Case Title: Mayo v. Wisconsin Injured Patients & Families Compensation Fund

Citation: 

Docket Number: 2014AP002812

State: wisconsin

Court: Wisconsin Supreme Court

Date: 2018-06-27T00:00:00Z

Document:
2018 WI 78 
 
SUPREME COURT OF WISCONSIN 
 
 
 
 
 
CASE NO.: 
2014AP2812 
COMPLETE TITLE: 
Ascaris Mayo and Antonio Mayo, 
          Plaintiffs-Respondents-Cross- 
          Appellants, 
United Healthcare Insurance Company and 
Wisconsin State Department of Health Services, 
          Involuntary-Plaintiffs, 
     v. 
Wisconsin Injured Patients and Families 
Compensation Fund, 
          Defendant-Appellant-Cross-Respondent- 
          Petitioner, 
Proassurance Wisconsin Insurance Company, Wyatt 
Jaffe, MD, Donald C. Gibson, Infinity 
Healthcare, Inc. and Medical College of 
Wisconsin Affiliated Hospitals, Inc., 
          Defendants. 
 
 
 
 
REVIEW OF DECISION OF THE COURT OF APPEALS 
Reported at 377 Wis. 2d 566, 901 N.W.2d 782 
PDC No:  2017 WI App 52 - Published 
 
 
OPINION FILED: 
June 27, 2018 
SUBMITTED ON BRIEFS: 
      
ORAL ARGUMENT: 
April 19, 2018 
 
 
SOURCE OF APPEAL: 
 
 
COURT: 
Circuit 
 
COUNTY: 
Milwaukee 
 
JUDGE: 
Jeffrey A. Conen 
 
 
 
JUSTICES: 
 
 
CONCURRED: 
R.G. BRADLEY, J., concurs, joined by KELLY, J. 
(opinion filed). 
 
DISSENTED: 
A.W. BRADLEY, J., dissents, joined by 
ABRAHAMSON, J. (opinion filed). 
 
NOT PARTICIPATING:          
 
 
 
ATTORNEYS: 
 
 
For 
the 
defendant-appellant-cross-respondent-petitioner, 
there were briefs filed by Kevin M. St. John, Roisin H. Bell, 
John N. Giftos, and Bell Giftos St. John LLC, Madison.  There 
was an oral argument by Kevin M. St. John. 
 
 
2 
For the plaintiffs-respondents-cross-appellants, there was 
a brief filed by Susan R. Tyndall, Daniel A. Rottier, James M. 
Fergal, and Habush Habush & Rottier, S.C., Madison.  There was 
an oral argument by Daniel A. Rottier. 
 
An amicus curiae brief was filed on behalf of the Wisconsin 
Academy 
of 
Family 
Physicians, 
the 
Wisconsin 
Academy 
of 
Ophthalmology, Inc., the Wisconsin Chapter of the American 
College of Emergency Physicians, Inc., the Wisconsin Orthopaedic 
Society, the Wisconsin Psychiatric Association, Inc., the 
Wisconsin Radiological Society, Inc., the Wisconsin Society of 
Anesthesiologists, Inc., and the Wisconsin Society of Plastic 
Surgeons, Inc. by Guy DuBeau and Axley Brynelson, LLP, Madison. 
 
An amicus curiae brief was filed on behalf of the State of 
Wisconsin by Misha Tseytlin, solicitor general, Brad D. Schimel, 
attorney general, and Amy C. Miller, assistant solicitor 
general.  There was an oral argument by Misha Tseytlin, 
solicitor general. 
 
An amicus curiae brief was filed on behalf of Wisconsin 
Hospital Association by Sara J. MacCarthy, Timothy W. Feeley, 
and Hall, Render, Killian, Heath & Lyman, P.C., Milwaukee. 
 
An amicus curiae brief was filed on behalf of Wisconsin 
Medical Society and American Medical Association Litigation 
Center by Anne Berleman Kearney and Appellate Consulting Group, 
Milwaukee. 
 
An amicus curiae brief was filed on behalf of The Physician 
Insurers Association of America by Samuel J. Leib, Brent A. 
Simerson, Brenden M. Leib, and Leib Knott Gaynor LLC, Milwaukee. 
 
 
 
3 
An amicus curiae brief was filed on behalf of Wisconsin 
Manufacturers and Commerce by Lucas T. Vebber, Corydon J. Fish, 
and Wisconsin Manufacturers and Commerce, Madison. 
 
An amicus curiae brief was filed on behalf of the Wisconsin 
Association for Justice by William C. Gleisner, III and Law 
Offices of William Gleisner, Brookfield, with whom on the brief 
were J. Michael End and End, Hierseman & Crain, LLC, Milwaukee. 
 
An amicus curiae brief was filed on behalf of Wisconsin 
Defense Counsel by Justin F. Wallace and Nash, Spindler, 
Grimstad, & McCracken, LLP, Manitowoc, with whom on the brief 
were Monte E. Weiss, Charles W. Kramer, and Weiss Law Office SC, 
Mequon. 
 
An amicus curiae brief was filed on behalf of the American 
Tort Reform Association, the Wisconsin Civil Justice Council, 
the National Federation of Independent Business, the Chamber of 
Commerce of the United States, and the Wisconsin Insurance 
Alliance by James A. Friedman, Bryan J. Cahill, and Godfrey & 
Kahn, S.C., Madison. 
 
 
 
2018 WI 78
NOTICE 
This opinion is subject to further 
editing and modification.  The final 
version will appear in the bound 
volume of the official reports.   
No.   2014AP2812 
(L.C. No. 
2012CV6272) 
STATE OF WISCONSIN  
 
 
   : 
IN SUPREME COURT 
 
 
Ascaris Mayo and Antonio Mayo, 
 
          Plaintiffs-Respondents-Cross-
 
Appellants, 
 
United Healthcare Insurance Company and 
Wisconsin State Department of Health Services, 
 
          Involuntary-Plaintiffs, 
 
     v. 
 
Wisconsin Injured Patients and Families 
Compensation Fund, 
 
          Defendant-Appellant-Cross-Respondent-
 
Petitioner, 
 
Proassurance Wisconsin Insurance Company,  
Wyatt Jaffe, MD, Donald C. Gibson, Infinity 
Healthcare, Inc. and Medical College of 
Wisconsin Affiliated Hospitals, Inc., 
 
          Defendants. 
 
FILED 
 
JUN 27, 2018 
 
Sheila T. Reiff 
Clerk of Supreme Court 
 
 
 
 
REVIEW of a decision of the Court of Appeals.  Reversed and 
cause remanded.   
 
No. 
2014AP2812   
 
2 
 
¶1 
PATIENCE DRAKE ROGGENSACK, C.J.   Our review considers 
whether the legislatively-enacted cap of $750,000 (the cap) on 
noneconomic damages for victims of medical malpractice that is 
set out in Wis. Stat. § 893.55 (2015-16)1 is unconstitutional 
facially or as applied, based on equal protection and due 
process grounds.  In reliance on Ferdon ex rel. Petrucelli v. 
Wis. Patients Comp. Fund, 2005 WI 125, 284 Wis. 2d 573, 701 
N.W.2d 440, the court of appeals concluded that the cap was 
facially unconstitutional.2  The court of appeals did not address 
whether § 893.55 was unconstitutional as applied to Ascaris and 
Antonio Mayo (the Mayos).  However, the circuit court had 
concluded that the $750,000 cap on noneconomic damages was 
unconstitutional as applied to the Mayos.3   
¶2 
We conclude that rational basis is the proper standard 
by which to judge the constitutionality of Wis. Stat. § 893.55; 
that § 893.55 is facially constitutional and constitutional as 
applied to the Mayos; and that Ferdon erroneously invaded the 
province of the legislature and applied an erroneous standard of 
review.  Accordingly, we reverse the court of appeals' decision, 
overrule 
Ferdon, 
and 
conclude 
that 
the 
$750,000 
cap 
on 
                                                 
1 All references to Wisconsin Statutes are to the 2015-16 
version unless otherwise noted. 
2 Mayo v. Wis. Injured Patients and Families Comp. Fund, 
2017 WI App 52, ¶1, 377 Wis. 2d 566, 901 N.W.2d 782. 
3 The Honorable Jeffrey A. Conen of Milwaukee County 
presided.   
No. 
2014AP2812   
 
3 
 
noneconomic 
damages 
in 
medical 
malpractice 
judgments 
and 
settlements is constitutional both facially and as applied to 
the Mayos. 
¶3 
Therefore, we reverse the court of appeals and remand 
to the circuit court to impose the $750,000 cap on noneconomic 
damages.   
I.  BACKGROUND 
A.  The Guaranteed Payment System 
¶4 
In 1975, as a result of what was deemed to be a 
"medical malpractice crisis," the legislature established a 
comprehensive system of guaranteed payments and controlled 
liability. 
 
The 
Wisconsin 
Injured 
Patients 
and 
Families 
Compensation Fund (the Fund) was created at that time as part of 
the legislature's comprehensive system.  Wis. Patients Comp. 
Fund v. Wis. Health Care Liab. Ins. Plan, 200 Wis. 2d 599, 607, 
547 N.W.2d 578 (1996) (hereinafter WHCLIP).  In addition to 
guaranteeing payment and controlling liability, the legislature 
established required procedures for processing and paying claims 
that alleged medical malpractice.  § 1, ch. 37, Laws of 1975. 
¶5 
Chapter 655 "provide[s] the exclusive procedure for a 
person to pursue a malpractice claim against a health care 
provider."  Rouse v. Theda Clark Med. Ctr., Inc., 2007 WI 87, 
¶35, 302 Wis. 2d 358, 735 N.W.2d 30.  Under Wisconsin's 
comprehensive system, each health care provider must maintain 
liability coverage of at least $1 million per claim and 
No. 
2014AP2812   
 
4 
 
$3 million for all claims in a given policy year, Wis. Stat. 
§ 655.23(4)(b)2, or qualify as a self-insurer, § 655.23(3)(a).4  
In addition to maintaining liability insurance, health care 
providers are required to participate in the Fund by paying 
annual assessments.  Wis. Stat. § 655.27(3)(a).   
¶6 
The combination of required insurance and required 
assessments by the Fund, which health care providers must pay, 
creates a mechanism for guaranteed payment to those who are 
injured by medical malpractice.  This is so because the Fund 
pays medical malpractice claims in excess of the health care 
provider's insurance coverage amount.  Wis. Stat. § 655.27(1).  
"In other words, the Fund is liable for payments 'after a health 
care provider's statutorily mandated liability coverage limits 
are exceeded.'"  Wis. Med. Soc'y v. Morgan, 2010 WI 94, ¶12, 328 
Wis. 2d 469, 787 N.W.2d 22 (quoting WHCLIP, 200 Wis. 2d at 613).5 
¶7 
In regard to those injured by medical malpractice, the 
Fund guarantees payment of 100 percent of all settlements and 
judgments for economic damages arising from medical malpractice.  
However, payments by the Fund for noneconomic damages are 
                                                 
4 Health care providers employed by the state, county, 
municipality and federal government are, however, exempt from 
the requirements of Chapter 655.  See Wis. Stat. § 655.003(1). 
5 The Fund also covers claims made against any provider's 
employee who is acting within the scope of his or her employment 
in providing health care services, ensuring that any person 
seeking care from a covered provider is protected under the 
Fund.  Wis. Stat. § 655.005(2).   
No. 
2014AP2812   
 
5 
 
limited to $750,000 for each claim.6  Wis. Stat. § 893.55(4)(d)1.  
So long as health care providers maintain the required insurance 
and annually contribute to the Fund, they are not personally 
liable for damages arising from medical malpractice.  Wis. Stat. 
§ 655.23(5).7   
¶8 
From the time the Fund was created, July 1, 1975, 
until March of 2005,8 the Fund paid approximately $586,300,000 in 
claims.  Morgan, 328 Wis. 2d 469, ¶21.  By December 31, 2007, 
the total claim payments had increased to $666,100,000.  Id.  
Through December 31, 2017, the fund has paid approximately 
$866,100,000 in claims.  2017 Functional and Progress Report, 
Wis. Office of the Comm'r of Ins. (Feb. 23, 2018), https:// 
oci.wi.gov/Documents/Funds/IPFCF2017FunctionalandProgressReport.
pdf.  The number of Fund claims begun in any given year 
fluctuates.  In 2013-14, there were 83 pending potential claims 
                                                 
6 "Noneconomic damages" are defined as "moneys intended to 
compensate for pain and suffering; humiliation; embarrassment; 
worry; mental distress; noneconomic effects of disability 
including loss of enjoyment of the normal activities, benefits 
and pleasures of life and loss of mental or physical health, 
well-being or bodily functions; loss of consortium, society and 
companionship; or loss of love and affection."  Wis. Stat. 
§ 893.55(4)(a). 
7 The statute directs that a provider is liable for "no more 
than the limits expressed in sub. (4) or the maximum liability 
limit for which the health care provider is insured, whichever 
is higher."  Wis. Stat. § 655.23(5). 
8 Our decision in Ferdon which eliminated the previous 
noneconomic damages cap was issued on July 14, 2005.  Ferdon ex 
rel. Petrucelli v. Wis. Patients Comp. Fund, 2005 WI 125, 284 
Wis. 2d 573, 701 N.W.2d 440. 
No. 
2014AP2812   
 
6 
 
against the Fund, followed just two years later in 2015-16 with 
40 potential claims, and the most recent report for 2016-17 
shows 55 potential claims against the Fund.  Id. 
¶9 
When the Fund was created in 1975, there was no cap on 
noneconomic damages.  It was not until 1986 that the legislature 
capped noneconomic damages.  The 1986 cap was $1 million.  1985 
Wis. Act 340, §§ 30, 72.  The initial cap expired on January 1, 
1991.  Id. 
¶10 After the expiration of the 1986 cap on noneconomic 
damages, the cost of insurance for health care providers rose, 
as did health care costs.  See Maurin v. Hall, 2004 WI 100, ¶65 
n.7, 274 Wis. 2d 28, 682 N.W.2d 866, overruled on other grounds 
by Bartholomew v. Wis. Patients Comp. Fund, 2006 WI 91, 293 
Wis. 2d 38, 717 N.W.2d 216.  In response, the legislature again 
enacted a cap on noneconomic damages, this time setting the 
limit at $350,000.  1995 Wis. Act 10, §§ 5, 9. 
¶11 The $350,000 cap remained in place until we concluded 
that it was unconstitutional in Ferdon.9  Following Ferdon, the 
legislature acted to impose the $750,000 cap on noneconomic 
damages that is before us.  2005 Wis. Act 183, §§ 1, 7.  For all 
other damages, payment is guaranteed to the injured party for 
100 percent of a judgment or settlement.   
                                                 
9 While the original amount of the cap was $350,000, the 
limit was indexed to inflation so that at the time of the Ferdon 
decision, the cap was $445,755.  Ferdon, 284 Wis. 2d 573, ¶200 
(Prosser, J., dissenting). 
No. 
2014AP2812   
 
7 
 
¶12 In creating the $750,000 cap for noneconomic damages, 
the legislature undertook substantial investigative efforts to 
assure that any future legislation in regard to a cap would be 
constitutionally appropriate.  The assembly established a 
"Medical Malpractice Task Force" with the aim of implementing 
revisions to the law in response to the court's Ferdon decision.  
The task force found that noneconomic damages are an aspect of 
recovery that often is based on emotion and not on any 
predictable standard.  The task force said that "[a] reasonable 
cap on noneconomic damages serves as a rational balance [in] the 
Legislature's 
plan 
to 
ensure 
that 
successful 
malpractice 
plaintiffs are able to recover appropriate damages."  Further, 
"[m]edical liability reform is part of a broad legislative 
strategy designed to keep health care affordable and available 
in 
Wisconsin." 
 
"[C]apping 
noneconomic 
damages 
for 
unquantifiable 
harms 
while 
continuing 
to 
allow 
unlimited 
recovery for economic damages is crucial to this strategy."  
¶13 Sixty-two members of a bipartisan committee of the 
legislature submitted new legislation that would increase the 
cap to $750,000.  See 2005 AB 1073, §§ 1, 7.  Hearings then were 
held, and testimony was provided both for and against the 
$750,000 cap.   
¶14 The legislature carefully set out its objectives, 
stating that "[t]he objective of the treatment of this section 
is to ensure affordable and accessible health care for all of 
the citizens of Wisconsin while providing adequate compensation 
to the victims of medical malpractice."  2005 Wis. Act 183, § 3.  
No. 
2014AP2812   
 
8 
 
Further, the legislature codified its reasoning by which 
"[e]stablishing a limitation on noneconomic damage awards 
accomplishes the objective:" 
1. Protecting access to health care services 
across the state and across medical specialties by 
limiting the disincentives for physicians to practice 
medicine in Wisconsin, such as the unavailability of 
professional liability insurance coverage, the high 
cost of insurance premiums, large fund assessments, 
and unpredictable or large noneconomic damage awards, 
as recognized by a 2003 U.S. congress joint economic 
committee report, a 2003 federal department of health 
and human services study, and a 2004 office of the 
commissioner of insurance report. 
2. Helping contain health care costs by limiting 
the incentive to practice defensive medicine, which 
increases the cost of patient care, as recognized by a 
2002 federal department of health and human services 
study, a 2003 U.S. congress joint economic committee 
report, a 2003 federal government accounting office 
study, and a 2005 office of the commissioner of 
insurance report. 
3. Helping contain health care costs by providing 
more predictability in noneconomic damage awards, 
allowing insurers to set insurance premiums that 
better reflect such insurers' financial risk, as 
recognized by a 2003 federal department of health and 
human services study. 
4. Helping contain health care costs by providing 
more predictability in noneconomic damage awards in 
order to protect the financial integrity of the fund 
and allow the fund's board of governors to approve 
reasonable assessments for health care providers, as 
recognized by a 2005 legislative fiscal bureau memo, a 
2001 legislative audit bureau report, and a 2005 
office of commissioner of insurance report. 
Wis. Stat. § 893.55(1)(d).   
¶15 Act 183 also said that "the limitation of $750,000 
represents an appropriate balance between providing reasonable 
No. 
2014AP2812   
 
9 
 
compensation for noneconomic damages associated with medical 
malpractice and ensuring affordable and accessible health care," 
and that "[t]his finding is based on actuarial studies provided 
to the legislature, the experiences of other states with and 
without limitations on noneconomic damages associated with 
medical malpractice, the testimony of experts, and other 
documentary evidence presented to the legislature."  2005 Wis. 
Act 183, § 3.  Finally, the legislature noted that "the number 
chosen is neither too high nor too low to accomplish the goals 
of affordable and accessible health care, is a reasonable and 
rational[] response to the current medical liability situation, 
and is reasonably and rationally supported by the legislative 
record."  Id. 
¶16 The $750,000 cap remained in effect until the court of 
appeals held it unconstitutional in this action. 
B.  The Mayos 
¶17 This action arose after Ascaris Mayo made two trips to 
two emergency rooms in May 2011.  On the first occasion, she 
visited the emergency room at Columbia St. Mary's Hospital in 
Milwaukee after experiencing abdominal pain and a high fever.  
She was seen by a physician and a physician's assistant and was 
advised to follow up with her gynecologist because she had a 
history of uterine fibroids.  The next day, Ascaris Mayo went to 
a different emergency room where she was diagnosed with sepsis 
that was caused by an untreated infection.  As the result of 
sepsis, many of her organs failed and all four of her limbs 
developed dry gangrene, necessitating amputation. 
No. 
2014AP2812   
 
10 
 
¶18 In June of 2012, the Mayos sued in Milwaukee County 
Circuit Court alleging medical malpractice and failure to 
provide proper information.  Their claims were tried to a jury.  
Neither the physician nor the physician's assistant who saw 
Ascaris Mayo at Columbia St. Mary's emergency room was found to 
have been negligent.  The jury did find, however, that neither 
provider gave Ascaris Mayo adequate information regarding 
alternate diagnoses and options for treatment of the alternate 
diagnoses. 
 
In 
addition 
to 
economic 
damages 
totaling 
$8,842,096,10 the jury awarded noneconomic damages of $15,000,000 
to Ascaris Mayo11 and $1,500,000 to her husband.12  
¶19 After the verdict was issued, the Fund moved to reduce 
the jury's noneconomic damage award to $750,000 as required by 
the cap.  The Mayos also made motions after verdict, moving for 
entry of judgment on the verdict, as well as for declaratory 
                                                 
10 This sum included $1,142,096 for past health care 
services; $7,100,000 for future health care services; $100,000 
for past loss of earning capacity; and $500,000 for future loss 
of earning capacity.   
11 These damages were for "pain, suffering, disability, and 
disfigurement." 
12 The compensation for Mayo's husband was for "the loss of 
society and companionship of his wife."   
No. 
2014AP2812   
 
11 
 
judgment 
that 
Wis. 
Stat. 
§§ 655.017 
and 
893.55(4) 
are 
unconstitutional facially and as applied to the Mayos.13  
¶20 The circuit court held that the cap was not facially 
unconstitutional, but concluded that it was unconstitutional as 
applied to the Mayos on equal protection and due process 
grounds.  In reaching its conclusion, the circuit court relied 
on the court's decision in Ferdon.   
¶21 The court of appeals, in a published opinion, affirmed 
the jury's noneconomic damage award, but on a different basis.  
The court of appeals "conclude[d] that the statutory cap on 
noneconomic damages is unconstitutional on its face because it 
violates the same principles our supreme court articulated in 
[Ferdon], by imposing an unfair and illogical burden only on 
catastrophically injured patients, thus denying them the equal 
protection of the laws."  Mayo v. Wis. Injured Patients and 
Families Comp. Fund, 2017 WI App 52, ¶1, 377 Wis. 2d 566, 901 
N.W.2d 782.  For the reasons stated below, we reverse the court 
of appeals decision, and conclude that the $750,000 cap on 
noneconomic 
damages 
in 
medical 
malpractice 
judgments 
and 
settlements is constitutional both facially and as applied to 
the Mayos.  
                                                 
13 As basis for their claims of unconstitutionality, the 
Mayos said that the statutes "violate [their] right to a jury 
trial, their right to a certain remedy, the separation of powers 
doctrine, and the due process and equal protection clauses of 
the Wisconsin Constitution."  
No. 
2014AP2812   
 
12 
 
II.  DISCUSSION 
¶22 The Mayos challenge the facial constitutionality of 
the cap and as the cap is applied to them.  They claim that the 
classification for those who suffer noneconomic damages in 
excess of the cap violates their right to due process and equal 
protection. 
 
The 
Mayos 
also 
argue 
that 
the 
cap 
is 
unconstitutional as applied to them because of the dramatic 
decrease to their noneconomic damages award.  The Fund, however, 
contends that under a rational basis review, the $750,000 cap 
survives constitutional scrutiny. 
A.  Standard of Review 
¶23 A facial challenge to the constitutionality of a 
statute presents a question of law that we review independently, 
while benefitting from the court of appeals' and the circuit 
court's discussions.  Milwaukee Branch of NAACP v. Walker, 2014 
WI 98, ¶21, 357 Wis. 2d 469, 851 N.W.2d 262.  An as-applied 
constitutional challenge also is subject to our independent 
review.  Society Ins. v. LIRC, 2010 WI 68, ¶13, 326 Wis. 2d 444, 
786 N.W.2d 385.  Although we uphold historical factual findings 
of the circuit court unless they are clearly erroneous, id., 
there is no contest about the relevant facts in the case before 
us.  
B.  General Principles of Constitutional Review 
¶24 There 
are 
two 
general 
types 
of 
constitutional 
challenges to statutes:  facial and as-applied.  League of Women 
Voters of Wis. Educ. Network, Inc. v. Walker, 2014 WI 97, ¶13, 
No. 
2014AP2812   
 
13 
 
357 Wis. 2d 360, 851 N.W.2d 302.  We previously have explained 
that:   
A party may challenge a law . . . as being 
unconstitutional on its face.  Under such a challenge, 
the challenger must show that the law cannot be 
enforced 
"under 
any 
circumstances." . . .  In 
contrast, in an as-applied challenge, we assess the 
merits of the challenge by considering the facts of 
the particular case in front of us, "not hypothetical 
facts in other situations."  Under such a challenge, 
the 
challenger 
must 
show 
that 
his 
or 
her 
constitutional rights were actually violated. 
Id. (quoting State v. Wood, 2010 WI 17, ¶13, 323 Wis. 2d 321, 
780 N.W.2d 63). 
¶25 In either type of constitutional challenge, we presume 
that the statute is constitutional.  League of Women Voters, 357 
Wis. 2d 360, ¶16; State v. McKellips, 2016 WI 51, ¶29, 369 Wis. 
2d 437, 881 N.W.2d 258; Madison Metro. Sewerage Dist. v. Stein, 
47 Wis. 2d 349, 357, 177 N.W.2d 131 (1970); Town of Beloit v. 
City of Beloit, 37 Wis. 2d 637, 643, 155 N.W.2d 633 (1968).    
¶26 Our presumption of constitutionality is based on 
respect for a co-equal branch of government and its legislative 
acts.  Dane Cty. Dep't of Human Servs. v. Ponn P., 2005 WI 32, 
¶16, 279 Wis. 2d 169, 694 N.W.2d 344.  If any doubt persists 
about whether a statute is constitutional, we resolve doubt in 
favor 
of 
concluding 
that 
the 
statute 
is 
constitutional.  
McKellips, 369 Wis. 2d 437, ¶29; Aicher v. Wis. Patients Comp. 
Fund, 2000 WI 98, ¶18, 237 Wis. 2d 99, 613 N.W.2d 849.  In our 
analysis, we do not 
reweigh the 
policy choices of 
the 
legislature.   
No. 
2014AP2812   
 
14 
 
¶27 A party challenging the constitutionality of a statute 
bears a very heavy burden in overcoming the presumption of 
constitutionality.  League of Women Voters, 357 Wis. 2d 360, 
¶17.  In order to be successful, the challenger must prove that 
the statute is unconstitutional "beyond a reasonable doubt."  
Id. 
 
In 
the 
context 
of 
a 
challenge 
to 
a 
statute's 
constitutionality, "beyond a reasonable doubt" "expresses the 
'force or conviction with which a court must conclude, as a 
matter of law, that a statute is unconstitutional before the 
statute . . . can be set aside.'"  Id. (quoting Ponn P., 279 
Wis. 2d 169, ¶18). 
¶28 Generally, Wisconsin courts have employed two levels 
of scrutiny when addressing equal protection challenges.  Thorp 
v. Town of Lebanon, 2000 WI 60, ¶38, 235 Wis. 2d 610, 612 N.W.2d 
59.  Strict scrutiny is applied to statutes that restrict a 
fundamental right.  League of Women Voters, 357 Wis. 2d 360, 
¶¶139-40 (concluding that the right to vote is fundamental).  
Strict scrutiny is also applied to the regulation of protected 
classes.  Thorp, 235 Wis. 2d 610, ¶38.  When strict scrutiny is 
applied, the statute must serve a compelling state interest; the 
statute must be necessary to serving that interest; and the 
statute must be narrowly tailored toward furthering that 
compelling state interest.  Id.  There has been no contention 
that the Mayos have a fundamental right to payment of all 
damages awarded by the jury nor that the $750,000 cap on 
noneconomic damages discriminates against a suspect class.  
Therefore, strict scrutiny does not apply.  Bostco LLC v. Milw. 
No. 
2014AP2812   
 
15 
 
Metro. Sewerage Dist., 2013 WI 78, ¶76, 350 Wis. 2d 554, 835 
N.W.2d 160.   
¶29 The more common level of statutory scrutiny is 
rational basis scrutiny, where statutes are upheld if there is 
any rational basis for the legislation.  Id.  "The basic test is 
not whether some inequality results from the classification, but 
whether there exists any reasonable basis to justify the 
classification."  Id. (citing Sambs v. City of Brookfield, 97 
Wis. 2d 356, 293 N.W.2d 504 (1980)).  In an as-applied challenge 
to the damages limited by Wis. Stat. § 893.80(3), we concluded 
that 
not 
all 
disparities 
are 
sufficient 
to 
sustain 
the 
contention of unconstitutionally disparate treatment.  Bostco 
LLC, 350 Wis. 2d 554, ¶79.    
¶30 In Ferdon, the majority opinion spent many paragraphs 
discussing rational basis and concluding that strict scrutiny 
was not appropriate in assessing the then $350,000 cap on 
noneconomic damages.  Ferdon, 284 Wis. 2d 573, ¶¶59-96.  Its 
discussion recited the usual rules applicable to a rational 
basis review.  However, after its thorough discussion, the court 
threw all of the principles of rational basis aside.  It created 
an intermediate level of review that it called "rational basis 
with teeth, or meaningful rational basis."  Id.   
¶31 The court gave this new level of scrutiny no standards 
by which to determine whether it should be applied; but instead, 
overturned the then existing cap on noneconomic damages through 
application of the majority's policy choice for Wisconsin.  For 
example, the court opined that "[a] cap on noneconomic damages 
No. 
2014AP2812   
 
16 
 
diminishes 
tort 
liability 
for 
health 
care 
providers 
and 
diminishes the deterrent effect of tort law."  Id., ¶89.  In 
concluding 
that 
the 
legislature's 
policy 
choice 
was 
constitutionally flawed, the majority opinion said, "[t]he 
legislature enjoys wide latitude in economic regulation.  But 
when the legislature shifts the economic burden of medical 
malpractice from insurance companies and negligent health care 
providers to a small group of vulnerable, injured patients, the 
legislative action does not appear rational."  Id., ¶101.  The 
majority did not consider that part of the legislative plan that 
guaranteed 100 percent payment of all other damages, a benefit 
that no other tort carries.  Accordingly, the test for rational 
basis with teeth is whether the petitioner's claim is in line 
with the Ferdon majority's policy choice for Wisconsin.   
¶32 We hereby overrule Ferdon.  Rational basis with teeth 
has no standards for application, usurps the policy forming role 
of the legislature and creates uncertainty under the law.  
Ferdon also creates new doctrine when it holds that "[a] statute 
may be constitutionally valid when enacted but may become 
constitutionally invalid because of changes in the conditions to 
which the statute applies.  A past crisis does not forever 
render a law valid."  Id., ¶114.  There is no law to support 
this extraordinary declaration and we overrule it as well as 
"rational basis with teeth."   
C.  Facial Challenge 
¶33 When 
a 
party 
challenges 
a 
law 
as 
being 
unconstitutional on its face, he or she must show that the law 
No. 
2014AP2812   
 
17 
 
cannot be enforced "under any circumstances."  Wood, 323 
Wis. 2d 321, ¶13.  A challenger must meet the highest level of 
proof, beyond a reasonable doubt, if he or she is to succeed.  
League of Women Voters, 357 Wis. 2d 360, ¶17.    
¶34 The Mayos argue that the cap on noneconomic damages in 
the context of medical malpractice "attempt[s] to resolve a 
perceived societal problem on the backs of the few, most 
severely injured, victims of medical malpractice."  Because of 
this alleged disparate treatment under the cap, the Mayos say 
that their rights to equal protection and due process have been 
violated. 
¶35 Article I, Section 1 of the Wisconsin Constitution 
provides that: 
All people are born equally free and independent, and 
have certain inherent rights; among these are life, 
liberty and the pursuit of happiness; to secure these 
rights, governments are instituted, deriving their 
just powers from the consent of the governed. 
Article I, Section 1 has been interpreted as providing the same 
equal protection and due process rights afforded by the 
Fourteenth Amendment to the United States Constitution.14  State 
                                                 
14 The text of the Fourteenth Amendment states, in relevant 
part: 
nor shall any State deprive any person of life, 
liberty, or property, without due process of law; nor 
deny to any person within its jurisdiction the equal 
protection of the laws. 
U.S. Const. amend XIV, § 1. 
No. 
2014AP2812   
 
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ex rel. Sonneborn v. Sylvester, 26 Wis. 2d 43, 49, 132 N.W.2d 
249 (1965). 
¶36 When a party makes a facial challenge, he or she bears 
a heavy burden because "legislative enactments are presumed 
constitutional, and we will resolve any reasonable doubt in 
favor of upholding the provision as constitutional."  Bostco 
LLC, 350 Wis. 2d 554, ¶76.  This presumption is grounded in our 
understanding and respect for the differing roles of the 
legislature and the judiciary.  Vincent v. Voight, 2000 WI 93, 
¶52 n.22, 236 Wis. 2d 588, 614 N.W.2d 388.  "In the context of 
an equal protection challenge, we will sustain a legislative 
enactment that creates a distinction between treatment of 
different groups, if there exists a rational basis to support 
that distinction, provided that the distinction does not 
implicate a suspect class or impinge upon a fundamental right."  
Bostco LLC, 350 Wis. 2d 554, ¶76.  Because, as we have said 
previously, the cap does not deny any fundamental right or 
implicate any suspect class, we apply rational basis review.  
State v. Smith, 2010 WI 16, ¶12, 323 Wis. 2d 377, 780 N.W.2d 90.  
¶37 In 
bringing 
an 
equal 
protection 
challenge, 
the 
challenging party must show that the statute "treats members of 
similarly situated classes differently."  Tomczak v. Bailey, 218 
Wis. 2d 245, 261, 578 N.W.2d 166 (1998).  In their facial 
challenge, the Mayos allege that the cap creates two classes:  
medical malpractice claimants who are fully compensated for 
noneconomic damages (noneconomic damages of $750,000 or less), 
and those who are not fully compensated (noneconomic damages 
No. 
2014AP2812   
 
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greater than $750,000).  Because the parties agree to employ 
this classification for purposes of the facial, equal protection 
challenge, we accept it too.   
¶38 With regard to due process, "[t]he touchstone of due 
process is protection of the individual against arbitrary action 
of government."  Wolff v. McDonnell, 418 U.S. 539, 558 (1974).  
Due 
process 
"bars 
certain 
arbitrary, 
wrongful 
government 
actions."  State v. Radke, 2003 WI 7, ¶12, 259 Wis. 2d 13, 657 
N.W.2d 66. 
¶39 While equal protection and due process challenges may 
have different implications, "[t]he analysis under both the due 
process and equal protection clauses is largely the same."  
State v. Quintana, 2008 WI 33, ¶78, 308 Wis. 2d 615, 748 
N.W.2d 447.  Therefore, as a practical matter, the rational 
basis analysis for the Mayos' facial, equal protection challenge 
will be relevant to their due process claim as well.  See Smith, 
323 Wis. 2d 377, ¶16. 
¶40 Having determined that we apply rational basis review, 
we must now determine whether the legislature had a rational 
basis for enacting the cap.  In our rational basis review, we 
consider 
not 
"whether 
some 
inequality 
results 
from 
the 
classification, but whether there exists any reasonable basis to 
justify the classification."  Bostco LLC, 350 Wis. 2d 554, ¶76 
(quoting Sambs, 97 Wis. 2d at 371).  When, as in the case before 
us, there is no fundamental right or suspect class implicated by 
the legislative enactment, the statute "must be sustained unless 
it is 'patently arbitrary' and bears no rational relationship to 
No. 
2014AP2812   
 
20 
 
a legitimate government interest."  Smith, 323 Wis. 2d 377, ¶12 
(quoting Frontiero v. Richardson, 411 U.S. 677, 683 (1973)).  We 
will not reweigh the policy choices of the legislature, State ex 
rel. Strykowski v. Wilkie, 81 Wis. 2d 491, 506, 261 N.W.2d 434 
(1978), because "[r]ational basis review does not 'allow us to 
substitute our personal notions of good public policy for those 
of' the legislature," Blake v. Jossart, 2016 WI 57, ¶32 n.16, 
370 Wis. 2d 1, 884 N.W.2d 484, cert. denied, 137 S. Ct. 669 
(2017) (quoting Schweiker v. Wilson, 450 U.S. 221, 234 (1981)).   
¶41 A statute is unconstitutional under rational basis 
scrutiny if the legislature "applied an irrational or arbitrary 
classification when it enacted the provision."  Aicher, 237 
Wis. 2d 99, ¶57.  "It is not our role to determine the wisdom or 
rationale underpinning a particular legislative pronouncement."  
Id.; see also FCC v. Beach Commc'ns, Inc., 508 U.S. 307, 313 
(1993) ("[E]qual protection is not a license for courts to judge 
the wisdom, fairness, or logic of legislative choices.").  While 
we recognize that legislative enactments can be imperfect and 
result in inequities, "our goal is to determine whether a 
classification [] rationally advances a legislative objective."  
Aicher, 237 Wis. 2d 99, ¶57. 
¶42 A classification created by legislative enactment will 
survive rational basis scrutiny upon meeting five criteria: 
(1) All 
classification[s] 
must 
be 
based 
upon 
substantial distinctions which make one class really 
different from another. 
(2) The classification adopted must be germane to the 
purpose of the law. 
No. 
2014AP2812   
 
21 
 
(3) The classification must not be based upon existing 
circumstances only.  [It must not be so constituted as 
to preclude addition to the numbers included within a 
class.] 
(4) To whatever class a law may apply, it must apply 
equally to each member thereof. 
(5) That the characteristics of each class should be 
so far different from those of other classes as to 
reasonably suggest at least the propriety, having 
regard to the public good, of substantially different 
legislation. 
Id., ¶58 (quoting Dane Cty. v. McManus, 55 Wis. 2d 413, 423, 198 
N.W.2d 667 (1972)). 
¶43 When we apply five-step rational basis scrutiny, as we 
explain further below, we conclude that the legislature's 
comprehensive plan that guarantees payment while controlling 
liability for medical malpractice through the use of insurance, 
contributions to the Fund and a cap on noneconomic damages has a 
rational basis.  Therefore, it is not facially unconstitutional.   
¶44 First, we determine whether the classification of 
those who have greater than $750,000 in noneconomic damages is 
substantially different from the class of injured patients who 
have less than $750,000 of noneconomic damages.  Aicher, 237 
Wis. 2d 99, ¶58.  This distinction is obviously "real" as a 
person who fits into the former category cannot also be part of 
the latter.  The first step of rational basis scrutiny is 
satisfied. 
¶45 Second, Chapter 655 of the Wisconsin Statutes creates 
a comprehensive plan for claims of medical malpractice in 
Wisconsin.  Included in this plan is the right to guaranteed 
No. 
2014AP2812   
 
22 
 
payment of unlimited damages for economic losses, as well as 
past and future health care costs.  Wis. Stat. § 655.23; 
Wis. Stat. § 655.27.  Payment of noneconomic damages up to, and 
including, $750,000 also is guaranteed.  Wis. Stat. § 655.017; 
Wis. Stat. § 893.55(1d)(b).   
¶46 When the legislature enacted Chapter 655 in 1975, it 
also made a number of legislative findings.  We will not relate 
them here because the legislature took a fresh look at medical 
malpractice damages in amending Chapter 655 after this court's 
decision in Ferdon.  In so doing, the legislature placed its 
policy rationale within the statutes so that it would be clearly 
understood.   
¶47 The legislature stated that the fund was "established 
to curb the rising costs of health care by financing part of the 
liability incurred by health care providers as a result of 
medical malpractice claims and to ensure that proper claims are 
satisfied."  Wis. Stat. § 655.27(6).  Additionally, with regard 
to the cap itself, the legislature explicitly laid out its 
objectives and support for the cap: 
The objective of the treatment of this section is to 
ensure affordable and accessible health care for all 
of the citizens of Wisconsin while providing adequate 
compensation to the victims of medical malpractice. 
Achieving this objective requires a balancing of many 
interests.  Based upon documentary evidence, testimony 
received at legislative hearings, and other relevant 
information, the legislature finds that a limitation 
on the amount of noneconomic damages recoverable by a 
claimant or plaintiff for acts or omissions of a 
health 
care 
provider, 
together 
with 
mandatory 
liability coverage for health care providers and 
mandatory participation in the injured patients and 
No. 
2014AP2812   
 
23 
 
families compensation fund by health care providers, 
while compensating victims of medical malpractice in 
appropriate 
circumstances 
by 
the 
availability 
of 
unlimited 
economic 
damages, 
ensures 
that 
these 
objectives are achieved.  Establishing a limitation on 
noneconomic damage awards accomplishes the objective 
by doing all of the following: 
1. Protecting access to health care services 
across the state and across medical specialties by 
limiting the disincentives for physicians to practice 
medicine in Wisconsin, such as the unavailability of 
professional liability insurance coverage, the high 
cost of insurance premiums, large fund assessments, 
and unpredictable or large noneconomic damage awards, 
as recognized by a 2003 U.S. congress joint economic 
committee report, a 2003 federal department of health 
and human services study, and a 2004 office of the 
commissioner of insurance report. 
2. Helping contain health care costs by limiting 
the incentive to practice defensive medicine, which 
increases the cost of patient care, as recognized by a 
2002 federal department of health and human services 
study, a 2003 U.S. congress joint economic committee 
report, a 2003 federal government accounting office 
study, and a 2005 office of the commissioner of 
insurance report. 
3. Helping contain health care costs by providing 
more predictability in noneconomic damage awards, 
allowing insurers to set insurance premiums that 
better reflect such insurers' financial risk, as 
recognized by a 2003 federal department of health and 
human services study. 
4. Helping contain health care costs by providing 
more predictability in noneconomic damage awards in 
order to protect the financial integrity of the fund 
and allow the fund's board of governors to approve 
reasonable assessments for health care providers, as 
recognized by a 2005 legislative fiscal bureau memo, a 
2001 legislative audit bureau report, and a 2005 
office of commissioner of insurance report. 
No. 
2014AP2812   
 
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Wis. Stat. § 893.55(1d)(a).  The legislature also stated further 
reasoning for the choice of $750,000 as a cap on noneconomic 
damages when it explained: 
Based on actuarial studies, documentary evidence, 
testimony, and the experiences of other states, the 
legislature concludes there is a dollar figure so low 
as to deprive the injured victim of reasonable 
noneconomic damages, and there is a dollar figure at 
which the cap number is so high that it fails to 
accomplish the goals of affordable and accessible 
health care.  The legislature concludes that the 
number chosen is neither too high nor too low to 
accomplish the goals of affordable and accessible 
health care, is a reasonable and rational response to 
the current medical liability situation, and is 
reasonably and rationally supported by the legislative 
record. 
§ 893.55(1d)(c). 
¶48 The cap on noneconomic damages was driven by a number 
of legislative goals that were advanced by the classification:  
(a) lowering 
health 
care 
costs 
and 
insurance 
rates, 
(b) incentivizing 
physicians 
to 
practice 
in 
Wisconsin, 
(c) limiting the amount of defensive medicine practiced thereby 
reducing costs to patients, (d) making noneconomic damage 
payments to claimants more predictable thereby controlling 
premium adjustments to health care providers and (e) protecting 
the integrity of the Fund.  Under a rational basis review, we do 
not consider whether the legislature achieved its goals.  
Rather, we recognize that the legislature had ample testimony 
before it to support its policy choices, and we will not reweigh 
legislative choices.  See Wilkie, 81 Wis. 2d at 506. 
No. 
2014AP2812   
 
25 
 
¶49 By enacting the cap, the legislature made a legitimate 
policy choice, knowing that there could be some harsh results 
for those who suffered medical malpractice and would not be able 
to recover the full amount of their noneconomic damages.  
However, any cap, by its very nature, will limit the amount that 
some people will be able to recover.  If the cap did not do so, 
it would have no economic effect. 
¶50 It must also be noted, however, that while there is a 
cap on noneconomic damages, there also is a guarantee of payment 
for all other categories of damages that a victim of medical 
malpractice may be awarded.  No other tort has a guarantee of 
unlimited payment for a jury's award of economic damages.   
¶51 Because the classification created by the cap supports 
the purpose of the law and the legislature's overarching goal of 
"ensur[ing] affordable and accessible health care for all of the 
citizens of Wisconsin while providing adequate compensation to 
the victims of medical malpractice, Wis. Stat. § 893.55(1d)(a),  
we continue to the third step of our rational basis review. 
¶52 The legislative classification must not be based 
solely upon existing circumstances.  Aicher, 237 Wis. 2d 99, 
¶58.  Here, the law does nothing to "preclude addition to the 
numbers included within a class," and "allow[s] expansion of the 
class" to include additional members in the future.  Id., ¶69.  
Therefore, the third factor is satisfied. 
¶53 Fourth, we consider whether the cap applies equally to 
the members of each class created.  Id., ¶58.  The Mayos argue 
that the cap does not apply equally to all members of the class 
No. 
2014AP2812   
 
26 
 
whose noneconomic damages exceed $750,000 because the greater 
the award given, the smaller the percentage of that award that 
is recovered.  However, contrary to the Mayos' argument, the cap 
on noneconomic damages remains at $750,000 regardless of whether 
an individual is awarded $750,000 or $15 million.  Therefore 
each person for whom the cap is a factor in recovery is treated 
exactly the same.  Their noneconomic damages will be capped at 
$750,000.  Because each member of the class is treated precisely 
the same under the cap, the fourth Aicher factor is met. 
¶54 Fifth, and finally, we must determine whether the 
characteristics of each class are so different from those of the 
other class to "reasonably suggest" legislation that is for the 
public good.  Id., ¶58.  The legislature was concerned with 
massive noneconomic damage awards because they are unpredictable 
and often based on emotion.  The legislature wanted to plan for 
accessible health care while providing reasonable compensation 
for those who are injured.  The legislature chose to provide a 
mechanism to pay 100 percent of all damages arising from medical 
malpractice except for noneconomic damages, on which it placed a 
$750,000 cap.  The legislature made a rational policy choice by 
No. 
2014AP2812   
 
27 
 
limiting noneconomic damages; therefore, we conclude that the 
fifth part of the Aicher rational basis review is satisfied.15   
¶55 The party who challenges the constitutionality of a 
statute bears a very heavy burden in overcoming the presumption 
of constitutionality.  The challenging party must prove that the 
statute is unconstitutional "beyond a reasonable doubt."  League 
of Women Voters, 357 Wis. 2d 360, ¶17.  All steps of the Aicher 
rational basis test have been fully satisfied; accordingly, we 
conclude that the Mayos have failed to show the cap on 
noneconomic damages is unconstitutional beyond a reasonable 
doubt.  As a result, their facial challenge fails.  However, 
because the Mayos also challenge the constitutionality of the 
cap on noneconomic damages as applied to them, our discussion 
continues. 
D.  As-applied Challenge 
¶56 As-applied challenges question the constitutionality 
of a statute "on the facts of a particular case or [as applied] 
to a particular party."  Smith, 323 Wis. 2d 377, ¶10 n.9. 
(quoting Challenge, Black's Law Dictionary 223 (7th Ed. 1999)).  
"In an as-applied challenge, the constitutionality of the 
statute itself is not attacked; accordingly, the presumption 
                                                 
15 The legislature has made similar policy choices that have 
limited damages for medical malpractice in other circumstances.  
For example, if the healthcare providers who interacted with 
Ascaris Mayo had been employees of a state hospital, the Mayos' 
damages for economic and noneconomic damages would have been 
limited to a total of $250,000.  Wis. Stat. § 655.003(1); Wis. 
Stat. § 893.82(6).   
No. 
2014AP2812   
 
28 
 
that the statute is constitutional applies, just as it does in a 
facial challenge."  In re Gwenevere T., 2011 WI 30, ¶47, 333 
Wis. 2d 273, 797 N.W.2d 854.  However, while we presume the 
statute is constitutional, "we do not presume that the State 
applies statutes in a constitutional manner."  Id., ¶48 (quoting 
Society Ins., 326 Wis. 2d 444, ¶27).   
¶57 Because as-applied challenges turn on their facts, 
each one is different.  Accordingly, we determine on a case-by-
case basis whether a petitioner's constitutional rights have 
been transgressed.  In re Gwenevere T., 333 Wis. 2d 273, ¶49. 
¶58 As we have mentioned above in discussing the facial 
constitutionality of the cap, because no fundamental right or 
suspect class is at issue here, we apply a rational basis 
review.  Smith, 323 Wis. 2d 377, ¶12.  In an as-applied 
challenge, the challenger must prove beyond a reasonable doubt 
that as applied to him or her the statute is unconstitutional.  
Id.  We will conclude that a statute has been applied in a 
constitutional manner "if the application of the statute bears a 
rational relation to a legitimate legislative objective."  In re 
Gwenevere T., 333 Wis. 2d 273, ¶53. 
¶59 Prior to considering the Mayos' circumstances, it is 
helpful 
to 
examine 
another 
as-applied 
challenge 
to 
the 
constitutionality of a statute that came before us in Blake, 370 
Wis. 2d 1.  In Blake, the plaintiff's childcare provider license 
was 
revoked 
due 
to 
legislation 
that 
required 
lifetime 
prohibition on granting a childcare license to persons convicted 
of certain criminal offenses.  The plaintiff's license was 
No. 
2014AP2812   
 
29 
 
revoked because of her conviction for welfare fraud, an offense 
coming within the statutory proscription against licensing for 
childcare.  Blake challenged the statute's constitutionality 
both facially and as applied to her. 
¶60 We held that neither Blake's facial nor her as-applied 
challenge had merit.  Blake asserted her right to equal 
protection was denied because of disparate treatment, in that 
others convicted of "dishonesty related offenses" did not suffer 
permanent denial of childcare licensure.  Id., ¶46.  We 
concluded, however, that Blake had "misidentifie[d] the proper 
scope for evaluating the classification."  Id.  Referring to a 
prior court of appeals case, we explained that the plaintiff 
identified "no evidence that she was treated differently from 
any similarly-situated childcare provider whose license was 
revoked under the new law."  Id. (quoting Brown v. DCF, 2012 
WI App 61, ¶43, 341 Wis. 2d 449, 819 N.W.2d 827).  We concluded 
that because Blake was treated "in a manner consistent with the 
treatment 
of 
similarly 
situated 
providers . . . and 
[the 
plaintiff] has not presented evidence to the contrary, her as-
applied equal protection claim fails."  Blake, 370 Wis. 2d 1, 
¶46. 
¶61 As with the plaintiff in Blake, the Mayos have not 
presented any evidence that they were treated differently than 
others who are similarly situated.  The Mayos argue that their 
noneconomic damages award is reduced by 95.46 percent when the 
cap is applied.  However, as with the plaintiff in Blake, the 
Mayos focus their attention on themselves as opposed to 
No. 
2014AP2812   
 
30 
 
analyzing whether they are treated differently than other 
similarly-situated persons.   
¶62 The Mayos were treated the same under the cap as any 
other persons for whom the jury has awarded noneconomic damages 
in excess of $750,000.  The cap applies regardless of how much 
in excess of $750,000 the award; how drastic the injury 
suffered; the gender, age, or race of the plaintiff; or the 
extent of a health care provider's culpability. The Mayos 
certainly are very sympathetic plaintiffs because of the severe 
injuries that Ascaris Mayo has suffered.  However, were we to 
construe the cap based on our emotional response to her injury, 
we would be substituting our policy choice for that of the 
legislature.   
¶63 Further, the Mayos have not shown that the cap as 
applied to them is "arbitrary and not rationally related to a 
legitimate government interest."  Smith, 323 Wis. 2d 377, ¶28.  
A continued point of contention in the Mayos' brief, as well as 
at oral argument, was that the Fund has very significant assets 
and, therefore, paying the Mayos would not endanger its 
solvency.  However, the size of the noneconomic damages award as 
compared with the balance in the Fund from which the Mayos seek 
an additional $15 million in compensation is not relevant to 
their constitutional challenge.16  The financial planning and 
maintenance of the Fund does not fall within the duties of the 
                                                 
16 The Fund has already paid more than $7 million dollars in 
economic damages to the Mayos.  
No. 
2014AP2812   
 
31 
 
judiciary; we do not set premiums or choose the Fund's 
investments; we do not set the amount that the Fund must contain 
to meet potential expenditures for pending claims.  Rather, we 
consider the legislature's creation of the Fund, the language of 
the enactment, the purposes it serves and whether it was applied 
consistent with those purposes in determining its validity.   
¶64 Furthermore, the Wisconsin Constitution permits the 
legislature to eliminate common law causes of action altogether.  
Under Article XIV, Section 13 of the Wisconsin Constitution, the 
common law may be "altered or suspended by the legislature."  A 
prominent 
example 
is 
worker's 
compensation, 
where 
the 
legislature has eliminated claims for noneconomic damages by 
workers against their employers.  See Wis. Stat. § 102.03(2).  
However, in medical malpractice, the legislature chose to 
continue to allow medical malpractice plaintiffs to recover 
noneconomic damages, but limited the amount to $750,000. 
¶65 Because 
we 
conclude 
that 
the 
$750,000 
cap 
on 
noneconomic damages established by Wis. Stat. § 893.55 has been 
applied 
in 
rational 
relation 
to 
legitimate 
legislative 
objectives, § 893.55 is not unconstitutional as applied to the 
Mayos. 
III.  CONCLUSION 
¶66 We conclude that rational basis is the proper standard 
by which to judge the constitutionality of Wis. Stat. § 893.55; 
that § 893.55 is facially constitutional and constitutional as 
applied to the Mayos; and that Ferdon erroneously invaded the 
province of the legislature and applied an erroneous standard of 
No. 
2014AP2812   
 
32 
 
review.  Accordingly, we reverse the court of appeals' decision, 
overrule 
Ferdon, 
and 
conclude 
that 
the 
$750,000 
cap 
on 
noneconomic 
damages 
in 
medical 
malpractice 
judgments 
and 
settlements is constitutional both facially and as applied to 
the Mayos. 
¶67 Therefore, we reverse the court of appeals and remand 
to the circuit court to impose the $750,000 cap on noneconomic 
damages.   
By the Court.—The decision of the court of appeals is 
reversed and the cause is remanded to the circuit court. 
 
No.  2014AP2812.rgb 
 
1 
 
 
¶68 REBECCA GRASSL BRADLEY, J.   (concurring).  I join the 
majority opinion.  I write separately, however, to address the 
presumptions afforded a statute undergoing a constitutional 
challenge and the challenger's burden of proof.  The Mayos bring 
both facial and as-applied challenges to the $750,000 cap on 
noneconomic damages for medical malpractice claimants prescribed 
by Wis. Stat. § 893.55 (2015-2016); that is, the Mayos assert 
the statute is unconstitutional in every circumstance and as 
applied specifically to them.  See State v. Smith, 2010 WI 16, 
¶10 n.9, 323 Wis. 2d 377, 780 N.W.2d 90 (discussing difference 
between facial and as-applied constitutional challenges).  The 
burden to prove a statute unconstitutional rests with the party 
challenging it.  For many years, this court has described that 
burden as a "heavy" one because the court presumes the 
legislation is constitutional, engages in every attempt to 
uphold it, and in a facial challenge, requires a party 
challenging a law to prove it "is unconstitutional beyond a 
reasonable doubt."  Id., ¶8.  To succeed in a facial challenge, 
a party must also show the law cannot be enforced under any 
circumstances.  State v. Wood, 2010 WI 17, ¶13, 323 Wis. 2d 321, 
780 N.W.2d 63.  I refer to these elements of the burden 
collectively as "the rule" and because it constitutes the 
current state of the law, I am bound to apply it. 
¶69 Regardless 
of 
the 
hurdles 
the 
court 
compels 
challengers to surmount, a statute either comports with the 
constitution or it does not.  Requiring a court to lend almost 
No.  2014AP2812.rgb 
 
2 
 
unfettered deference to the legislature seems incompatible with 
our duty of ensuring the legislature does not exceed its 
constitutional powers.  Indeed, imposing a burden of proof 
heavily weighted in favor of the legislature on matters of 
constitutional interpretation is an abdication of our core 
judicial powers to exercise impartial judgment in cases and 
controversies and to say what the law is.  See generally Gabler 
v. Crime Victims Rights Board, 2017 WI 67, ¶37, 376 Wis. 2d 147, 
897 N.W.2d 384 (2017).  "[T]he judiciary are to declare a 
legislative Act void which conflicts with the constitution, or 
else that instrument is reduced to nothing."  James B. Thayer, 
The Origin and Scope of the American Doctrine of Constitutional 
Law, 7 Harvard L. Rev. 129, 139 (1893) (citing Marbury v. 
Madison, 5 U.S. (1 Cranch) 137, 178 (1803)).   
¶70 Although I join the majority, I write separately to 
question the court's continued adherence to an evidentiary 
burden of proof when deciding a statute's constitutionality.  
Additionally, I write to clarify that the court's elimination of 
rational basis with bite as a standard of review should not be 
interpreted as relaxing the level of review applied to statutes 
implicating fundamental constitutional rights.  I agree that it 
would be inappropriate to apply rational basis with bite in 
reviewing the statutory cap on non-economic damages, but I would 
preserve a meaningful standard of judicial review for laws 
encroaching on fundamental constitutional rights.   
I 
No.  2014AP2812.rgb 
 
3 
 
 
¶71 Under current law, we presume the statute in question 
is constitutional.  Aicher v. Wis. Patients Comp. Fund, 2000 WI 
98, ¶18, 237 Wis. 2d 99, 613 N.W.2d 849.  We will decide 
otherwise 
only 
if 
a 
challenger 
proves 
the 
statute 
is 
unconstitutional beyond a reasonable doubt.  Id., ¶19.  A 
showing that the statute is "probably unconstitutional" or that 
its constitutionality is "doubtful" is insufficient to overcome 
the presumption.  State v. Cole, 2003 WI 112, ¶11, 264 
Wis. 2d 520, 665 N.W.2d 328. 
¶72 A facial challenge requires near-absolute proof that 
any application of the statute is unconstitutional.  But the 
"proof" required in such challenges is assuredly not evidentiary 
proof——it is a rather mixed bag of concrete and hypothetical 
proof sufficient to "establish[] the force or conviction with 
which a court must conclude, as a matter of law, that a statute 
is unconstitutional."  Dane Cty. Dep't of Human Services v. Ponn 
P., 2005 WI 32, ¶18, 279 Wis. 2d 169, 694 N.W.2d 344.     
II 
¶73 Debate about the propriety of the presumption and 
burden traces back centuries, indeed to our nation's founding.  
See generally Thayer, supra ¶2, at 140 ("When did this rule of 
administration begin?  Very early.") (tracing the history of 
heightened deference to legislative acts in the states and the 
federal system to the American Revolution).  In the late 18th 
century through the 19th century, both federal and state courts 
grounded their approach to determining the constitutionality of 
a statute in deference to the legislature.  Id. at 142-43 n.1 
No.  2014AP2812.rgb 
 
4 
 
(collecting examples of this rule's application by the United 
States Supreme Court and state courts in Massachusetts, New 
York, New Hampshire, Ohio, Louisiana, and Florida).  Among the 
expressed rationales for such deference, courts uniformly agreed 
that heightened deference preserved the essential balance 
between 
the 
legislature's 
law-creating 
function 
and 
the 
judiciary's duty to "say what the law is."  See id.   
¶74 Arguing a case in a Massachusetts court, Daniel 
Webster identified a principal weakness of the rule, an argument 
that persists today:   
[M]embers of the legislature sometimes vote for a law, 
of the constitutionality of which they doubt, on the 
consideration that the question may be determined by 
the judges. . . .  If . . . the judge is to hold it 
valid because its unconstitutionality is doubtful, in 
what a predicament is the citizen placed! . . . [I]f 
the question is not met and decided here [by the 
court] 
on 
principle, 
responsibility 
rests 
nowhere. . . . Judicial tribunals are the only ones 
suitable for the investigation of difficult questions 
of private right.[1] 
Such "double deference" threatens the Constitution because both 
branches punt the issue to the other:  "While the courts are 
deferring to the legislature, the legislature in turn is 
deferring to the courts.  By this ruse, any scrutiny of 
legislation to ensure it is within the just powers of a 
legislature is avoided."  Randy E. Barnett, Our Republican 
                                                 
1 James B. Thayer, The Origin and Scope of the American 
Doctrine of Constitutional Law, 7 Harvard L. Rev. 129, 146 
(1893). 
No.  2014AP2812.rgb 
 
5 
 
Constitution:  Securing the Liberty and Sovereignty of We the 
People 128 (2016).    
¶75 Like many other states, Wisconsin courts employed the 
rule, although the rationale for its adoption was never fully 
articulated.  As early as 1842, when Wisconsin remained a 
territory, the precursor to this court applied a different 
variation of the rule whereby "[t]o justify a court in declaring 
a law of the legislature unconstitutional, the case must be 
clear and manifest."  Norton v. Rooker, 1 Pin. 195, 204 (1842) 
(emphasis added); see also Dickson v. State, 1 Wis. 122, 126 
(1853) ("clearly").  Courts sometimes equivocated between 
requiring proof that was "clear and manifest" and today's rule 
requiring proof "beyond a reasonable doubt," often resulting in 
the two standards being equated.  See, e.g., Smith v. Odell, 1 
Pin. 449, 455 (1844) ("The judiciary is a co-ordinate branch of 
the government, and has a right to declare an act of the 
legislature void, when repugnant to the constitution, but it 
must be a very clear and unequivocal case to induce a court to 
pronounce an act of the legislature unconstitutional.  When a 
judge is convinced that an act is unconstitutional, it is his 
duty to set it aside, but he must examine it with every legal 
intendment and presumption in favor of its validity.  He is not 
to resort to a forced, rigid or doubtful construction of an act 
for the purpose of determining its unconstitutionality.  Before 
the 
court 
will 
declare 
an 
act 
of 
the 
legislature 
unconstitutional, a case should be presented in which there is 
no rational doubt." (emphasis added) (citations omitted)); see 
No.  2014AP2812.rgb 
 
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also Christopher R. Green, Clarity and Reasonable Doubt in Early 
State-Constitutional Judicial Review, 57 S. Tex. L. Rev. 169, 
171 (2015) (suggesting that, in some instances, courts took the 
two 
standards 
and 
equated 
them 
"as 
alternative 
verbal 
formulations of the same rule").   
¶76 In 1861, this court borrowed from the Michigan Supreme 
Court in expressing the rule as follows:  "that to warrant us in 
declaring a statute unconstitutional, we should be able to lay 
our finger on the part of the constitution violated, and that 
the infraction should be clear and free from a reasonable 
doubt."  State ex rel. Chandler v. Main, 16 Wis. 398, 415 (1863) 
(quoting Tyler v. The People, 8 Mich. 320, 333 (1860)).  The 
precursor to "beyond a reasonable doubt" of "clear and free from 
a reasonable doubt" apparently was imported from a foreign 
jurisdiction.  
¶77 In Wisconsin's early history, the presumption of 
constitutionality could, in theory at least, be rebutted.  For 
example, this court opined that "[i]t follows, logically, that 
the legitimacy of legislative regulation . . . must be tested 
with reference to appropriateness of ends sought to be attained 
and also of means to such ends."  State ex rel. McGrael v. 
Phelps, 144 Wis. 1, 22, 128 N.W. 1041 (1910).  In practice, 
successful rebuttal of the presumption is rare, particularly in 
facial challenges, which require the challenger to identify an 
unlimited number of circumstances to which the statute may apply 
and successfully show the law cannot be enforced in any of them. 
No.  2014AP2812.rgb 
 
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¶78 In federal courts, judicial deference has waned in 
recent decades.  "[T]he strength of the presumption [of 
constitutionality] has weakened.  This weakening is suggested 
both by shifts in the language that the Court has used to 
describe the presumption and by the significant modern increase 
in the rate at which the Court has invalidated federal 
statutes."  Edward C. Dawson, Adjusting the Presumption of 
Constitutionality Based on Margin of Statutory Passage, 16 U. 
Pa. J. Const. L. 97, 108 (2013).  No United States Supreme Court 
case 
since 
1984 
has 
applied 
a 
strong 
presumption 
of 
constitutionality in challenges to federal statutes.  Id. at 
109, n.43 ("[W]hile there are nine majority decisions between 
1931 and 1984 describing the presumption of constitutionality 
afforded 
federal 
statutes 
as 
'strong,' . . . no 
majority 
decisions 
since 
1984 
mention 
a 
'strong' 
presumption 
of 
constitutionality").2  The rule seems to have essentially 
disappeared from United States Supreme Court jurisprudence.  Id.  
("The 
'beyond 
a 
reasonable 
doubt' 
formulation 
has 
disappeared.").  Our court of appeals noted this in Guzman v. 
St. Francis Hosp., Inc., 2001 WI App 21, ¶4 n.3, 240 
Wis. 2d 559, 568, 623 N.W.2d 776, but lacking the power to 
overrule this court's precedent, it was compelled to apply the 
rule.   
                                                 
2 The strong presumption of constitutionality has not 
reappeared in any United States Supreme Court decision published 
in 2013 or thereafter. 
No.  2014AP2812.rgb 
 
8 
 
¶79 In 
its 
place, 
the 
United 
States 
Supreme 
Court 
sometimes employs a "plain showing" standard of review:  "Due 
respect for the decisions of a coordinate branch of Government 
demands that we invalidate a congressional enactment only upon a 
plain showing that Congress has exceeded its constitutional 
bounds."  United States v. Morrison, 529 U.S. 598, 607 (2000).  
Even more recently, the United States Supreme Court harkened 
back to a 19th century expression of the standard:  "'Proper 
respect for a co-ordinate branch of the government' requires 
that we strike down an Act of Congress only if 'the lack of 
constitutional authority to pass [the] act in question is 
clearly demonstrated.'"  Nat'l Fed'n of Indep. Bus. v. Sebelius, 
567 U.S. 519, 538 (2012) (citing United States v. Harris, 106 
U.S. 629, 635 (1883)). 
¶80 This court continues to reflexively apply the rule 
without any acknowledgement of the United States Supreme Court's 
reformulation of the standard.  See, e.g., Voters with Facts v. 
City of Eau Claire, 2018 WI 63, ¶65, ___ Wis. 2d ___, ___ 
N.W.2d ___ ("All legislative acts are presumed constitutional 
and we must indulge every presumption to sustain the law." 
(quoting Madison Teachers, Inc. v. Walker, 2014 WI 99, ¶13, 358 
Wis. 2d 1, 851 N.W.2d 337)); State v. Grandberry, 2018 WI 29, 
¶12, 380 Wis. 2d 541, 910 N.W.2d 214; Blake v. Jossart, 2016 WI 
57, ¶27, 370 Wis. 2d 1, 884 N.W.2d 484, cert. denied, 137 S. Ct. 
669 (2017) ("A party challenging a statute overcomes the strong 
presumption of constitutionality only by demonstrating that the 
statute is unconstitutional beyond a reasonable doubt." (citing 
No.  2014AP2812.rgb 
 
9 
 
Aicher, 237 Wis. 2d 99, ¶18)); Winnebago Cty. v. Christopher S., 
2016 WI 1, ¶33, 366 Wis. 2d 1, 878 N.W.2d 109, cert. denied sub 
nom., Christopher S. v. Winnebago Cty., 136 S. Ct. 2464 (2016) 
("Every presumption must be indulged to sustain the law if at 
all possible and, wherever doubt exists as to a legislative 
enactment's constitutionality, it must be resolved in favor of 
constitutionality." (quoting State v. Dennis H., 2002 WI 104, 
¶12, 255 Wis. 2d 359, 647 N.W.2d 851)).  The United States 
Supreme Court will strike down statutes upon a "plain showing" 
of their unconstitutionality, or when their unconstitutionality 
is "clearly demonstrated."  The latter wording is strikingly 
similar to the "clear and manifest" standard applied in very 
early Wisconsin case law. 
¶81 Legal scholarship advocating for a weaker presumption 
of constitutionality (or its elimination altogether) sustains 
the ongoing debate over the proper balance of constitutional 
powers between the legislature and the judiciary.  See, e.g., 
Randy Barnett, Restoring the Lost Constitution:  The Presumption 
of Liberty 273 (2003) (arguing that courts should change the 
standard 
from 
a 
"presumption 
of 
constitutionality" 
to 
a 
"presumption of liberty" wherein the government, not the 
challenger, must prove the "necessity and propriety of its 
restrictions on liberty"); Green, supra ¶8, at 171 (suggesting 
that the "the middle requirement, clarity, has the best 
historical pedigree" and should be the standard).  They present 
many 
logical, 
practical, 
and, 
of 
greatest 
importance, 
No.  2014AP2812.rgb 
 
10 
 
constitutional reasons for altering the burden of proof in 
constitutional challenges to statutes. 
¶82 To begin with, the current standard in Wisconsin is 
unworkable, given that a party not only must challenge the 
legislature's expressed reasoning behind implementing a statute, 
but must also disprove any rational speculation that could be 
invoked to support the statute's constitutionality——regardless 
of whether the legislature actually relied upon that rationale 
in adopting it.  See David M. Burke, The Presumption of 
Constitutionality Doctrine and the Rehnquist Court: A Lethal 
Combination for Individual Liberty, 18 Harv. J. L. & Pub. Pol'y 
73, 86 (1994-95) (a petitioner must show there is no conceivable 
interpretation of the Constitution that could support the 
statute); id. ("'[I]f any state of facts reasonably may be 
conceived to justify' a legislative determination, then it is 
'constitutionally irrelevant whether this reasoning in fact 
underlay the legislative decision.'" (first quoting McGowan v. 
Maryland, 366 U.S. 420, 426 (1961); then quoting Flemming v. 
Nestor, 363 U.S. 603, 612 (1960) (footnotes omitted))); see also 
Barnett, 
supra 
¶14, 
at 
228 
(asking 
rhetorically, 
"who 
'realistically' is in the best position to present a court with 
empirical 
information 
for 
or 
against 
the 
necessity" 
and 
answering implicitly, the government).  If the justifications 
available for a challenged law are not tied to the actual 
reasons the law was passed, then the constitutional validity of 
a statute rests on the imagination of the State's lawyers.   
No.  2014AP2812.rgb 
 
11 
 
¶83 It has never been clear why courts choose to apply an 
evidentiary burden of proof for establishing guilt in criminal 
cases in assessing the constitutionality of a statute.  This 
court previously explained away this concern:   
While this burden of proof is often associated with 
the requisite proof of guilt in a criminal case, in 
the context of a challenge to the constitutionality of 
a statute, the phrase "beyond a reasonable doubt" 
expresses the "force or conviction with which a court 
must conclude, as a matter of law, that a statute is 
unconstitutional before the statute or its application 
can be set aside."   
League of Women Voters of Wis. Educ. Network, Inc. v. Walker, 
2014 WI 97, ¶17, 357 Wis. 2d 360, 851 N.W.2d 382 (emphasis 
added) (quoting Ponn P., 279 Wis. 2d 169, ¶18).  If "beyond a 
reasonable doubt" means something different in assessing the 
constitutionality of statutes, we should not transfer the exact 
same words from a criminal evidentiary standard applied to facts 
into an analysis of the law.  See Island Cty. v. State, 955 P.2d 
377, 386 (Wash. 1998) (Sanders, J., concurring) ("[L]egal 
questions are not ordinarily presumptive candidates because the 
law is at hand.  Thus, all courts determine legal issues de 
novo." (citations omitted)).  In assessing the constitutionality 
of a law, the court examines just that:  the law.  See Appling 
v. Walker, 2014 WI 96, ¶18, 358 Wis. 2d 132, 853 N.W.2d 888.  It 
does not examine the law in the same way the finder of fact in a 
criminal 
trial 
evaluates 
witness' 
factual 
testimony 
for 
credibility or reliability in order to ascertain the defendant's 
guilt or innocence.   
No.  2014AP2812.rgb 
 
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¶84 Rather, as the constitutional body vested with the 
power to say "what the law is," the judiciary evaluates a 
statute for its fidelity to the constitution, and "an act of the 
legislature, repugnant to the constitution, is void."  Marbury, 
5 U.S. (1 Cranch) at 177.  When a law contravenes the 
constitution, it is our duty to say so.  The "beyond a 
reasonable 
doubt" 
standard 
interferes 
with 
this 
judicial 
responsibility.  Applying this standard places courts in an 
absurd position:  We could determine a law is more likely than 
not unconstitutional, and we would still uphold it.3  We could 
even conclude a party has shown clearly and convincingly that a 
law is unconstitutional, and still we would sustain it.4  This 
scheme of review scrambles the constitutional roles of the 
judiciary and the legislature, making legislators the judges of 
their own laws.  "If it be said that the legislative body are 
themselves the constitutional judges of their own powers, and 
that the construction they put upon them is conclusive upon the 
other departments, it may be answered, that this cannot be the 
                                                 
3 Reviewing an issue for "proof by a preponderance of the 
evidence," i.e., proof that is "more likely than not" true, 
encompasses the lowest burden of proof used in ordinary civil 
cases.  See Kruse v. Horlamus Indus., Inc., 130 Wis. 2d 357, 
362–63, 387 N.W.2d 64 (1986); State v. Wanta, 224 Wis. 2d 679, 
693, 592 N.W.2d 645 (Ct. App. 1999).  It requires the trier of 
fact to determine the existence of a fact "to a reasonable 
certainty by the greater weight of the credible evidence."  
Kruse, 130 Wis. 2d at 362–63. 
4 "This burden, while greater than required in ordinary 
civil cases, is not as great as 'beyond a reasonable doubt' used 
in criminal cases."  City of Madison v. Geier, 27 Wis. 2d 687, 
691, 135 N.W.2d 761 (1965). 
No.  2014AP2812.rgb 
 
13 
 
natural presumption, where it is not to be collected from any 
particular provisions in the Constitution."  The Federalist No. 
78 at 467 (Alexander Hamilton) (Clinton Rossiter ed., 1961).  
The "beyond a reasonable doubt" standard also disrupts the 
hierarchy 
of 
laws 
by 
making 
statutes 
superior 
to 
the 
constitution.   
The Constitution is either a superior, paramount law, 
unchangeable by ordinary means, or it is on a level 
with ordinary legislative acts, and, like other acts, 
is alterable when the legislature shall please to 
alter it.  If the former part of the alternative be 
true, 
then 
a 
legislative 
act 
contrary 
to 
the 
Constitution is not law; if the latter part be true, 
then written Constitutions are absurd attempts on the 
part of the people to limit a power in its own nature 
illimitable.   
Marbury, 5 U.S. (1 Cranch) at 177.  Judicial respect for its co-
equal branch, the legislature, cannot amount to surrender of 
judicial power or abdication of judicial duty.   
¶85 The burden of proof in criminal cases purportedly is 
rooted in Blackstone's observation that "it is better that ten 
guilty persons escape than one innocent suffer."  4 William 
Blackstone, Commentaries *358.  This precept does not translate 
in the context of examining a statute's constitutionality:  Is 
it better that the constitution be violated ten times lest one 
constitutional law be struck down?  Is it better that we deny 
the people's constitutional rights ten times to avoid mistakenly 
striking down a single constitutional law?  Notably, the 
consequences of upholding unconstitutional laws are not confined 
to a single party in a single case.  Rather, failure to strike 
No.  2014AP2812.rgb 
 
14 
 
down an unconstitutional law harms all of the people of this 
state in potential perpetuity. 
 
¶86 Employing the "beyond a reasonable doubt" burden of 
proof in judging a statute's constitutionality substantiates one 
of the Framers' chief concerns:  that Legislatures should not be 
the "constitutional judges of their own powers."  Burke, supra 
¶15, at 90 ("[I]n a constitutional system of delegated authority 
it 'cannot be the natural presumption' that the members of 
Congress are to be regarded as 'the constitutional judges of 
their own powers . . . .'" (citing The Federalist No. 78, supra 
¶17, at 467 (Alexander Hamilton)). 
¶87 Under the current framework, in contrast to the 
structural separation of powers our framers envisioned, judicial 
deference gives the legislature both the pen and the gavel over 
their own laws, and imposes a "tremendous burden" on individuals 
attempting to limit the constitutional overreach of legislative 
power.  Burke, supra ¶15, at 90.  Imposing a "beyond a 
reasonable doubt" standard is currently at odds with the 
constitutional principle that the legislature, not the people, 
should be the one to identify the legislature's source of power.  
Id. at 84 ("The powers of Congress . . . have as their sole 
origin a Constitution which delegates and limits powers. It 
necessarily follows, then, that the burden lies with Congress to 
point to its source of power."). 
¶88 This court recently reiterated the importance of the 
separation of powers in establishing and preserving a government 
of, by, and for the people.  Gabler, 376 Wis. 2d 147, ¶39 ("If 
No.  2014AP2812.rgb 
 
15 
 
the judiciary passively permits another branch to arrogate 
judicial power unto itself, however estimable the professed 
purpose for asserting this prerogative, the people inevitably 
suffer. . . . [T]he people lose their independent arbiters of 
the law, the balance of powers tips, and the republican form of 
government 
is 
lost."). 
 
We 
recently 
jettisoned 
judicial 
deference 
long 
afforded 
to 
interpretations 
of 
law 
by 
administrative agencies.  Tetra Tech EC, Inc. v. DOR, 2018 WI 
75, ___ Wis. 2d ___, ___ N.W.2d __.  The time is ripe for this 
court to embrace its constitutional duty to protect the people 
from encroachments by the legislature on constitutional rights.   
¶89 A strong presumption of constitutionality empowers 
legislators to serve as "judges in their own case when a citizen 
claims that a law restricting his or her liberty is irrational 
or arbitrary."  Barnett, supra ¶7, at 245.  In Federalist 10, 
James Madison warned that "a body of men are unfit to be both 
judges and parties at the same time," recognizing that "many of 
the 
most 
important 
acts 
of 
legislation" 
are 
"judicial 
determinations."  The Federalist No. 10, supra ¶17, at 79 (James 
Madison).  Serving as the protector of constitutional rights 
ultimately rests with "courts of justice, whose duty it must be 
to declare all acts contrary to the manifest tenor of the 
Constitution void.  Without this, all the reservations of 
particular rights or privileges would amount to nothing."  The 
Federalist No. 78, supra ¶17, at 466 (Alexander Hamilton) 
(emphasis added). 
No.  2014AP2812.rgb 
 
16 
 
¶90 Replacing the "beyond a reasonable doubt" burden with 
one 
requiring 
a 
"plain 
showing" 
or 
simply 
clarity 
in 
establishing the unconstitutionality of a statute, as the United 
States Supreme Court did decades ago, would restore the balance 
of power between the judiciary and the legislature in Wisconsin.  
Such a standard of review would conserve the legislature's 
constitutional lawmaking function while reinstating the courts' 
role as the "bulwarks of a limited Constitution against 
legislative encroachments . . . ."  The Federalist No. 78, supra 
¶17, at 469 (Alexander Hamilton). 
 
¶91 The Constitution's supremacy over legislation bears 
repeating:  "the Constitution is to be considered in court as a 
paramount law" and "a law repugnant to the Constitution is void, 
and. . . courts, as well as other departments, are bound by that 
instrument."  See Marbury, 5 U.S. (1 Cranch) at 178, 180.   
III 
¶92 The majority aptly criticizes the Ferdon court's 
application of "rational basis with teeth" to strike the prior 
cap on noneconomic damages for usurping the legislature's 
policymaking role.  Majority op., ¶32.  As the State accurately 
argued 
in 
its 
amicus 
brief, 
"the 
cap's 
level 
is 
a 
quintessentially legislative judgment" which makes it the 
prerogative of the legislature to set.  The cap implicates no 
constitutional 
rights 
whatsoever; 
as 
plaintiffs' 
counsel 
conceded at oral argument, the legislature could set the cap at 
zero——thereby eliminating the recovery of noneconomic damages 
altogether——without offending the constitution.  Recovery of 
No.  2014AP2812.rgb 
 
17 
 
such damages is a matter of common law, not constitutional law.  
The legislature retains full authority to define, limit, or 
abrogate common law causes of action.  Aicher, 237 Wis. 2d 99, 
¶51.  The Wisconsin Constitution expressly permits this.  
Majority op., ¶64.  And because the cap treats all medical 
malpractice plaintiffs exactly the same, no equal protection or 
due process inquiry is necessary.    
¶93 Because the majority opts to apply rational basis 
review in this case, I would clarify that this lower level of 
review is appropriate for laws that confer a benefit, such as 
the system of guaranteed recovery for medical malpractice 
claimants we consider here.  However, when laws are alleged to 
impair fundamental constitutional rights, courts must apply a 
higher level of scrutiny.  Porter v. State, 2018 WI 79, ___ Wis. 
2d ___, ___ N.W.2d __ (R. Grassl Bradley, J., and Kelly, J., 
dissenting). 
IV 
¶94 Wisconsin courts must afford appropriate deference to 
legislatures in their lawmaking function.  Legislators are the 
people's representatives, elected to enact laws that reflect the 
policy preferences of the people.  However, the constitution 
imposes limits on that broad power; the legislature may not 
enact laws that infringe constitutional rights.  Under our 
structural separation of powers, the people task the judiciary 
with 
the 
ultimate 
authority 
to 
declare 
legislative 
acts 
unconstitutional.  The judiciary does not fulfill this duty if 
it subordinates its independent judgment to the legislature's by 
No.  2014AP2812.rgb 
 
18 
 
making legislative acts superior to the constitution.  "[T]here 
is no liberty, if the judiciary power be not separate from the 
legislative."  7 B. De Montesquieu, Spirit of the Laws 152 
(Nugent ed., 1823).   
¶95 I join the majority in upholding the statutory cap on 
noneconomic damages in medical malpractice actions set forth in 
Wis. Stat. § 893.55, which does not implicate or offend any 
constitutional right.  I write separately to urge this court to 
reconsider its application of the "beyond a reasonable doubt" 
standard in cases that present constitutional challenges.  
¶96 I respectfully concur.   
¶97 I am authorized to state that Justice DANIEL KELLY 
joins this concurrence. 
 
 
No.  2014AP2812.awb 
 
1 
 
¶98 ANN 
WALSH 
BRADLEY, 
J.   (dissenting). 
 
After 
a 
harrowing 
and 
unimaginable 
ordeal 
that 
resulted 
in 
the 
amputation of all four of Ascaris Mayo's extremities, the 
majority denies Ascaris and Antonio Mayo 95 percent of the 
recovery to which a jury determined they are entitled.  The 
majority restricts the Mayos' recovery based on Wisconsin's 
statutory cap on noneconomic damages in medical malpractice 
cases, which it now declares to be constitutional.  See Wis. 
Stat. § 893.55. 
¶99 This is not the first time this court has addressed 
the constitutionality of a cap on noneconomic damages in medical 
malpractice actions.  In Ferdon ex rel. Petrucelli v. Wisconsin 
Patients Comp. Fund, the court determined that a medical 
malpractice noneconomic damages cap of $350,000 violated the 
constitutional guarantee of equal protection.  2005 WI 125, ¶10, 
284 Wis. 2d 573, 701 N.W.2d 440. 
¶100 Ferdon 
exhaustively, 
and 
correctly, 
analyzed 
the 
constitutional infirmities of a damage cap of $350,000.  The 
only difference between this case and Ferdon is that the medical 
malpractice noneconomic damages cap is set at $750,000 rather 
than $350,000. 
¶101 Raising 
the 
cap 
by 
$400,000 
does 
not 
fix 
the 
fundamental constitutional problems with the damage cap that the 
Ferdon court identified.  The cap still makes the most severely 
injured 
bear 
the 
greatest 
burden 
in 
violation 
of 
equal 
protection. 
No.  2014AP2812.awb 
 
2 
 
¶102 I agree with a unanimous court of appeals that 
determined that the statutory cap on noneconomic damages remains 
unconstitutional.1  The cap imposes "an unfair and illogical 
burden only on catastrophically injured patients, thus denying 
them the equal protection of the laws."  Mayo v. Wis. Injured 
Patients and Families Compensation Fund, 2017 WI App 52, ¶1, 377 
Wis. 2d 566, 901 N.W.2d 782. 
¶103 Ferdon identified several areas of constitutional 
infirmity with regard to the $350,000 cap at issue.  As the 
court of appeals in this case explained, the Ferdon court 
concluded that the $350,000 damages cap then at issue lacked a 
rational basis because:  (1) the existence or nonexistence of 
noneconomic damages caps does not affect doctors' migration; (2) 
defensive medicine is not susceptible to accurate measurement 
and does not contribute significantly to the cost of health 
care; (3) the correlation between noneconomic damages caps and 
lower medical malpractice premiums or overall health care costs 
is weak; and (4) the cap was unnecessary to the financial 
integrity of the Fund.  Mayo, 377 Wis. 2d 566, ¶20 (citing 
Ferdon, 284 Wis. 2d 573, ¶¶168, 174, 166, 158). 
¶104 Simply raising the cap from $350,000 to $750,000 does 
not magically transform any of these considerations into 
                                                 
1 Although Judge Brash concurred, taking the position that 
the damages cap is unconstitutional as applied to the Mayos 
rather than facially unconstitutional, the court of appeals was 
unanimous that the damages cap violates the constitutional 
guarantee of equal protection. 
No.  2014AP2812.awb 
 
3 
 
rational bases for the legislature's action.2  I agree with the 
court of appeals' analysis on each point. 
                                                 
2 The legislature sets forth the damage cap's objectives in 
Wis. Stat. § 893.55(1d)(a).  The four bases advanced are: 
1. Protecting access to health care services across 
the state and across medical specialties by limiting 
the disincentives for physicians to practice medicine 
in 
Wisconsin, 
such 
as 
the 
unavailability 
of 
professional liability insurance coverage, the high 
cost of insurance premiums, large fund assessments, 
and unpredictable or large noneconomic damage awards, 
as recognized by a 2003 U.S. [C]ongress joint economic 
committee report, a 2003 federal department of health 
and human services study, and a 2004 office of the 
commissioner of insurance report. 
2. Helping contain health care costs by limiting the 
incentive 
to 
practice 
defensive 
medicine, 
which 
increases the cost of patient care, as recognized by a 
2002 federal department of health and human services 
study, a 2003 U.S. [C]ongress joint economic committee 
report, a 2003 federal government accounting office 
study, and a 2005 office of the commissioner of 
insurance report. 
3. Helping contain health care costs by providing more 
predictability in noneconomic damage awards, allowing 
insurers to set insurance premiums that better reflect 
such insurers' financial risk, as recognized by a 2003 
federal department of health and human services study. 
4. Helping contain health care costs by providing more 
predictability in noneconomic damage awards in order 
to protect the financial integrity of the fund and 
allow the fund's board of governors to approve 
reasonable assessments for health care providers, as 
recognized by a 2005 legislative fiscal bureau memo, a 
2001 legislative audit bureau report, and a 2005 
office of commissioner of insurance report. 
Wis. Stat. § 893.55(1d)(a)1.-4.  Although these four reasons are 
more detailed, they essentially present the same justifications 
that were tested and rejected in Ferdon.  See Mayo v. Wis. 
Injured Patients and Families Comp. Fund, 2017 WI App 52, ¶27, 
377 Wis. 2d 566, 901 N.W.2d 782. 
No.  2014AP2812.awb 
 
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¶105 First, as did the Ferdon court, the court of appeals 
here concluded that the "current noneconomic damages cap is not 
rationally related to the legislative objective of retaining 
physicians in Wisconsin."  Mayo, 377 Wis. 2d 566, ¶21.  It 
reached this conclusion because data demonstrates that the 
number of physicians participating in the Fund has increased 
each year since Ferdon, and that many states with no damages cap 
at all "actually have higher physician retention rates than 
Wisconsin."3  Id. 
¶106 Second, in accord with the Ferdon court, the court of 
appeals here determined that the damages cap is "not rationally 
related to the legislative objective of curtailing the practice 
of defensive medicine."  Id., ¶22.  Rather, the record 
demonstrates that the financial impact of defensive medicine is 
not readily measurable, and this has not changed in the time 
since Ferdon was decided.  Id.  Further, the requirements that 
doctors have primary medical malpractice coverage and make 
contributions to the Fund mean that there is no risk of a doctor 
facing personal liability for a judgment.  Id.  As the court of 
appeals stated, "[t]his lack of uninsured personal liability 
would logically appear to remove any incentive to practice 
'defensive medicine.'"  Id. 
                                                 
3 For example, our neighboring state of Minnesota, which has 
no damage cap, retains its physicians at a higher rate than does 
Wisconsin.  See Ass'n of American Medical Colleges, 2011 State 
Physician 
Workforce 
Data 
Book 
54-55 
(Nov. 
2011), 
https://www.aamc.org/download/263512/data/statedata2011.pdf. 
No.  2014AP2812.awb 
 
5 
 
¶107 Third, the court of appeals concluded that, as in 
Ferdon, 
"the 
record 
before 
us 
does 
not 
demonstrate 
any 
correlation between medical malpractice premiums and caps on 
noneconomic damages."  Id., ¶24.  Other jurisdictions, and even 
medical malpractice insurers, have also failed to establish such 
a connection.  Id. 
¶108 Finally, as the court of appeals determined, the 
record does not demonstrate that the integrity of the Fund rises 
and falls based on the damages cap.  The Ferdon court observed 
that "the Fund has flourished both with and without a cap."  
Ferdon, 284 Wis. 2d 573, ¶158.  This remains true today.  The 
Fund's assets have grown, while both claims and payments have 
decreased.  As the court of appeals concluded, "[i]t is obvious 
that the Fund's financial solvency has not been negatively 
impacted by claims when, in fact, the Fund's assets have grown."4  
Mayo, 377 Wis. 2d 566, ¶25. 
¶109  Before concluding, I observe that the majority's 
analysis and its overruling of Ferdon depart from the time-
honored principle of stare decisis.  We decided Ferdon only 
thirteen 
years 
ago. 
 
"[R]espect 
for 
prior 
decisions 
is 
fundamental to the rule of law."  Johnson Controls, Inc. v. 
                                                 
4 According to the Fund's 2016 Functional and Progress 
Report, as of June 30, 2016, the assets of the Fund totaled over 
$1.3 billion, over $878 million of which is surplus.  Wisconsin 
Injured Patients and Families Compensation Fund, Office of the 
Commissioner of Insurance (OCI), 2016 Functional and Progress 
Report 
13-14, 
https://oci.wi.gov/Documents/Funds/IPFCFANNRPT16.pdf.  This is 
more than ample to cover the Fund's obligations. 
No.  2014AP2812.awb 
 
6 
 
Emp'rs Ins. of Wausau, 2003 WI 108, ¶94, 264 Wis. 2d 60, 665 
N.W.2d 257 (2003). 
¶110 "Stare decisis is the preferred course of judicial 
action 
because 
it 
promotes 
evenhanded, 
predictable, 
and 
consistent development of legal principles . . . and contributes 
to the actual and perceived integrity of the judicial process."  
Id., ¶95.  "The decision to overturn a prior case must not be 
undertaken merely because the composition of the court has 
changed."  Id.; see also Bartholomew v. Wisconsin Patients Comp. 
Fund and Compcare Health Servs. Ins. Corp., 2006 WI 91, ¶32, 293 
Wis. 2d 38, 717 N.W.2d 216 ("No change in the law is justified 
by a change in the membership of the court[.]"). 
¶111 Equal protection guarantees that people similarly 
situated are treated similarly.  State ex rel. Harr v. Berge, 
2004 WI App 105, ¶5, 273 Wis. 2d 481, 681 N.W.2d 282.  Yet, the 
$750,000 damage cap singles out the most severely injured and 
treats them differently.  It places the largest burden on them 
and guarantees that this specific, vulnerable class of injured 
patients will receive but a tiny fraction of the compensation 
due. 
¶112 Only those with the most catastrophic injuries will be 
denied a full and fair damages award.  Under the majority's 
analysis, the Mayos will receive merely five percent of what a 
jury assessed was due for their noneconomic damages, while those 
less severely injured will get 100 percent.  It makes no sense 
that those who are injured most get the least.  This senseless 
No.  2014AP2812.awb 
 
7 
 
and unequal result is compounded by the lack of a rational basis 
for the cap, rendering it unconstitutional. 
¶113 This court got it right in Ferdon, as did the 
unanimous court of appeals in this case. 
¶114 For the reasons set forth above, I respectfully 
dissent. 
¶115 I am authorized to state that Justice SHIRLEY S. 
ABRAHAMSON joins this dissent. 
 
 
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