged to a patient while 
the second, far more relevant statistic should not be.  Under 
Scaria and its progeny as well as the codification of Scaria as 
Wis. Stat. § 448.30, the second statistic would be material to the 
patient's exercise of an intelligent and informed consent 
regarding treatment options.  A circuit court may in its 
discretion conclude that the second statistic is admissible.  
 
The doctrine of informed consent requires disclosure of "all 
of the viable alternatives and risks of the treatment proposed" 
which would be material to a patient's decision.  Martin, 192 
Wis. 2d at 174.  We therefore conclude that when different 
physicians have substantially different success rates with the 
same procedure and a reasonable person in the patient's position 
would consider such information material, the circuit court may 
admit this statistical evidence.
32  
                     
     
32 
See Aaron D. Twerski & Neil B. Cohen, Comparing Medical 
Providers:  A First Look at the New Era of Medical Statistics, 58 
Brook. L. Rev. 5 (1992).  Professors Twerski and Cohen note that 
the development of sophisticated data regarding risks of various 
procedures and statistical models comparing the success rates of 
medical providers signal changes in informed consent law.  
Specifically, they state: 
 
The duty to provide information may require more than a 
 
No. 93-3099 
 
 
 
30 
 
We caution, as did the court of appeals, that our decision 
will not always require physicians to give patients comparative 
risk evidence in statistical terms to obtain informed consent.
33  
Rather, we hold that evidence of the morbidity and mortality 
outcomes of different physicians was admissible under the 
circumstances of this case.  
 
In 
keeping 
with 
the 
fact-driven 
and 
context-specific 
application of informed consent doctrine, questions regarding 
whether statistics are sufficiently material to a patient's 
decision to be admissible and sufficiently reliable to be non-
prejudicial are best resolved on a case-by-case basis.  The 
(..continued) 
simple sharing of visceral concerns about the wisdom of 
undertaking a given therapeutic procedure.  Physicians 
may have a responsibility to identify and correlate risk 
factors and to communicate the results to patients as a 
predicate to fulfilling their obligation to inform.  
 
 Id. at 6. 
 
 
See also Douglas Sharrott, Provider-Specific Quality-of-Care 
Data:  A Proposal for Limited Mandatory Disclosure, 58 Brook L. 
Rev. 85 (1992) (stating that it is difficult to refute the 
argument that provider-specific data, once disclosed to the public 
by the government, should also be disclosed to patients because 
the doctrine of informed consent requires a physician to inform a 
patient of both material risks and alternatives to a proposed 
course of treatment). 
     
33  For criticisms of medical performance statistics and 
cautions 
that 
provider-specific 
outcome 
statistics must 
be 
carefully evaluated to insure their reliability and validity when 
used as evidence, see, e.g., Jesse Green, Problems in the Use of 
Outcome Statistics to Compare Health Care Providers, 58 Brook. L. 
Rev. 55 (1992); Paul D. Rheingold, The Admissibility of Evidence 
in Malpractice Cases:  The Performance Records of Practitioners, 
58 Brook. L. Rev. 75, 78-79 (1992); Sharrott, supra, at 92-94, 
120; Twerski & Cohen, supra, at 8-9. 
 
No. 93-3099 
 
 
 
31 
fundamental issue in an informed consent case is less a question 
of how a physician chooses to explain the panoply of treatment 
options and risks necessary to a patient's informed consent than a 
question of assessing whether a patient has been advised that such 
options and risks exist. 
 
As the court of appeals observed, in this case it was the 
defendant himself who elected to explain the risks confronting the 
plaintiff in statistical terms.  He did this because, as he stated 
at trial, "numbers giv[e] some perspective to the framework of the 
very real, immediate, human threat that is involved with this 
condition."  Because the defendant elected to explain the risks 
confronting the plaintiff in statistical terms, it stands to 
reason that in her effort to demonstrate how the defendant's 
numbers dramatically understated the risks of her surgery, the 
plaintiff would seek to introduce other statistical evidence.  
Such evidence was integral to her claim that the defendant's 
nondisclosure denied her the ability to exercise informed consent. 
  
 
VI. 
 
The defendant also asserts that the circuit court erred as a 
matter of law in allowing the plaintiff to introduce expert 
testimony that because of the difficulties associated with 
operating on the plaintiff's aneurysm, the defendant should have 
referred her to a tertiary care center containing a proper 
neurological intensive care unit, more extensive microsurgical 
 
No. 93-3099 
 
 
 
32 
facilities and more experienced surgeons.  While evidence that a 
physician should have referred a patient elsewhere may support an 
action alleging negligent treatment, argues the defendant, it has 
no place in an informed consent action.   
 
The court of appeals agreed with the defendant that this 
evidence should have been excluded, and it further concluded that 
admission of this evidence created "a serious danger [that] the 
jury may confuse a duty to provide average quality care with a 
duty to adequately inform of medical risks."  Johnson, 188 Wis. 2d 
at 224.  
 
We share the concern expressed by the court of appeals and 
underscored by the defendant, but their concern is misplaced in 
this case.  Here, the plaintiff was not asserting a claim for 
negligent performance.  Just because expert testimony is relevant 
to one claim does not mean that it is not relevant to another.  
 
When faced with an allegation that a physician breached a 
duty of informed consent, the pertinent inquiry concerns what 
information a reasonable person in the patient's position would 
have considered material to an exercise of intelligent and 
informed consent.  Scaria, 68 Wis. 2d at 13; Martin, 192 Wis. 2d 
at 174.  Under the facts and circumstances presented by this case, 
the circuit court could declare, in the exercise of its 
discretion, that evidence of referral would have been material to 
the ability of a reasonable person in the plaintiff's position to 
render informed consent.  
 
No. 93-3099 
 
 
 
33 
 
The plaintiff's medical experts testified that given the 
nature and difficulty of the surgery at issue, the plaintiff could 
not make an intelligent decision or give an informed consent 
without being made aware that surgery in a tertiary facility would 
have decreased the risk she faced.  One of the plaintiff's 
experts, Dr. Haring J.W. Nauta, stated that "it's not fair not to 
bring up the subject of referral to another center when the 
problem is as difficult to treat" as the plaintiff's aneurysm was. 
 Another of the plaintiff's experts, Dr. Robert Narotzky, 
testified that the defendant's "very limited" experience with 
aneurysm surgery rendered reasonable a referral to "someone with a 
lot more experience in dealing with this kind of problem."  Dr. 
Fredric Somach, also testifying for the plaintiff, stated as 
follows:   
[S]he should have been told that this was an extremely 
difficult, formidable lesion and that there are people 
in the immediate geographic vicinity that are very 
experienced and that have had a great deal of contact 
with this type of aneurysm and that she should consider 
having at least a second opinion, if not going directly 
to one of these other [physicians].  
Articles from the medical literature introduced by the plaintiff 
also stated categorically that the surgery at issue should be 
performed at a tertiary care center while being "excluded" from 
the community setting because of "the limited surgical experience" 
and lack of proper equipment and facilities available in such 
hospitals.  
 
No. 93-3099 
 
 
 
34 
 
Scaria instructs us that "[t]he disclosures which would be 
made by doctors of good standing, under the same or similar 
circumstances, are certainly relevant and material" to a patient's 
exercise of informed consent.  Scaria, 68 Wis. 2d at 12.  
Testimony by the plaintiff's medical experts indicated that 
"doctors of good standing" would have referred her to a tertiary 
care center housing better equipment and staffed by more 
experienced physicians.  Hence under the materiality standard 
announced in Scaria, we conclude that the circuit court properly 
exercised its discretion in admitting evidence that the defendant 
should have advised the plaintiff of the possibility of undergoing 
surgery at a tertiary care facility.   
 
The defendant asserts that the plaintiff knew she could go 
elsewhere.  This claim is both true and beside the point.  
Credible evidence in this case demonstrates that the plaintiff 
chose not to go elsewhere because the defendant gave her the 
impression that her surgery was routine and that it therefore made 
no difference who performed it.  The pertinent inquiry, then, is 
not whether a reasonable person in the plaintiff's position would 
have known generally that she might have surgery elsewhere, but 
rather whether such a person would have chosen to have surgery 
elsewhere had the defendant adequately disclosed the comparable 
risks attending surgery performed by him and surgery performed at 
a tertiary care facility such as the Mayo Clinic, only 90 miles 
away. 
 
No. 93-3099 
 
 
 
35 
 
The defendant also argues that evidence of referral is 
prejudicial 
because 
it 
might 
have 
affected 
the 
jury's 
determination of causation.  The court of appeals reasoned that if 
a complainant could introduce evidence that a physician should 
have referred her elsewhere, "a patient so informed would almost 
certainly forego the procedure with that doctor."  Johnson, 188 
Wis. 2d at 224.
34   
 
The court of appeals concluded that admitting evidence 
regarding a physician's failure to refer was prejudicial error 
because it probably affected the jury's decision about causation 
in favor of the plaintiff.
35  Contending that a causal connection 
between his failure to divulge and the plaintiff's damage is 
required, the defendant seems to assert that the plaintiff has 
offered no evidence that the defendant's failure to disclose his 
relevant experience or his statistical risk harmed the plaintiff. 
 Even had the surgery been performed by a "master," the defendant 
argues, a bad result may have occurred.
36   
                     
     
34  The court of appeals expressed concern that the 
plaintiff's evidence regarding the defendant's failure to refer 
might cause the jury to confuse a physician's duty to procure a 
patient's informed consent with a separate and distinct tort 
establishing a physician's duty to refer.  While acknowledging 
that other jurisdictions had recognized a distinct duty to refer, 
the court of appeals observed that Wisconsin has never done so.  
Nor does the court do so today. We merely hold that a physician's 
failure to refer may, under some circumstances, be material to a 
patient's exercise of an intelligent and informed consent. 
     
35  The dissenting opinion in the court of appeals determined 
the error to be harmless. 
     
36  For discussion of this aspect of causation, see Twerski & 
 
No. 93-3099 
 
 
 
36 
 
The defendant appears to attack the basic concept of 
causation applied in claims based on informed consent.  As 
reflected in the informed consent jury instruction (Wis JI—Civil 
1023.3 (1992)), which the defendant himself proposed and which was 
given at trial, the question confronting a jury in an informed 
consent case is whether a reasonable person in the patient's 
position would have arrived at a different decision about the 
treatment or surgery had he or she been fully informed.  As 
reflected in the special verdict question in this case, that 
question asked whether "a reasonable person in Donna Johnson's 
position [would] have refused to consent to the surgery by Dr. 
Richard Kokemoor had she been fully informed of the risks and 
advantages of surgery."  If the defendant is arguing here that the 
standard causation instruction is not applicable in a case in 
which provider-specific evidence is admitted, this contention has 
not been fully presented and developed.  
 
Finally, the defendant argues that if his duty to procure the 
plaintiff's informed consent includes an obligation to disclose 
that she consider seeking treatment elsewhere, then there will be 
no logical stopping point to what the doctrine of informed consent 
might encompass.  We disagree with the defendant.  As the 
plaintiff noted in her brief to this court, "[i]t is a rare 
exception when the vast body of medical literature and expert 
(..continued) 
Cohen, supra. 
 
No. 93-3099 
 
 
 
37 
opinion agree that the difference in experience of the surgeon 
performing 
the 
operation 
will 
impact 
the 
risk 
of 
morbidity/mortality as was the case here," thereby requiring 
referral.  Brief for Petitioner at 40.  At oral argument before 
this court, counsel for the plaintiff stated that under "many 
circumstances" and indeed "probably most circumstances," whether 
or not a physician referred a patient elsewhere would be "utterly 
irrelevant" in an informed consent case.  In the vast majority of 
significantly less complicated cases, such a referral would be 
irrelevant and unnecessary. 
 
Moreover, we have already concluded that comparative risk 
data distinguishing the defendant's morbidity and mortality rate 
from the rate of more experienced physicians was properly before 
the jury.  A close link exists between such data and the propriety 
of referring a patient elsewhere.  A physician who discloses that 
other physicians might have lower morbidity and mortality rates 
when performing the same procedure will presumably have access to 
information regarding who some of those physicians are.  When the 
duty to share comparative risk data is material to a patient's 
exercise of informed consent, an ensuing referral elsewhere will 
often represent no more than a modest and logical next step.
37 
                     
     
37  The Canterbury court included a duty to refer among its 
examples of information which, under the facts and circumstances 
of a particular case, a physician might be required to disclose in 
order to procure a patient's informed consent.  The court stated: 
 "The typical situation is where a general practitioner discovers 
that the patient's malady calls for specialized treatment, 
whereupon the duty generally arises to advise the patient to 
 
No. 93-3099 
 
 
 
38 
 
Given the difficulties involved in performing the surgery at 
issue in this case, coupled with evidence that the defendant 
exaggerated his own prior experience while downplaying the risks 
confronting the plaintiff, the circuit court properly exercised 
its discretion in admitting evidence that a physician of good 
standing would have made the plaintiff aware of the alternative of 
lower risk surgery with a different, more experienced surgeon in a 
better-equipped facility.   
 
For the reasons set forth, we conclude that the circuit court 
did not erroneously exercise its discretion in admitting the 
evidence at issue, and accordingly, we reverse the decision of the 
court of appeals and remand the cause to the circuit court for 
further proceedings consistent with this opinion. 
 
By the Court.—The decision of the court of appeals is 
reversed and the cause is remanded to the circuit court with 
directions. 
 
Justice Ann Walsh Bradley did not participate. 
(..continued) 
consult a specialist."  Canterbury, 464 F.2d at 781 n.22.  
 
No. 93-3099 
 
 
 
39 
 
 
 
SUPREME COURT OF WISCONSIN 
 
                                                              
 
Case No.: 
 
93-3099 
                                                              
 
Complete Title 
of Case: 
Donna L. Johnson, By her Guardian Ad Litem, 
 
 
 
Timothy J. Adler, 
 
 
 
 
Plaintiff-Respondent-Petitioner, 
 
 
 
 
v. 
 
 
 
Dr. Richard Kokemoor, Physicians Insurance 
 
 
 
Company of Wisconsin and Wisconsin Patients 
 
 
 
Compensation Fund, 
 
 
 
 
Defendants-Appellants-Cross Petitioners, 
 
 
 
Sacred Heart Hospital, Wisconsin Healthcare 
 
 
 
Liability Plan, Wisconsin Department of 
 
 
 
Health and Social Services and Healthcare 
 
 
 
Financing Administration, 
 
 
 
 
Defendants. 
 
 
 
______________________________________________ 
 
 
 
 
REVIEW OF A DECISION OF THE COURT OF APPEALS 
 
 
 
Reported at:  188 Wis. 2d 202, 525 N.W.2d 71 
 
 
 
 
 
 
 
(Ct. App. 1994) 
 
 
 
 
 
 
 
PUBLISHED 
 
                                                              
 
Opinion Filed:  
March 20, 1996 
Submitted on Briefs: 
 
Oral Argument: 
November 1, 1995 
 
                                                              
 
Source of APPEAL 
 
COURT: 
Circuit 
 
COUNTY: 
Chippewa 
 
JUDGE: 
RICHARD STAFFORD 
 
                                                              
 
 
 
 
 
No. 93-3099 
 
 
JUSTICES: 
 
 
Concurred: 
 
 
Dissented: 
 
 
Not Participating: 
BRADLEY, J., did not participate 
                                                              
 
 
ATTORNEYS:  
For the plaintiff-respondent-petitioner there were 
briefs by D. Charles Jordan, Dana J. Wachs, Heidi L. Atkins and 
Jordan & Wachs, Eau Claire and oral argument by D. Charles Jordan. 
 
 
For the defendants-appellants-cross petitioners there were 
briefs by Douglas J. Klingberg, James F. Harrington and Ruder, 
Ware & Michler, S.C., Wausau and oral argument by Douglas J. 
Klingberg. 
 
 
Amicus curiae brief was filed by Nancy M. Rottier, counsel, 
Madison and Dean P. Laing and O'Neil, Cannon & Hollman, S.C., 
Milwaukee for the Wisconsin Academy of Trial Lawyers.