Case Title: ANGELINA ROYBAL v. GREGORY F. BELL, D.D.S.

Citation: 

Docket Number: 88-292

State: wyoming

Court: Wyoming Supreme Court

Date: 1989-07-27T00:00:00Z

Document:
ANGELINA ROYBAL v. GREGORY F. BELL, D.D.S.1989 WY 161778 P.2d 108Case Number: 88-292Decided: 07/27/1989Supreme Court of Wyoming
ANGELINA ROYBAL, 
APPELLANT (PLAINTIFF),

v.

GREGORY F. BELL, D.D.S., 
APPELLEE (DEFENDANT).

Appeal from the District 
Court, LaramieCounty, Harold Joffe, 
J.

Rodger McDaniel, 
Cheyenne, and Jack Kintzele, Denver, Colo., for appellant.

Larry B. Kehl 
and George J. Argeris of Guy, Williams, White & Argeris, Cheyenne, for appellee.

Before CARDINE, 
C.J., and THOMAS, URBIGKIT, MACY and GOLDEN, JJ.

MACY, 
Justice.

[¶1.]     This is a dental 
malpractice case specifically involving the question of informed consent. The 
district court granted summary judgment to appellee Gregory F. Bell, D.D.S., and 
appellant Angelina Roybal pursued this appeal.

[¶2.]     Although variously 
stated by the parties, the substance of the issues presented is simply whether 
or not factual questions exist on the elements of appellant's claim which would 
preclude the entry of summary judgment. We conclude that material factual 
disputes are indicated in the record, and therefore we 
reverse.

[¶3.]     In May 1983, appellant 
began an extensive course of dental treatment which eventually involved the 
three dentists originally named as defendants in this case: appellee Bell, Dr. Richard Giovale, 
and Dr. Rex Dolan. Appellant first saw Dr. Giovale in May 1983 regarding a loose 
bridge. In June 1983 Dr. Giovale performed a root canal for appellant on a tooth 
designated as tooth # 20, which was located in the lower left jaw. Thereafter, 
appellant reported experiencing pain associated with tooth # 20. According to 
appellant, attempts by Dr. Giovale over the next several months to alleviate the 
continuing problems with tooth # 20 were unsuccessful.

[¶4.]     Dr. Giovale 
concurrently was performing various dental work on appellant's upper right 
teeth, including bridge work and at least one further root canal. One of the 
teeth in the upper right developed an abscess on the root requiring an oral 
surgical procedure known as an apicoectomy.1 Appellant was referred to appellee 
for this procedure. This apicoectomy was completed successfully by appellee in 
July 1984.

[¶5.]     Appellant continued to 
experience problems with tooth # 20, and in early 1985 Dr. Giovale referred her 
to appellee for an apicoectomy on that tooth. The apicoectomy on tooth # 20 was 
performed in April 1985. After the apicoectomy on tooth # 20, appellant 
experienced continued pain and numbness (paresthesia) in the general area of 
that tooth. Consequently, after further consultation and a referral for a second 
opinion, Dr. Giovale referred appellant to Dr. Dolan for extraction of tooth # 
20, which was performed in January 1986. According to appellant, the extraction 
of the tooth did not remedy the pain and paresthesia. Appellant asserts, with 
support in the record, that she sustained permanent nerve damage as a result of 
the dental procedures associated with tooth # 20.2

[¶6.]     On August 11, 1987, 
appellant initiated an action against appellee, Dr. Giovale, and Dr. Dolan by 
filing a complaint in the district court. Appellant asserted causes of action 
premised on theories of negligent treatment, negligent failure to obtain an 
informed consent, res ipsa loquitur, and breach of warranty.3 Each defendant answered, generally 
denying the allegations. Thereafter, the defendants filed motions for summary 
judgment supported by affidavits, exhibits, memoranda, and the deposition of 
appellant. On July 15, 1988, the district court entered an order dismissing Dr. 
Dolan from the action pursuant to a stipulation between appellant and that 
defendant. Appellant then submitted a memorandum in opposition to summary 
judgment accompanied by her deposition, an affidavit containing the expert 
opinion of Dr. Boyd Tomasetti, and various documentary materials primarily 
consisting of appellant's dental records. Prior to the summary judgment hearing, 
appellant and Dr. Giovale reached an out-of-court 
settlement.

[¶7.]     The summary judgment 
hearing was held on August 1, 1988, with appellee as the only remaining 
defendant. A transcript of the motion hearing has not been provided in the 
record on appeal. Apparently, however, as reflected in the briefs of the 
parties, counsel for appellant informed the district court at the hearing that 
appellant was dropping all claims against appellee except the claim relating to 
the alleged failure to obtain an informed consent in connection with the 
apicoectomy on tooth # 20. After requesting and receiving further briefing on 
the question of informed consent, the district court entered its decision letter 
and order granting summary judgment to appellee. This appeal 
followed.

[¶8.]     We begin by reiterating 
our standard for reviewing a summary judgment. Summary judgment is proper only 
when there are no genuine issues of material fact and the prevailing party is 
entitled to judgment as a matter of law. Doud v. First Interstate Bank of 
Gillette, 769 P.2d 927 (Wyo. 1989); Teton Plumbing and Heating, Inc. v. Board of 
Trustees, Laramie County School District Number One, 763 P.2d 843 (Wyo. 1988). 
We review a grant of summary judgment in the same light as the district court, 
using the same information and following the same standards. Doud, 769 P.2d 927; 
Johnston v. Conoco, Inc., 758 P.2d 566 
(Wyo. 1988). 
We examine the record from the vantage point most favorable to the party 
opposing the motion, giving that party the benefit of all favorable inferences 
which may be drawn from the record. Doud, 769 P.2d 927; Albrecht v. Zwaanshoek 
Holding En Financiering, B.V., 762 P.2d 1174 (Wyo. 1988). We have often stated that summary 
judgment is not favored in negligence actions. O'Donnell v. City of Casper, 696 P.2d 1278 (Wyo. 1985); DeHerrera v. MemorialHospital of CarbonCounty, 590 P.2d 1342 (Wyo. 1979). In DeHerrera, we 
said:

"[S]ummary judgment 
procedures should be applied with special caution in negligence actions. This is 
particularly true in malpractice suits where, as here, the attending facts are 
peculiarly within the knowledge of the movants and the showing of negligence is 
generally dependent upon expert testimony as to the standard of care required 
and observed."

Id. at 1345 (quoting Holl v. 
Talcott, 191 So. 2d 40, 46 (Fla. 1966) (citations 
omitted)).

[¶9.]     This Court has not had 
occasion to address the law of informed consent since the case of Stundon v. 
Stadnik, 469 P.2d 16 (Wyo. 1970), which in turn 
relied heavily upon the prior case of Govin v. Hunter, 374 P.2d 421 (Wyo. 1962). Informed 
consent law has evolved as a variant of medical malpractice. Bloskas v. 
Murray, 646 P.2d 907, 914, 42 A.L.R.4th 527 
(Colo. 1982). 
See generally 1 S. Pegalis and H. Wachsman, American Law of Medical Malpractice 
§§ 2:1 and 2:15 (1980). Originally conceived as an offshoot of the law of 
battery, informed consent is now generally treated under a theory of negligence. 
1 S. Pegalis and H. Wachsman, supra at § 2:15; 2 D. Louisell and H. Williams, 
Medical Malpractice ¶ 22.04 (1988).4 The essential elements in a 
malpractice action are equally applicable in an informed consent case. The 
plaintiff must establish (1) that the practitioner owed a duty to the plaintiff; 
(2) that the practitioner failed to perform the duty; (3) that the breach of 
duty proximately caused (4) injury to the plaintiff. Fiedler v. Steger, 713 P.2d 773, 775 (Wyo. 1986); Vassos v. Roussalis, 625 P.2d 768 (Wyo. 1981) (Vassos I), appeal after 
remand 658 P.2d 1284 (Wyo. 1983) (Vassos II); 
Harris v. Grizzle, 625 P.2d 747 (Wyo. 1981). Further, we have stated that the 
mere fact of injury or a bad result, standing alone, is not proof of negligence 
and will not overcome a motion for summary judgment. Siebert v. Fowler, 637 P.2d 255, 257 (Wyo. 
1981); Harris, 625 P.2d 747.

[¶10.]  The determination of the standard of care 
or duty imposed upon the defendant is a matter of law and is not within the 
province of the jury. Vassos II, 658 P.2d  at 1287. The existence of the 
physician-patient relationship establishes a duty, and the standard is fixed as 
that which is required of a reasonable person in the light of all the 
circumstances. Kobos by and through Kobos v. Everts, 768 P.2d 534, 538 
(Wyo. 1989); 
Vassos I, 625 P.2d 768. In Govin, 374 P.2d  at 423, we elaborated upon the duty 
of disclosure required for informed consent:

We realize that under 
certain circumstances a physician has a duty to reveal any serious risks which 
are involved in a contemplated operation. But, how a physician chooses to 
discharge his obligations to a patient involves primarily a question of medical 
judgment. As long as his disclosure is sufficient to assure an informed consent, 
and if it appears that he proceeded as competent medical men would have done in 
a similar situation, the physician's actions should not be called into 
question.

We further 
stated:

Whether or not a surgeon 
is under a duty to warn a patient of the possibility of a specific adverse 
result of a proposed treatment depends upon the circumstances of the particular 
case and upon the general practice followed by the medical profession in the 
locality; and the custom of the medical profession to warn must be established 
by expert medical testimony.

Id. at 424, quoted in 
Stundon, 469 P.2d  at 21.

[¶11.]  The above standards regarding informed 
consent must be read in conjunction with the more recent pronouncements of this 
Court regarding medical malpractice in general. We have moved away from strict 
adherence to the "locality" rule recited in Govin. Kobos by and through Kobos, 
768 P.2d 534; DeHerrera, 590 P.2d 1342. Thus, we said in Vassos I, 625 P.2d at 
772:

[A] physician or surgeon 
must exercise the skill, diligence and knowledge, and must apply the means and 
methods, which would reasonably be exercised and applied under similar 
circumstances by members of his profession in good standing and in the same line 
of practice.

The skill, 
diligence, knowledge, means and methods are not those "ordinarily" or 
"generally" or "customarily" exercised or applied, but are those that are 
"reasonably" exercised or applied. Negligence cannot be excused on the grounds 
that others practice the same kind of negligence. Medicine is not an exact 
science and the proper practice cannot be gauged by a fixed 
rule.

(Citations 
omitted.)

[¶12.]  Wyoming adheres to the majority position, 
known as the "traditional" or "professional" view, with respect to the required 
scope of disclosure. This standard provides that the physician is required to 
disclose only such risks that a reasonable practitioner of like training would 
have disclosed in the same or similar circumstances. 2 D. Louisell and H. 
Williams, supra, ¶ 22.07 at 22-28; 1 S. Pegalis and H. Wachsman, supra, § 2:15 
at 98-99 (citing Govin, 374 P.2d 421); F. Rozovsky, Consent to Treatment, ch. 1C 
at 41 (1984). Under this standard, expert testimony is required to establish 
what a reasonable practitioner would disclose in the same or similar 
circumstances. Stundon, 469 P.2d  at 21; Govin, 374 P.2d  at 424; 2 D. Louisell 
and H. Williams, supra, at ¶ 17B.10; 1 S. Pegalis and H. Wachsman, supra at § 
2:15.5

[¶13.]  In order to overcome a motion for summary 
judgment, a plaintiff in a medical malpractice case must also present evidence, 
usually in the form of expert testimony, indicating the departure by a medical 
practitioner from a recognized standard of practice was a proximate cause of her 
injury. Harris, 625 P.2d 747. A plaintiff establishes proximate cause in an 
informed consent case by proof that proper disclosure would have resulted in a 
decision against the proposed treatment or procedure. 2 D. Louisell and H. 
Williams, supra at ¶ 22.14; F. Rozovsky, supra at § 1.13.4. Two approaches have 
evolved with respect to the appropriate test for measuring the causal connection 
in informed consent cases. The subjective test considers what the plaintiff 
would have done if the risks had been properly disclosed. This test has been 
criticized because the question of causation turns on the credibility of the 
hindsight of the person seeking recovery after an undesirable result and also 
because this test would probably preclude recovery if the patient had died as a 
result of the treatment received. The majority of jurisdictions, therefore, 
apply an objective test which focuses on what a reasonable person in the 
plaintiff's position would have done if the risks had been adequately disclosed. 
Under the objective test, the patient's hindsight testimony is relevant but not 
controlling. F. Rozovsky, id.; 2 D. Louisell and H. Williams, supra at ¶ 22.14; 
1 S. Pegalis and H. Wachsman, supra at § 2:15, 
and cases cited therein. We think the majority approach, i.e., the objective 
test, is the better reasoned, and we herein adopt that test as the appropriate 
test for measuring causation in informed consent cases in Wyoming.

[¶14.]  With the foregoing principles in mind, we 
look to the materials in the record to determine if genuine issues of material 
fact exist which would preclude the entry of summary judgment. In support of his 
motion for summary judgment, appellee submitted his own affidavit in which he 
stated that he was aware of the standard required for informed consent for 
dentists practicing his specialty, that he fully informed appellant of the risks 
associated with the apicoectomy on tooth # 20, including the risk of nerve 
damage, and further that this disclosure was accomplished by use of a diagram, a 
copy of which was attached to his affidavit.

[¶15.]  Appellee also relied upon the affidavit 
of Dr. Giovale in which Dr. Giovale stated he was fully familiar with the 
standard of care required of dentists with regard to the disclosures necessary 
for informed consent in referral situations and that, prior to referring 
appellant to appellee for the apicoectomy on tooth # 20, he discussed with her 
the specific risks involved, including the possibility of nerve injury and 
paresthesia. Dr. Giovale attached to his affidavit a copy of his office charts 
with notations indicating he had apprised appellant of possible nerve injury and 
paresthesia on this occasion.

[¶16.]  Appellee additionally submitted the 
affidavit of Dr. Joseph Devine, a Cheyenne, Wyoming, dentist. Dr. Devine stated he had 
reviewed appellant's dental records and other relevant materials in the record, 
including the pleadings, the affidavits of appellee and Dr. Giovale, and an 
outline of appellant's deposition. Dr. Devine said he was familiar with the 
applicable standard of care, although, as with the affidavits of appellee and 
Dr. Giovale, Dr. Devine did not delineate what the applicable standard of 
disclosure required under the circumstances. Thus, without stating what the 
standard of care required, Dr. Devine stated that, in treating appellant, 
appellee exercised that degree of care ordinarily possessed and exercised by 
dentists in good standing practicing in the community or elsewhere. With respect 
to the question of proximate cause, Dr. Devine stated: "[I]t is unreasonable to 
believe that a patient being fully informed would have elected any other 
procedure."

[¶17.]  In opposition to the above materials, 
appellant submitted the affidavit of Dr. Boyd Tomasetti, a Colorado dentist and oral 
surgeon. Dr. Tomasetti stated that he had reviewed the relevant materials 
including the affidavits and appellant's dental records and that he had 
personally examined appellant. Dr. Tomasetti said he was familiar with the 
applicable standard of care relative to obtaining an informed consent for an 
apicoectomy. He then described the relevant standard:

That based upon my 
education, training and experience, it is my opinion that the standard of care 
applicable to Dr. Gregory F. Bell regarding obtaining an informed consent from 
Angelina Roybal to perform an apicoectomy on tooth no. 20 is as follows: a) The 
patient must be informed of the nature of the condition of tooth no. 20 prior to 
the procedure; b) The practitioner must, prior to the procedure, explain to the 
patient the more common risks and complications of the procedure, which risks 
and complications include: i) recurrent and chronic infection of the tooth and 
surrounding areas, ii) possible nerve damage, par[e]sthesia and hyperesthesia to 
the area of the tooth and the face, iii) potential loss of the tooth from 
failure of the treatment, and iv) possible damage to adjacent teeth requiring 
additional root canal treatment; c) The practitioner must, prior to the 
procedure, explain to the patient the options available to the patient in lieu 
of the apicoectomy which would be extraction of the tooth; d) The practitioner 
must make a written note in his charts or records that all of the above were 
reviewed with the patient by the practitioner and further the records or charts 
must reflect that the review was prior to the procedure; and e) The practitioner 
must, prior to the procedure, obtain a signed consent from the patient to 
perform the procedure * * *.

 

Dr. Tomasetti 
further opined that, on the basis of a review of appellee's records and charts, 
appellee did not comply with the requisite standard of care in obtaining an 
informed consent from appellant in the following particulars: failure to review 
with appellant the condition of the tooth prior to the procedure; failure to 
review with appellant prior to the procedure the more common risks and 
complications associated with the procedure; failure to review with appellant 
the options available; failure to inform appellant of the possible loss of the 
tooth; and failure to obtain a signed consent to the procedure. Finally, Dr. 
Tomasetti stated that it was reasonable to believe that a fully informed patient 
in appellant's position would have elected an alternative 
procedure.

[¶18.]  Appellant additionally relied upon her 
own deposition testimony in opposing the summary judgment. In her deposition 
appellant stated that neither appellee nor Dr. Giovale made any specific 
disclosures as to the risks or possible complications associated with an 
apicoectomy on the occasion of the apicoectomy on tooth # 20 nor did they do so 
when she had the prior apicoectomy on the upper right side. Appellant further 
stated that, if the office records of appellee and Dr. Giovale indicate 
disclosure, the records are false. Appellant said that, had she been warned of 
the possible complications and problems, she would have refused the apicoectomy 
on tooth # 20 and would have opted initially for 
extraction.

[¶19.]  Although we have described the materials 
submitted by appellant in opposition to the motion for summary judgment, we need 
not consider the sufficiency of such materials because we conclude that appellee 
failed to meet his initial burden of demonstrating the absence of a genuine 
issue of material fact. See Metzger v. Kalke, 709 P.2d 414 (Wyo. 1985). The 
affidavits of appellee, Dr. Giovale, and Dr. Devine are defective in that each 
fails to state the prevailing standard of care by which to measure the adequacy 
of the consent obtained, if any. The standard of care must be stated with 
specificity sufficient to enable the court to determine if appellee properly 
disclosed the risks and alternatives in conformance with the standard. Hurtt v. 
Goleburn, 330 A.2d 134 (Del.Supr. 1974). Because these supporting affidavits 
fail in this important respect, appellee, as movant, did not meet his initial 
burden of proving the nonexistence of a genuine issue of material 
fact.

[¶20.]  Since appellee failed to properly support 
his motion for summary judgment, appellant was entitled to rely upon her 
allegation that she did not receive adequate information to enable her to give 
an informed consent, and she had no obligation to present any factual support 
for her allegation. Petersen v. Campbell County Memorial Hospital District, 760 P.2d 992 (Wyo. 
1988); Metzger, 709 P.2d 414; Hurtt, 330 A.2d 134. Her unrefuted allegation is 
sufficient to state a claim upon which relief can be granted, and the pleadings 
of the parties structure a question of fact as to appellee's alleged negligent 
failure to obtain informed consent. Petersen, 760 P.2d 992; Metzger, 709 P.2d 414.

[¶21.]  We also note appellee's argument that the 
fact appellant had previously undergone a successful apicoectomy indicates her 
informed consent to the second procedure. We cannot agree with this proposition. 
We are unable to conceive how informed consent to a second surgery can be 
inferred from a successful prior procedure performed without informed consent, 
if such was the case.

[¶22.]  Summary judgment was improvidently 
granted to appellee and cannot be sustained. Reversed and remanded for further 
proceedings.

URBIGKIT, J., filed a dissenting 
opinion.

FOOTNOTES

1 An apicoectomy is 
defined in 1 J. Schmidt, Attorneys' Dictionary of Medicine at A-285 (1986) as: 
"Excision of the apex of the root of a tooth" or "excision of the root of a 
tooth."

2 According to appellant's 
deposition testimony, she has been advised by dental and neurological 
specialists in Denver, Colorado, that the only treatment alternatives remaining 
for her are either to have the affected nerve severed, which would result in a 
total loss of sensation on much of the left side of her face, or to learn to 
live with the pain and paresthesia.

3 Certain of the 
allegations in the complaint refer to dental procedures performed by the 
defendants other than those associated with tooth # 20 and which are not 
involved in the issues presented in this appeal.

4 The battery theory 
remains applicable where a treatment or procedure was completely unauthorized, 
whereas negligence principles apply to the more often encountered situation 
where the treatment or procedure was authorized but the consent was uninformed. 
2 D. Louisell and H. Williams, supra.

5 An exception to the 
requirement that the plaintiff must establish the accepted standard of care by 
expert testimony arises only where the "asserted negligence consists of conduct 
so obviously wanting in reasonable medical skill and prudence that it may be so 
adjudged even by laymen." Stundon, 469 P.2d  at 22, quoted in Harris, 625 P.2d  at 
752.

URBIGKIT, Justice, 
dissenting.

[¶23.]  This is a multi-dentist/multi-complaint 
lawsuit which was reformed fairly quickly into one charge against one dentist. 
Appellant claims now that appellee failed to advise her adequately that she 
could have had her tooth pulled in lieu of his efforts to try to save the tooth. 
The effort to save the tooth was a match to the same process the dentist had 
performed successfully on another one of her teeth nine months 
earlier.

[¶24.]  Appellant was no stranger to dental 
treatment when this course of events developed. Appellant first started dental 
treatment with Dr. Richard John Giovale, D.D.S. in May 1983 for repair of a 
bridge which was installed in the early 1960's as part of a multi-bridge 
installation.1 From initial interview, treatments 
continued through more than twenty sessions to repair and replace bridges and 
cure the continuing complaints of pain. During this course of treatment, which 
extended from May 2, 1983 through April 1, 1986, appellant was twice referred to 
Dr. Gregory F. Bell, D.D.S., M.S.D. for the apicoectomy; first for tooth 
designated number two on July 31, 1984 and then for a second tooth, designated 
number twenty, on April 18, 1985. Following continued pain in that tooth, number 
twenty, which had been initially considered during the first interview in 1983 
as painful, appellant was referred to Dr. Rex Dolan, D.D.S., who, in January 
1986, pulled the tooth.

[¶25.]  After leaving Wyoming, appellant 
returned to the state to file suit against all three dentists, which litigation 
remains today as her criticism of the intermediate dental treatment provided by 
Dr. Bell from contended failure to be furnished sufficient information for her 
informed consent to decide whether to undertake the second apicoectomy. In 
reality, what the case really means is that appellant, Angelina Roybal, claims 
failure to understand that she had a choice in July 1984 of extraction instead 
of continuing efforts for retention. That present contention is consistent with 
an original pleading change which she made against Dr. Giovale raising a failure 
of warranty claim. It belies a scintilla of evidence question, Cordova v. Gosar, 
719 P.2d 625 (Wyo. 1986), that the patient in 1985 did not realize that before 
the second apicoectomy was performed that she could have otherwise chosen 
extraction, since clearly the tooth had been continually causing her problems during the entire period of treatment 
commencing with Dr. Giovale's first interview in May 1983. Appellant elected 
to hope that like the benefit she received from the procedure on tooth number 
two, a similar result could be obtained on tooth number twenty and permit 
retention instead of extraction.

[¶26.]  I dissent without conclusion that a 
written consent is not preferable, nor by ignoring current knowledge that 
dentistry has now joined the real world of litigation involving doctors, lawyers 
and accountants, which mandates detailed records and all-inclusive forms. 
Essentially, I do not disagree with the concise and accurate analysis of the law 
of informed consent provided by the majority.

[¶27.]  Conversely and specifically, I do not 
find a viable question in the controversy in this case disclaiming that 
appellant was not informed and did consent to the second procedure. She knew 
what the procedure would be when she went to the other dentist's office and what 
would be done, as she both voluntarily went and submitted. I decline to unburden 
probabilities to adversely assess chances that she did not exactly, specifically 
and completely understand her three choices: do nothing, have the procedure, or 
pull the offending tooth. It is my conception and concern that we now substitute 
formula and formalism for actuality. It is in the concept of informed consent 
where this case is now postured that the well-established conceptualization of 
actuality occurs that there are three worlds: what I see, what you see and what 
actually is. Likewise in communication, there are three objective functions: 
what I intended to tell you, what you thought I meant and what the disassociated 
person perceives to have been said or written without the overlay of association 
as its attribution for implied meaning.

[¶28.]  Each lawyer involved and the practitioner 
in the healing arts should comprehensively consider the current Illinois law journal 
article, Twerski and Cohen, Informed Decision Making and the Law of Torts: The 
Myth of Justiciable Causation, 1988 U.Ill.L.Rev. 607 (1988). Undoubtedly, the 
fact that hope springs eternal cannot be ignored as a functioning psychological 
content of informed consent. The litigative corollary thereafter may appear that 
if success is not achieved, consent may have not been adequate because an 
undesired result would not have been willingly chosen.

As long as courts and 
scholars insist on measuring informed consent damages by focusing on the 
resultant personal injuries, they cannot escape the causation dilemma. In 
recognizing the essential nonjusticiability of this personal injury model for 
informed choice cases, we do not suggest that this genre of litigation be 
obliterated. Instead, we suggest a radical restructuring of the informed choice 
doctrine. Rather than focusing on personal injury damages flowing from the 
hypothetical "but for," which seeks to determine what the plaintiff would have 
decided had the defendant provided the information, we suggest that courts 
should identify and value the decision rights of the plaintiff which the 
defendant destroyed by withholding adequate information.

Id. at 
608-09.

[¶29.]  I conclude that this record reveals an 
alternative choice to pull or not to pull the tooth and nothing to suggest that 
appellant had inadequate information to make that choice. The travesty of what 
we do in many legal processes is to create fictions.2 Here, that fiction is that a 
patient, by signing a form, is provided usable information for reasoned 
decision. I do not find the form, which was included in the mass of material 
submitted by appellant's expert witness, even minimally informative in making 
the choice whether appellant should continue treating the tooth or abandon hope 
and have it pulled. It is in the nature of the oral discussions between the 
health-care practitioner and the patient that can only provide a basis for 
realistic decision and not pro forma forms that mean nothing to either party in 
the real world of present choice with illness decisions immediately 
presented.

[¶30.]  In the informed consent article earlier 
referenced, the authors remind us that matter of presentation predominates over 
what is said:

Everyone knows that 
"half-empty" and "half-full" have different connotations. Similarly, in many 
circumstances, descriptions of the risks of a medical procedure in terms of the 
chances of success or the chances of failure may have different connotations and 
lead to different decisions.

For example, consider the 
following problems presented to two groups of subjects by Professors Kahneman 
and Tversky. In the first problem, seventy subjects were told that, in addition 
to whatever they own, they have been presented with $1000. The subjects were 
then asked to choose between (a) a 50% chance of an additional $1000, and (b) a 
100% chance of an additional $500. In the second problem, sixty-eight subjects 
were told that, in addition to whatever they own, they have been presented with 
$2000; they were then asked to choose between (a) a 50% chance of losing $1000, 
and (b) a 100% chance of losing $500.

A moments's reflection 
will reveal that the two problems are identical. In both problems, the subjects 
were asked to choose between (a) a gamble in which they had an even chance of 
ending up with either $1000 or $2000, and (b) a sure $1500. Yet the preferences 
expressed by the two groups of subjects were far from identical. In the first 
problem, 84% of the subjects selected the sure $1500 ($500 in addition to the 
original $1000); 16% chose the gamble. In the second problem, however, only 31% 
chose the sure $1500 ($2000 minus $500); 69% chose the 
gamble.

Professors Kahneman and 
Tversky theorize that the explanation for the disparity between the two groups 
of subjects is that "people normally perceive outcomes as gains or losses, 
rather than as final states of wealth or welfare." Quite obviously, then, 
whether the risks of a medical procedure are framed as gains or losses could 
have a significant impact on the patient's choice.

An example of the framing 
phenomenon in the medical decision-making context is provided in a study by 
Professors McNeil, Pauker, Sox, and Tversky. The researchers asked subjects to 
imagine that they had lung cancer and to choose between surgery and radiation 
treatment based on the information presented to them. Identical outcomes were 
framed differently for different subjects: they told some subjects the range of 
possible outcomes in terms of the probability of living at various points (e.g., 
68% chance of living for more than one year), while they told others the range 
of possible outcomes in terms of the probability of dying (e.g., 32% chance of 
dying by the end of one year).

The framing of the 
various results in terms of survival or mortality had a significant impact. On 
the average, subjects preferred radiation therapy to surgery 42% of the time 
when the information was presented in terms of the probability of dying, but 
only 25% of the time when information was presented in terms of the probability 
of living.

Twerski and 
Cohen, supra, 1988 U.Ill.L. Rev. at 634-35 (quoting Kahneman & Tversky, 
Prospect Theory: An Analysis of Decision Under Risk, 47 Econometrica 263, 273 
(1979)) (footnotes omitted).

[¶31.]  After an analysis of functions of the 
thinking process and the reasoning capacity, the authors, in consideration of 
aspects in the functionality of reasoning, including illogical processing of 
information - under utilization of base rate information - assessing multiple 
risks or availability - manner of presentation invoking framing effects - 
anchoring and primacy, as accentuated by the effect of prior idiosyncratic 
information, conclude:

Unquestionably, the legal 
system's insistence on determining the hypothetical results of a hypothetical 
decision-making process incorporates so much uncertainty that its credibility is 
minimal. Accordingly, determinations about decision causation in the informed 
choice arena can only be made by blinding ourselves to the complexities inherent 
in the process. The uncertainties are so great, and the margin for error so 
small, that any judgment, either way, cannot be made with any 
confidence.

Twerski and 
Cohen, supra, 1988 U.Ill.L. Rev. at 641.

[¶32.]  All of this returns in application for 
this case to the factual totality that the real question involved was since it 
worked on tooth two, shall we try and see if similar success will occur with 
tooth twenty? Cf. Comment, Torts - Informed Consent - Informed Consent is 
Determined by Prudent Patient Rather Than Reasonable Physician Standard. Largey 
v. Rothman, 110 N.J. 204, 540 A.2d 504 (1988), 20 Rutgers L.J. 837 (1989).

[¶33.]  The summary judgment decision of the 
trial court should be related dispositively to this case and appellant's 
decision to continue to try to save the pain producing tooth (on employer 
provided insurance). The affidavit of appellant's expert encouraging greater 
documentation convinces me that formalism without effective function in decision 
may be required for the law, but provides nothing for 
medicine.

[¶34.]  We return in concept in this case to 
analyze whether a form, which would have been helpful as evidence but perhaps 
communicatively meaningless in medicine, must be required in law. I am satisfied 
that our tests of Govin v. Hunter, 374 P.2d 421 (Wyo. 1962) and Stundon v. Stadnik, 469 P.2d 16 (Wyo. 1970, developed generally in Vassos v. Roussalis, 625 P.2d 768 (Wyo. 1981) and Kobos By and Through 
Kobos v. Everts, 768 P.2d 534 (Wyo. 1989), are fulfilled in justification of 
the summary judgment granted. My reverse concern is formalistic reliance on 
which we can easily provide an inadequate foundation for the patient to make the 
thoughtful decision constituting "informed consent." Having a heart by-pass or 
commencing chemotherapy may require expert assistance for the patient to assess 
the risk-benefit ratio which is the quantum of choices that life provides. 
However, the go or no go in tooth extraction cannot, I believe, fit under that 
umbrella of informational need.

[¶35.]  I would affirm.

FOOTNOTES

1 Appellant testified in 
deposition that the reason for her commencement of treatment with Dr. Giovale 
was a loose bridge.

Q. Were you having any 
pain when you first went to see him?

A. 
No.

Q. None at 
all?

A. 
No.

Dr. Giovale's 
initial interview records and comprehensive detail reveal a status absolutely to 
the contrary, since her pain is pervasively shown as the motivation for starting 
that sequence of dental treatment.

2 Defined by dissent in 
Andersen v. Corbitt, 777 P.2d 48, 53, (Wyo. 1989) (quoting Black's Law Dictionary 804 
(5th ed. 1979)) as:

"Assumption of fact made 
by court as basis for deciding a legal question. A situation contrived by the 
law to permit a court to dispose of a matter, though it need not be created 
improperly; e.g. fiction of lost grant as basis for title by adverse 
possession."