Title: IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM FOR BENEFITS FOR HOWARD W. WILLIAMS, DECEASED EMPLOYEE OF CAPITOL CITY MAINTENANCE, INC.: SHARON WILLIAMS V. STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION

State: wyoming

Issuer: Wyoming Supreme Court

Document:

IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM FOR BENEFITS FOR HOWARD W. WILLIAMS, DECEASED EMPLOYEE OF CAPITOL CITY MAINTENANCE, INC.: SHARON WILLIAMS V. STATE OF WYOMING ex rel. WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2009 WY 57205 P.3d 1024Case Number: S-08-0034Decided: 04/21/2009
APRIL 
TERM, A.D. 2009

 
 
IN 
THE MATTER OF THE WORKER'S COMPENSATION CLAIM FOR BENEFITS FOR HOWARD W. 
WILLIAMS, DECEASED EMPLOYEE OF CAPITOL CITY MAINTENANCE, INC.: SHARON 
WILLIAMS,Appellant(Petitioner),v.STATE OF WYOMING ex 
rel. WYOMING WORKERS' SAFETY AND COMPENSATION 
DIVISION,Appellee(Respondent).

 
 
W.R.A.P. 
12.09(b) Certification

from 
the District Court of Laramie County

The 
Honorable Edward L. Grant, Judge

 
 

Representing 
Appellant:

Donald 
J. Sullivan of Sullivan Law Offices, P.C., Cheyenne, Wyoming. 

 
 

Representing 
Appellee:

Bruce 
A. Salzburg, Wyoming Attorney General; John W. Renneisen, Deputy Attorney 
General; James Michael Causey, Senior Assistant Attorney General; J.C. Demers, 
Special Assistant Attorney General.  
Argument by Mr. Causey.

Representing 
Amicus Curiae Watchtower Bible and Tract Society of New York, 
Inc.:

Paul 
D. Polidoro and Keturah A. Dunne, Associate General Counsel, Patterson, New 
York; Diana Sampson Rhodes of Rhodes Law Firm, LLC, Cheyenne, Wyoming. 

 
 
Before 
VOIGT, C.J., and GOLDEN, HILL, KITE, BURKE, JJ.

 
 
GOLDEN, 
J., delivers the opinion of the Court; VOIGT, C.J., files a dissenting 
opinion.

 
 

GOLDEN, 
Justice.

 
 
[¶1]      Appellant, Sharon 
Williams, sought worker's compensation death benefits as the surviving spouse of 
Howard W. Williams, who died from injuries suffered in a work-related car 
accident.  Appellee, the Wyoming 
Workers' Safety and Compensation Division (Division), denied Mrs. Williams' 
claim for death benefits on the basis that Mr. Williams refused reasonable and 
necessary medical treatment.  On 
appeal, the Office of Administrative Hearings hearing examiner also denied 
benefits.  The hearing examiner 
determined that, pursuant to Wyo. Stat. Ann. § 27-14-407, Mr. Williams had 
forfeited all right to benefits under the Wyoming Worker's Compensation Act when 
he refused to allow the use of blood products to treat his injuries.  Mrs. Williams petitioned for review by 
the district court, and the matter was certified to this Court.  On the specific facts and evidence in 
this case, we reverse and remand with directions that the applicable death 
benefits be awarded to Mrs. Williams.

 
 

ISSUES

 
 
[¶2]      Mrs. Williams 
raises the following issues:

 
 
I.          
Whether the State may constitutionally refuse Worker's Compensation 
benefits where an injured worker, on the basis of sincere religious grounds, 
declines to accept human blood products from another person, without thereby 
violating his constitutionally-protected religious 
liberties?

 
 
II.         
Whether the forfeiture-of-benefits statute even applies to a situation 
that does not involve knowing and persistent misconduct which affirmatively 
harms the medical situation, but rather where the worker merely makes an 
election among various available methods of medical care?

 
 
III.        
Whether the Division, which without dispute has the burden of proof in 
urging forfeiture, may prevail where it produces no evidence to satisfy any of 
the several distinct conditions of the forfeiture statute?

 
 
IV.       Whether the 
forfeiture statute can be extended to include the new scope the Division seeks 
to adopt?

 
 
In 
response, the Division presents these issues:

 
 
I.          
Is the hearing examiner's finding regarding Employee's forfeiture of 
benefits under Wyo. Stat. Ann. § 27-14-407 supported by substantial 
evidence?

 
 
II.         
Are the constitutional issues raised in the Brief of Appellant properly 
before this Court?

 
 

FACTS

 
 
[¶3]      On February 9, 
2006, Mr. Williams, a maintenance technician for Capital City Maintenance, Inc. 
(CCM), was riding in an automobile on the interstate to a job site in Laramie, 
Wyoming.  The driver of the vehicle, 
Mrs. Williams, lost control, the vehicle rolled several times, and Mr. Williams 
was severely injured.1  He was subsequently transported by 
ambulance to United Medical Center (UMC) in Cheyenne.  Mrs. Williams was also injured in the 
accident and transported by ambulance to UMC.  The record indicates that her injuries 
were less severe than Mr. Williams and she was alert and able to converse with 
medical personnel.  

 
 
[¶4]      According to Dr. 
M. Whitney Parnell, the treating physician, Mr. Williams was "pretty banged 
up."  Mr. Williams showed signs of 
external trauma to his left side, he had tenderness over that area and his lower 
ribs, and he was hypotensive, meaning his blood pressure was "fairly low."  Dr. Parnell suspected that Mr. Williams 
had a splenic injury and was bleeding internally.  In her Consultation Report, Dr. Parnell 
described her initial impression:

 
 
This 
is a 67-year-old gentleman who was involved in a severe motor vehicle accident 
in which he was the passenger who was thrown from the front seat of the vehicle 
to the back.  The patient has 
obviously suffered a significant splenic injury with splenic rupture and free 
intraabdominal bleeding.  

 
 
[¶5]      Mr. and Mrs. 
Williams indicated to Dr. Parnell that they were Jehovah's Witnesses and, as 
such, they did not want any blood products used in the treatment of Mr. 
Williams.  Dr. Parnell inquired if 
other substances with similar properties, such as albumin, were allowed.  Mrs. Williams was unsure, and asked Dr. 
Parnell not to administer any albumin until her son arrived at the 
hospital.  Dr. Parnell also inquired 
about the use of Cell Saver, which is an individual's own blood cleansed.2  Mr. Williams was uncertain if the use of 
Cell Saver was appropriate and asked Dr. Parnell to wait until his son 
arrived.  

 
 
[¶6]      While awaiting 
the son's arrival, Dr. Parnell gave Mr. Williams non-blood fluid resuscitation 
products and obtained a chest x-ray and computed tomography (CT) scans.  Dr. Parnell's Consultation Report 
explained her treatment during this period of time and what the chest x-ray and 
CT scans revealed:

 
 
Initially 
a STAT portable chest x-ray had been obtained and I thought it was without 
evidence of pneumothorax.  It did 
have a slight haze on the left side of the chest.  The film did appear slightly 
under-penetrated.  There was no 
obvious mediastinal widening and the diaphragm appeared to be in normal 
position.

 
 
At 
this point I continued saline resuscitation and elected to give him 500 cc of 
Hespan resuscitation also.  The 
patient continued to be hypotensive, blood pressures anywhere from 79-100.  At this point when the blood pressure 
got up to 100, I asked that we get infusion of dopamine and bring this to the CT 
scan room for resuscitative measures if needed.  Computed tomography scan examinations 
revealed the following: . . .

 
 
1.  Computed tomography scan of the head was 
without evidence of acute trauma.

2.  Computed tomography scan of the cervical 
spine was without evidence of acute trauma.

                                    
3.  Computed tomography scan 
of the chest was without evidence of acute trauma.

                                    
4.  Computed tomography scan 
of the abdomen and pelvis showed evidence of a diffuse hemoperitoneum with 
obvious splenic rupture and free fluid throughout the abdomen.  There was a questionable haziness around 
the bladder suggestive of possible rupture.  The only other injury found was a slight 
fracture of the vertebral body to T4.  

 
 
[¶7]      Mr. Williams' son 
subsequently arrived at the hospital and consented to the Cell Saver 
procedure.  Based on the information 
garnered from the CT scans, Dr. Parnell decided to perform an emergency 
splenectomy.  Dr. Parnell informed 
Mr. Williams' son that "the decision not to allow any blood products, including 
whole blood, packed red blood cells, plasma, and/or platelets, cryoprecipitate, 
etc, may indeed make it very difficult to resuscitate and manage [Mr. 
Williams]."  The son indicated he 
understood the situation, and the surgery was performed without the use of any 
foreign blood products.  

 
 
[¶8]      According to Dr. 
Parnell's Operative Report, Mr. Williams had "massive intraabdominal" bleeding, 
his spleen was in two pieces, and he had lost five liters of blood.  Dr. Parnell removed Mr. Williams' spleen 
and retransfused two liters of Mr. Williams' blood into him using the Cell 
Saver.  The Operative Report 
indicates that Dr. Parnell also evaluated the rest of Mr. Williams' abdominal 
cavity and pelvic area during the surgery and found no signs of trauma.  

 
 
[¶9]      After the 
surgery, Mr. Williams was taken to the intensive care unit, where his condition 
deteriorated.  Despite aggressive 
fluid resuscitation efforts, Mr. Williams remained hypotensive and his blood 
pressure continued to drop. According to the Consultation Report of Dr. Laura 
Brausch, who provided a consultation at the request of Dr. Parnell, Mr. 
Williams' blood pressure was "65/34" and was dropping "into the 30s and 
40s."  Dr. Brausch described her 
impression as follows:

 
 
This 
is a 67-year-old male status post motor vehicle accident who sustained a severe 
splenic injury and very significant blood loss.  This severe hemorrhage, we are not able 
to replace with blood products and replacing at this point with saline, albumin 
and even hetastarch is not helping this patient.  We have him on high doses of both 
Norepinephrine and Dopamine in addition to rapid infusion of IV fluids without 
benefit.  He has received calcium 
times two and bicarbonate times three.  
We are all afraid that the patient is dying and we have used the 
resources we are allowed to use to their fullest extent.  

 
 
Mr. 
Williams died at 6:36 p.m., after his heart stopped from lack of blood 
pressure.  According to Dr. Parnell, 
Mr. Williams essentially bled to death.  

 
 
[¶10]   Mrs. Williams filed a claim for 
death benefits and funeral expenses.  
On March 24, 2006, the Division denied her claim for the reason that the 
"medical documentation submitted to the Division indicates the cause of death 
was due to the refusal of reasonable and necessary medical care."  Mrs. Williams objected to the denial and 
requested a hearing.  The Division 
thereafter filed a petition for forfeiture of benefits pursuant to Wyo. Stat. 
Ann. § 27-14-407 (LexisNexis 2007), which provides:

 
 
If 
an injured employee knowingly engages or persists in an unsanitary or injurious 
practice which tends to imperil or retard his recovery, or if he refuses to 
submit to medical or surgical treatment reasonably essential to promote his 
recovery, he forfeits all right to compensation under this act.  Forfeiture shall be determined by the 
hearing examiner upon application by the division or 
employer.

 
 
[¶11]   At the contested case hearing held 
on November 20, 2006, the hearing examiner was presented with numerous medical 
records, the affidavit and testimony of Howard Williams, CCM's president, and 
the deposition testimony of Dr. Parnell.  
Of relevant importance to the hearing examiner's decision is the 
following testimony provided by Dr. Parnell:

 
 
Q.        Can 
you give us your best sense, knowing everything that you know, at the point that 
you first evaluated [Mr. Williams] and with the benefit of hindsight, how good 
or not good were his chances of survival?

 
 
A.        In 
general, I think he had potentially survivable injuries, but not 
guaranteed.

 
 
Q.        
Okay.  And one of the 
striking features of this patient's case is the refusal of human blood 
products.  Can you give us your 
sense, Doctor, of the difference, if any, that his decision not to accept human 
blood products  did that change his outcome?

 
 
A.        I 
don't  I can't say that it changed his outcome.  I can say it changed my 
management.

 
 
Q.        What 
do you mean by that?

 
 
A.        I 
would have taken him to the operating room sooner because I wouldn't have had to 
wait for the son.  And actually, Mr. 
Williams was requesting that I wait for the son before going; and also, I felt 
his best chance of survival was to use the Cell Saver.  Had he declined use of the Cell Saver, I 
think he would have died in the operating room.

 
 
And 
that was my sense prior to starting it is that if we had no ability to give him 
back even his own blood, then he probably would have expired in the operating 
room.

 
 
The 
management was just  it was like a fork in the road; and I went down a 
different road because of his religious beliefs, which is absolutely within his 
power to do so.  Whether or not he 
would have survived with or without blood products, I don't know that I can 
say.

 
 
I 
can say that it changed my management but that he had significant injuries.  He had a  he had an obvious significant 
injury to his spleen, his back.  I 
presume if he had time, we probably could have found ribs and pulmonary 
issues.  And these are enough in a 
67-year-old gentleman to have them  they could be fatal.  This constellation of problems can be 
fatal, despite our best efforts.  

 
 
Q.        And 
is there  is there any way that you or another good surgeon can say with any 
level of certainty that had this patient accepted human blood that he would have 
survived and lived to leave the hospital?

 
 
A.        I 
don't know that anyone could say that with certainty.

 
 
*  *  
*  *

 
 
Q.        If he 
had allowed  if there had been no issue in terms of providing the transfusion, 
what would have been done differently?

 
 
A.        He 
would have gone to surgery sooner; and I probably would have transfused, in 
addition to his own blood, other blood products, not just red blood cells but 
clotting factors.  And that's 
probably  would have assisted in his management.

 
 
Q.        And 
when you say "clotting factors," that would have  you would have been doing two 
things, then; one is replacing the lost blood and the other is also slowing the 
bleeding?

 
 
A.        It's 
really not slowing the bleeding, it's assisting with the clotting  . . . so 
that I'm replacing not only the lost blood with blood components, the platelets 
and clotting factors that assist with clotting throughout the whole 
body.

 
 
Q.        
Okay.  And how is that 
helpful assisting with the clotting?

 
 
A.        Well, 
when you bleed, you don't just bleed red blood cells, you bleed  in our society 
today we don't transfuse whole blood, except for in the military.  But when you bleed, you bleed whole 
blood; so we fractionate it into a variety of product, red blood cells, 
platelets, white cells, fresh frozen plasma.

 
 
There's 
a variety of factors, even down to specific clotting factors to, say, a 
hemophiliac is in need of.  And 
those clotting factors are important just as actually transfusing the red blood 
cells.

 
 
In 
general, when you give the Cell Saver blood back, that's really all you're 
getting back.  It cleanses a lot of 
stuff out, but I don't know how much of the clotting factors it cleanses 
out.

 
 
Q.        So 
clotting factors are important to survival?

 
 
A.        
Yes.

 
 
*  *  
*  *

 
 
Q.        
Okay.  In this case there was 
a splenic injury and apparently a splenic laceration and significant bleeding, 
correct?

 
 
A.        
Yes.

 
 
Q.        
Typically are splenic injuries fatal?

 
 
A.        Can 
be.  I had a patient die this year, 
so Mr. Williams is not the only one.

 
 
Q.        What 
percentage of splenic ruptures survive?

 
 
A.        I 
don't know.

 
 
Q.        Is 
there a high percentage of them that survive?

 
 
A.        I 
think that that would be a difficult question to answer; because if you have an 
isolated splenic injury, that's different than if you have constellation of 
injuries that  in total.

 
 
In 
general, what we do when you're looking at survivability is you look at an 
injury severity score, and that takes into account not just the main injury but 
also other complicating factors.  
And an isolated splenic injury in an 18-year-old is a lot  has a higher 
probability of survival than an isolated splenic injury in a 57 (sic) 
-year-old.

 
 
So 
it's not . . . apples to apples.

 
 
*  *  
*  *

 
 
Q.        
Okay.  In this case, if you'd 
been able to use whatever blood products you wanted to, would it have increased 
the likelihood of survival?

 
 
A.        I 
think it would have increased the likelihood of survival.  I could not have guaranteed 
survival.

 
 
*  *  
*  *

 
 
Q.        The 
failure to use blood products or the allowance to use whatever blood products 
you wanted to imperiled recovery?

 
 
*  *  
*  *

 
 
A.        I've 
said it affected my management, you know; but it's difficult to say  and I've 
said this again  that it changed management of this 
patient.

 
 
My 
inability to use blood products in management of this patient, whether it be 
before surgery, during surgery or after  it affected my management throughout 
the duration.

 
 
But 
I can't say  I can't say for certain had I used them postoperatively that he 
would have survived, even if the family would have changed their mind.  I don't know that he would have 
survived.

 
 
Q.        Well, 
let me ask you this:  It changed 
your management, you would have used a different protocol; and just so I'm 
clear, that's not  when you say it changed your management, it doesn't just 
mean that it might have made it more difficult to you or changed what you did, 
it changed your management in the sense that you didn't utilize what you would 
have otherwise considered optimal in terms of promoting recovery, 
correct?

 
 
A.        I 
would have changed the timing of surgery.  
I probably would not have gotten all the CT scans, but I had time to do 
so because we were waiting on the son.  
And I would have taken him probably more directly to surgery, and I 
probably would have continued to use blood products throughout his course, 
whatever laboratory backup, you know, would have given me as to, you know, if 
the clotting factors are off or if platelet counts are low.  I would have transfused those 
units.

 
 
But 
it was, like I said, a fork in the road.  
I went down a different fork, managed it the way that the patient 
requested, which is absolutely within his right.

 
 
Q.        I 
understand that you went down a less optimal fork.

 
 
A.        I 
don't know that it's less optimal, because it is  it is absolutely within his 
right to make these decisions and 

 
 
Q.        I 
understand, Doctor.  And we're 
getting tied up in philosophical issues.  
I just want it to be physiological.

 
 
A.        I'm 
just saying it's not the way that a non-Jehovah's Witness patient is managed. 
 I would not have  the reason I 
managed the patient this way is because he requested that.

 
 
*  *  
*  *

 
 
Q.        
Okay.  A delay in surgery in 
a case like this reduces the likelihood of recovery, 
correct?

 
 
A.        By 
"recovery," you mean survival?

 
 
Q.        
Survival.

 
 
A.        I 
think any delays in the field, delays to the operating room, delay to surgery  
I think that it obviously affects survival.

 
 
Q.        
Reduces the likelihood?

 
 
A.        
Yes.

 
 
Q.        
Okay.  And the inability to 
transfuse, to use blood products, reduced the likelihood of survival in this 
case, correct?

 
 
A.        I 
think that that would have benefitted him, yes.  Using blood products would have 
benefitted him.

 
 
Q.        
Okay.  So it reduced the 
likelihood of survival?

 
 
A.        
Yes.

 
 
*  *  
*  *

 
 
Q.        
.  .  .  
by how much?

 
 
A.        I 
don't know that I could ever quantify that, and I've said that 
before.

 
 
I 
think that I could not have guaranteed survival with an elderly gentlemen like 
this with the fairly long transport time that he had, because I think he was out 
on I-80, if I remember correctly.  
It was kind of a long period of time.

 
 
He 
presented hypotensive.  He had 
already bled quite a bit.  I don't 
know that this entire process would have been reversible; but I agree with your 
statement that his odds of survival would have improved had I had all the arrows 
in my quiver, but I didn't.  

 
 
[¶12]   In his Findings of Fact, 
Conclusions of Law and Order rendered on December 20, 2006, the hearing examiner 
reversed the Division's denial of Mrs. Williams' claim for benefits.3  The hearing examiner 
found:

 
 
36.       Mrs. 
Williams has proved that Mr. Williams suffered an "injury" as it is defined in 
Wyo. Stat. Ann. § 27-14-102(a)(xi) (Lexis[Nexis] 2005). Furthermore, Mrs. 
Williams has proved that there is a causal connection between Mr. Williams' 
injuries and his employment.  
According to the undisputed affidavit of Mr. Williams' son, who was also 
Mr. Williams' employer, Mr. Williams was traveling for his employment as a 
maintenance technician and was being reimbursed for his travel expenses when the 
motor vehicle accident occurred.  
The medical reports indicate Mr. Williams' injuries were caused by the 
motor vehicle accident.

 
 
37.       The 
Division's Final Determination denying benefits because Mr. Williams' "cause of 
death was due to refusal of reasonable and necessary medical care" is not 
supported by the evidence.  Dr. 
Parnell testified in her deposition she could not guarantee Mr. Williams would 
have survived if she had been able to use blood products and if she could have 
gotten him to surgery sooner.  The 
evidence demonstrates Mr. Williams' spleen was lacerated during his work-related 
car accident and his lacerated spleen was the cause of his massive blood loss 
and subsequent death.  

 
 
[¶13]   The hearing examiner, however, 
ultimately determined Mrs. Williams was not entitled to benefits, agreeing with 
the Division that Mr. Williams had forfeited all right to worker's compensation 
benefits by refusing to allow the use of foreign blood products to treat his 
splenic injury:

 
 
39.       The 
Division has proved, by a preponderance of the evidence, that Mr. Williams 
"refused to submit to medical or surgical treatment reasonably essential to 
promote his recovery."  The medical 
reports indicate that Mr. Williams was alert enough to converse with Dr. Parnell 
when he came into the emergency room.  
The reports are undisputed that Mr. Williams told Dr. Parnell that he did 
not want any blood products and that Dr. Parnell should wait until his son 
arrived before using the Cell Saver. . . . Therefore, Mr. Williams clearly 
"refused to submit to medical or surgical treatment."  Although Dr. Parnell never stated or 
noted that the use of blood products were "reasonably essential to promote [Mr. 
Williams'] recovery," Dr. Parnell's deposition testimony and consultation report 
disclose the essential nature of blood products in treating Mr. William's [sic] 
injury.  In her Consultation Report, 
Dr. Parnell reveals the importance of the use of blood products when she 
described her conversation with Williams' son:  "I spoke quite frankly that the decision 
not to allow any blood products including whole blood, packed red blood cells, 
plasma, and/or platelets, cryoprecipitate, etc, may indeed make it very 
difficult to resuscitate and manage the patient." . . . In addition, Dr. Parnell 
stated in her deposition testimony, she would have used blood products if she 
had been permitted, the use of blood products would have benefited and assisted 
Mr. Williams and it would have increased Mr. Williams' likelihood for 
survival.  Dr. Parnell put it quite 
succinctly when she stated, "I agree with your statement that his odds of 
survival would have improved had I had all the arrows in my quiver."  The importance of treating Mr. Williams' 
injury with blood products is also demonstrated by Dr. Brausch's Consultation 
Report which states, "[w]e are all afraid that the patient is dying and we have 
used the resources we are allowed to use to their fullest 
extent."

 
 
40.       Although 
this case falls more squarely within the second prong of Wyo. Stat. [Ann.] § 
27-14-407 (Lexis[Nexis] 2005)  a refusal to submit to reasonably essential 
medical or surgical treatment  the facts also support a conclusion that Mr. 
Williams knowingly engaged in an injurious practice which tended to imperil or 
retard his recovery, the first prong of the statute.  The Wyoming Supreme Court stated, "[t]he 
unambiguous language of § 27-14-407 requires that a showing be made that an 
employee has engaged in some action or activity which tends' to impact his 
recovery."  [Celotex Corp. v.] Andren, 917 P.2d [178,] 181 [Wyo. 
1996)].  Mr. Williams' knowing 
refusal to allow blood products was an "action" which tended to impact his 
recovery.  According to Dr. Parnell, 
that action decreased his chances for survival.  A refusal or failure to take action may 
amount to an injurious practice.  Hanberg [v. World Wide Construction], 741 P.2d 
[107,] 108 [(Wyo. 1987)] (failure to report to court-ordered alcohol rehab was 
an injurious practice).  

 
 
41.       Mr. 
Williams forfeited all right to compensation under the Worker's Compensation Act 
because his refusal to allow the use of blood products to treat his lacerated 
spleen was, (1) an injurious practice tending to impact his recovery, and (2) a 
refusal to submit to medical or surgical treatment reasonably essential to 
promote his recovery.

 
 
[¶14]   Mrs. Williams disagreed with the 
hearing examiner's decision and sought review by the district court.  The district court certified the matter 
to this Court, which we accepted pursuant to W.R.A.P. 
12.09(b).

 
 

STANDARD 
OF REVIEW

 
 
[¶15]   The scope of our review of 
administrative agency decisions is governed by Wyo. Stat. Ann. § 16-3-114(c) 
(LexisNexis 2007), which provides in pertinent part:

 
 
(c)  To the extent necessary to make a 
decision and when presented, the reviewing court shall decide all relevant 
questions of law, interpret constitutional and statutory provisions, and 
determine the meaning or applicability of the terms of an agency action. In 
making the following determinations, the court shall review the whole record or 
those parts of it cited by a party and due account shall be taken of the rule of 
prejudicial error. The reviewing court shall: 

 

                                    
*  *  *  
*

 
 
(ii)  Hold unlawful and set aside agency 
action, findings and conclusions found to be: 

 

(A)  Arbitrary, capricious, an abuse of 
discretion or otherwise not in accordance with law; 

 

(B)  Contrary to constitutional right, power, 
privilege or immunity; 

 

(C)  In excess of statutory jurisdiction, 
authority or limitations or lacking statutory right; 

 

(D)  Without observance of procedure required 
by law; or 

 

(E)  Unsupported by substantial evidence in a 
case reviewed on the record of an agency hearing provided by 
statute.

 
 
[¶16]   We recently set forth the proper 
application of these standards in Dale v. 
S & S Builders, LLC, 2008 WY 84, ¶¶ 20-26, 188 P.3d 554, 560-62 (Wyo. 
2008).  In short, if the agency's 
finding favors the burdened party, as in this case, we must determine if 
substantial evidence exists to support that finding by "considering whether 
there is relevant evidence in the entire record which a reasonable mind might 
accept in support of the agency's conclusions."  Id., ¶ 22, 188 P.3d  at 561.  We review an agency's conclusions of law 
de novo, and will affirm only if they are in accordance with the law.  Id., ¶ 26, 188 P.3d  at 
561-62.

 
 

DISCUSSION

 
 

Constitutionality 
of § 27-14-407

 
 
[¶17]   Mrs. Williams' first argument 
challenges the constitutionality of § 27-14-407.  She claims the statute, as applied to 
Mr. Williams' refusal to accept blood products, violated his constitutionally 
protected right to the free exercise of religion.4  Mrs. Williams raised the same 
constitutional issue before the hearing examiner.  The hearing examiner correctly concluded 
that administrative agencies do not have the authority to determine the 
constitutionality of a statute.  

 
 
[¶18]   Procedurally, Mrs. Williams is 
barred from raising this constitutional claim in the context of this case.  The law is clear that administrative 
agencies have no authority to determine the constitutionality of a statute and 
that neither the district court nor this Court has jurisdiction on appeal of 
agency action to consider the issue.  
Escarcega v. State ex rel. Wyoming 
Dep't of Transportation, 2007 WY 38, ¶ 22, 153 P.3d 264, 270 (Wyo. 2007); Torres v. State ex rel., Wyoming Workers' 
Safety & Comp. Div., 2004 WY 92, ¶¶ 6-8, 95 P.3d 794, 795-96 (Wyo. 
2004); Billings v. Wyoming Bd. of 
Outfitters & Guides, 2001 WY 81, ¶ 41, 30 P.3d 557, 572 (Wyo. 2001); Dorr v. Wyoming Bd. of Certified Public 
Accountants, 2001 WY 37, ¶ 13, 21 P.3d 735, 742 (Wyo. 2001); Shryack v. Carr Constr. Co., Inc., 3 P.3d 850, 856 (Wyo. 2000); Riedel v. 
Anderson, 972 P.2d 586, 586-88 (Wyo. 1999).  This prohibition exists regardless of 
whether the question concerns "the constitutionality of the statute per se or 
the constitutionality of the statute as applied."  Escarcega, ¶ 22, 153 P.3d  at 270 
(quoting Riedel, 972 P.2d at 
587).  The proper avenue for 
challenging the constitutionality of a statute is an independent action for 
declaratory judgment pursuant to W.R.A.P. 12.12.  Id.; Torres, ¶ 8, 95 P.3d  at 796; Riedel, 972 P.2d  at 587.  Because the issue is not properly before 
us, we will not address Mrs. Williams' argument.

 
 
Substantial 
evidence

 
 
[¶19]   The parties present many 
interesting questions but our resolution of the instant case requires analysis 
of only one question.  The decisive 
question in the instant case is whether the hearing examiner's determination 
that Mr. Williams' decisions ran afoul of § 27-14-407 is supported by 
substantial evidence viewed in light of the record as a whole.  We find the record evidence does not 
adequately support such a determination.  
Section 27-14-407, in pertinent part, reads:

 
 
If 
an injured employee knowingly engages or persists in an unsanitary or injurious 
practice which tends to imperil or retard his recovery, or if he refuses to 
submit to medical or surgical treatment reasonably essential to promote his 
recovery, he forfeits all right to compensation under this 
act.

 
 
As 
a general observation, we have said that the forfeiture statute "states a rule 
in regard to avoidable consequences.  
It was intended to prevent compensation for disability resulting from 
unreasonable conduct of the injured workman."  Stanolind Oil & Gas Co. v. Harvey, 
52 Wyo. 349, 356, 75 P.2d 1, 2 (1938) (referring to the substantially similar 
precursor to the current statute).  
It is the Division's burden to prove a claimant has forfeited his 
benefits under this statute.  See Celotex Corp. v. Andren, 917 P.2d 178, 180 (Wyo. 1996); Kilburn Tire v. 
Meredith, 743 P.2d 874, 876 (Wyo. 1987); Stanolind Oil, 52 Wyo. at 356, 75 P.2d  
at 2.

 
 
[¶20]   By this statute, the legislature 
has established two forms of conduct by which a claimant forfeits 
compensation.  First, compensation 
is forfeited if a claimant "engages or persists in an unsanitary or injurious 
practice which tends to imperil or retard his recovery."  Second, compensation is forfeited if a 
claimant "refuses to submit to medical or surgical treatment reasonably 
essential to promote his recovery."  
In the instant case, the hearing examiner determined Mr. Williams had 
engaged in both forms of conduct by "his refusal to allow the use of blood 
products to treat his lacerated spleen."

 
 
[¶21]   In order to work a forfeiture of 
benefits for engaging or persisting in an unsanitary or injurious practice which 
tends to imperil or retard his recovery:

 
 
proof 
of more than a mere possibility is required . . . . We caution that more is 
required than proof of a mere potential for harm or a possibility of harm;  there must be proof that the worker's 
acts were not benign, but did, in some way, contribute to recovery 
problems.  

 
 

State 
ex rel. Wyoming Workers' Comp. Div. v. Bergeron, 
948 P.2d 1367, 1370 (Wyo. 1997).  
The proof in the instant case does not rise beyond a suggestion of the 
possibility of harm by the refusal to allow the use of foreign blood 
products.  The critical evidence is 
Dr. Parnell's testimony.   
While she testified Mr. Williams would have had a better chance of 
survival with a transfusion of appropriate blood products, she never quantified 
his chance of survival in either event.  
Indeed, she repeatedly testified that she could not say whether Mr. 
Williams would have survived had blood products been transfused.  For example, she testified Mr. Williams' 
injuries "could be fatal, despite our best efforts" and opined "whether or not 
he would have survived with or without blood products, I don't know that I can 
say."  This testimony does not 
support a determination that Mr. Williams engaged in a practice that, in some 
way, contributed to his demise.

 
 
[¶22]   For the same evidentiary reasons, 
the hearing examiner's determination that Mr. Williams refused to submit to 
medical or surgical treatment reasonably essential to promote his recovery also 
fails.  The evidence in the record 
portrays a situation where Mr. Williams was critically injured and did not 
arrive at the hospital for an extended period of time.  He had already lost a great deal of 
blood by the time he reached the hospital.  
He ultimately died.  Dr. 
Parnell could not say that "this entire process would have been 
reversible."  Therefore, under the 
specific facts of this case, the acceptance of the transfusion of blood products 
cannot be deemed to be "reasonably essential" to Mr. Williams' survival.  

 
 
CONCLUSION

 
 
[¶23]   The constitutionality of § 
27-14-407 is not properly before this Court.  As for the evidentiary issue, the 
Division needed to present positive evidence that Mr. Williams failed to survive 
because of his refusal to accept foreign blood products.  It did not do so.  The determination granting forfeiture of 
benefits is reversed.  We remand the 
case to the district court with instructions that it reverse the order of the 
Office of Administrative Hearings and enter its order that the Division award 
the applicable death benefits to Mrs. Williams.

 
 
FOOTNOTES

 
 

1According to CCM's president, Howard Williams, also the Williamses' son, 
it was customary for CCM's maintenance technicians to use their personal 
vehicles when performing work outside of Cheyenne, and it was customary for Mr. 
and Mrs. Williams to travel together and share the driving when Mr. Williams 
journeyed out of Cheyenne to perform maintenance services.  

 
 

2Cell Saver is the process of taking the "patient's own shed blood, 
cleaning it, processing it and then retransfusing it into the patient."  

 
 

3The Division has not challenged this ruling on 
appeal.

 
 

4The Watchtower Bible and Tract Society of New York, Inc., having sought 
and obtained permission to participate in this case as amicus curiae, also 
endeavored to challenge the constitutionality of the statute  as applied to Mr. Williams' refusal to 
accept blood products. 

 
 

VOIGT, 
Chief Justice, 
dissenting.

 
 
[¶24]   I respectfully dissent.  The underlying facts are not in dispute, 
and there is not even a question as to whether the employee refused to submit to 
medical or surgical treatment.  Of 
course he did.  The only question is 
whether the treatment he refused was "reasonably essential to promote his 
recovery."1  While the treating physician 
understandably was not willing to say that the employee's refusal to accept 
blood products, and his delay of surgery until his son's arrival, were the 
difference between life and death, she said everything just short of that.  In that regard, it must be remembered 
that the statutory test, established by the legislature as the test to be 
applied in these situations, is not whether the refused treatment would have 
saved the employee's life.  Rather, 
the test is, as just stated, whether the refused treatment was "reasonably 
essential to promote his recovery."

 
 
[¶25]   I will not repeat at length the 
portions of Dr. Parnell's medical reports and testimony set forth in the 
majority opinion, but will note a few points that I believe clearly show that 
the refused treatment was just what the statute has in mind.  Dr. Parnell's initial impressions 
included the observation that the employee "obviously" was suffering from "free 
intraabdominal bleeding."  Dr. 
Parnell told the employee's son upon his eventual arrival that "the decision not 
to allow blood products, including whole blood, packed red blood cells, plasma, 
and/or platelets, cryoprecipitate, etc, may indeed make it very difficult to 
resuscitate and manage [the employee]."  
Because she was limited to the use of Cell Saver, Dr. Parnell was able to 
re-transfuse only two liters of the employee's blood, even though he had massive 
intraabdominal bleeding and had lost five liters of blood.  It was Dr. Parnell's opinion that the 
employee essentially bled to death. 

 
 
[¶26]   Dr. Parnell's deposition testimony 
contains the following colloquies:

 
 
. 
. . .

 
 
            
Q.  Okay.  In this case, if you'd been able to use 
whatever blood products you wanted to, would it have increased the likelihood of 
survival?

 
 
            
A.  I think it would have 
increased the likelihood of survival.  
I could not have guaranteed survival.

 
 
 
 
. 
. . .

 
 
            
Q.  Well, let me ask you 
this:  It changed your management, 
you would have used a different protocol; and just so I'm clear, that's not  
when you say it changed your management, it doesn't just mean that it might have 
made it more difficult to you or changed what you did, it changed your 
management in the sense that you didn't utilize what you would have otherwise 
considered optimal in terms of promoting recovery, 
correct?

 
 
            
A.  I would have changed the 
timing of surgery.  I probably would 
not have gotten all the CT scans, but I had time to do so because we were 
waiting on the son.  And I would 
have taken him probably more directly to surgery, and I probably would have 
continued to use blood products throughout his course, whatever laboratory 
backup, you know, would have given me as to, you know, if the clotting factors 
are off or if platelet counts are low.  
I would have transfused those units.

 
 
            
But it was, like I said, a fork in the road.  I went down a different fork, managed it 
the way that the patient requested, which is absolutely his 
right.

 
 
. 
. . .

 
 
            
Q.  Okay.  And the inability to transfuse, to use 
blood products, reduced the likelihood of survival in this case, 
correct?

 
 
            
A.  I think that that would 
have benefitted him, yes.  Using 
blood products would have benefitted him.

 
 
            
Q.  Okay.  So it reduced the likelihood of 
survival?

 
 
            
A.  
Yes.

 
 
. 
. . .

 
 
            
Q.  . . . by how 
much?

 
 
            
A.  I don't know that I could 
ever quantify that, and I've said that before.

 
 
            
I think that I could not have guaranteed survival with an elderly 
gentleman like this with the fairly long transport time that he had, because I 
think he was out on I-80, if I remember correctly.  It was kind of a long period of 
time.

 
 
            
He presented hypotensive.  He 
had already bled quite a bit.  I 
don't know that this entire process would have been reversible; but I agree with 
your statement that his odds of survival would have improved had I had all the 
arrows in my quiver, but I didn't.

 
 
[¶27]   Dr. Parnell's observations were 
corroborated by Dr. Brausch, who provided a consultation at Dr. Parnell's 
request.  Dr. Brausch indicated the 
following in her report:

 
 
This 
is a 67-year-old male status post motor vehicle accident who sustained a severe 
splenic injury and very significant blood loss.  This severe hemorrhage, we are not able 
to replace with blood products and replacing at this point with saline, albumin 
and even hetastarch is not helping this patient.  We have him on high doses of both 
Norepinephrine and Dopamine in addition to rapid infusion of IV fluids without 
benefit.  He has received calcium 
times two and bicarbonate times three.  
We are all afraid that the patient is dying and we have used the 
resources we are allowed to use to their fullest extent.

 
 
[¶28]   Admittedly, these snippets are 
taken from the larger context of the entire record, but there is sufficient 
evidence here from which the hearing examiner could determine that blood product 
treatment and immediate surgery were reasonably essential to promote the 
employee's recovery.  When Dr. 
Parnell took the fork in the road mandated by the employee and his son, she 
clearly took the road less traveled.  
I would affirm the decision of the hearing 
examiner.

 
 
FOOTNOTES

 
 

1The hearing examiner also concluded that the employee engaged in an 
injurious practice tending to impact his recovery, which is the first-stated 
test for forfeiture of benefits under the statute.  While I agree that the employee's 
conduct also met this test, I believe these facts are more appropriately 
analyzed under the second-stated test of refusing to submit to medical or 
surgical treatment.