Title: Kimberly Schreiber v. Physicians Insurance Company of Wisconsin
Citation: N/A
Docket Number: 1996AP003676
State: Wisconsin
Issuer: Wisconsin Supreme Court
Date: January 26, 1999

SUPREME COURT OF WISCONSIN 
 
 
Case No.: 
96-3676 
 
 
Complete Title 
of Case: 
 
 
Kimberly Schreiber, a minor by her Guardian ad 
Litem, John Krueger; Gerald Schreiber and Janice 
Schreiber,  
 
Plaintiffs-Appellants, 
 
v. 
Physicians Insurance Company of Wisconsin; Paul 
K.H. Figge, Jr., M.D.; Wisconsin Patients 
Compensation Fund,  
 
Defendants-Respondents-Petitioners, 
State of Wisconsin and Employers Health  
Insurance Company,  
 
Defendants.  
 
ON REVIEW OF A DECISION OF THE COURT OF APPEALS 
Reported at:  217 Wis. 2d 94, 579 N.W.2d 730 
 
 
 
(Ct. App. 1998-Published) 
 
 
Opinion Filed: 
January 26, 1999 
Submitted on Briefs: 
 
Oral Argument: 
October 7, 1998 
 
 
Source of APPEAL 
 
COURT: 
Circuit 
 
COUNTY: 
Oneida  
 
JUDGE: 
James W. Karch 
 
 
JUSTICES: 
 
Concurred: 
 
 
Dissented: 
 
 
Not Participating:  
 
 
ATTORNEYS: 
For the defendants-respondents-petitioners there 
were briefs by Susan R. Tyndall and Hinshaw & Culbertson, 
Milwaukee and oral argument by Susan R Tyndall. 
 
 
For the plaintiffs-appellants there was a brief 
by D.J. Weis and Habush, Habush, Davis & Rottier, S.C., 
 
Rhinelander and oral argument by D.J. Weiss. 
 
 
Amicus curiae brief was filed by Lynn R. 
Laufenberg and Cannon & Dunphy, S.C., Brookfield for the 
Wisconsin Academy of Trial Lawyers. 
 
No.  96-3676 
 
 
1 
  
NOTICE 
This opinion is subject to further editing and 
modification.  The final version will appear in 
the bound volume of the official reports. 
 
 
No. 96-3676 
 
 
STATE OF WISCONSIN               :        
        
 
 
 
 
IN SUPREME COURT 
 
 
Kimberly Schreiber, a minor by her  
Guardian ad Litem, John Krueger; Gerald  
Schreiber and Janice Schreiber,  
 
          Plaintiffs-Appellants, 
 
     v. 
 
Physicians Insurance Company of  
Wisconsin; Paul K.H. Figge, Jr., M.D.;  
Wisconsin Patients Compensation Fund,  
 
          Defendants-Respondents- 
          Petitioners, 
 
State of Wisconsin and Employers Health  
Insurance Company,  
 
          Defendants.  
FILED 
 
JAN 26, 1999 
 
Marilyn L. Graves 
Clerk of Supreme Court 
Madison, WI 
 
 
 
 
 
REVIEW of a decision of the Court of Appeals.  Affirmed. 
¶1 
ANN WALSH BRADLEY, J.   The defendants, Physicians 
Insurance Company of Wisconsin ("Physicians Insurance"), Dr. 
Paul K.H. Figge, Jr., and Wisconsin Patients Compensation Fund, 
seek review of a published decision of the court of appeals that 
reversed the circuit court's dismissal of a suit brought by the 
plaintiffs Kimberly Schreiber and her parents, Janice and Gerald 
No.  96-3676 
 
 
2 
Schreiber.1  They allege that Figge violated Janice's right to 
informed consent by failing to again conduct an informed consent 
discussion after Janice withdrew her consent to a vaginal 
delivery while in labor.2  Because we determine that during her 
labor Janice withdrew her consent to a vaginal delivery and that 
at the time of her withdrawal there existed medically viable 
options 
for 
treatment, 
we 
conclude 
that 
her 
withdrawal 
constitutes a substantial change in circumstances requiring a 
new informed consent discussion.  Additionally, we determine 
that a subjective test should be applied to the question of 
whether Figge's failure to conduct another informed consent 
discussion 
was 
a 
cause 
of 
the 
Schreibers' 
injuries.  
Accordingly, we affirm the court of appeals. 
¶2 
The relevant facts are essentially undisputed.  This 
action stems from Janice Schreiber's labor and delivery of 
Kimberly Schreiber at Saint Mary's Hospital in Rhinelander, 
Wisconsin.  This was Janice's third pregnancy.  Figge served as 
Janice's obstetrician in all three of her pregnancies and 
delivered all three of her children.  Her first two children 
were delivered by way of cesarean sections.  Figge performed the 
first cesarean delivery in 1981 because after over 17 hours of 
labor Janice still had not progressed to a point where a vaginal 
                     
1 Schreiber v. Physicians Ins. Co., 217 Wis. 2d 94, 579 
N.W.2d 730 (Ct. App. 1998) (reversing judgment of Circuit Court 
for Oneida County, James W. Karch, Reserve Judge). 
2 Informed consent is codified at Wis. Stat. § 448.30 (1995-
96).  Unless otherwise noted, all further references to the 
Wisconsin Statutes will be to the 1995-96 version.  
No.  96-3676 
 
 
3 
delivery was possible.  At the time of Janice's second delivery 
in 1984, the prevailing medical practice followed the "once a 
cesarean always a cesarean" rule.  As a result, Janice had her 
second child by cesarean delivery.   
¶3 
By the time of her pregnancy with Kimberly in 1987, 
the prevailing medical research and practice suggested that 
having a vaginal birth after cesarean ("VBAC") was no more 
dangerous than having another cesarean delivery.  In some 
circumstances a VBAC presented less risk to the health of both 
the mother and child than did another cesarean delivery.  In the 
course of Janice's prenatal care she and Figge discussed a VBAC 
delivery as an alternative to another cesarean delivery.  Figge 
recommended attempting the VBAC and Janice agreed to that course 
of treatment.  Janice testified at trial that she was under the 
impression that she would first attempt the VBAC but could 
change her mind during labor and instead have another cesarean 
delivery.  Figge testified that he understood Janice's pre-labor 
choice of the VBAC to be decisive, meaning that once her labor 
began Kimberly would be delivered vaginally unless and until 
Janice's symptoms medically warranted a cesarean section.  
¶4 
As her delivery neared, Janice went into labor and was 
admitted into the hospital at approximately 4:00 a.m.  Janice 
signed consent forms for both a VBAC and cesarean delivery as 
part of her hospital admission.  Figge first visited Janice's 
hospital room at 8:00 a.m. to see how her labor was progressing. 
 At that 8:00 a.m. visit Janice told Figge that she had changed 
her mind and wanted to abandon her plan for a VBAC and instead 
No.  96-3676 
 
 
4 
have another cesarean delivery.  Figge urged Janice to continue 
with the VBAC.  At approximately 8:30 a.m., Figge concluded that 
Janice's labor was not progressing as he had hoped.  He then 
manually broke Janice's amniotic fluid sac in an effort to speed 
up the labor.  Janice thereafter began experiencing excruciating 
abdominal pains sharply different from her contractions and 
unlike anything she had experienced with her prior deliveries.  
Nurses attempted unsuccessfully to ease the pain with various 
medicines.  The pain was so unbearable that at one point Janice 
sent her husband to locate their nurse so that the nurse would 
again relay to Figge Janice's desire for a cesarean delivery. 
¶5 
Figge next checked on Janice at approximately 1:00 
p.m.  Again Janice complained of the abdominal pain.  Figge 
attempted to diagnose the source of the pain but could not 
determine conclusively that it was caused by either a uterine 
rupture or separation of the placenta from the wall of the 
uterus.  Figge concluded that the abdominal pains did not pose a 
danger to either Janice or Kimberly.  He based this diagnosis 
primarily on his experience of seeing other women in labor 
suffer from similar abdominal pains that disappeared after 
delivery. 
¶6 
Also at this 1:00 p.m. visit Janice again informed 
Figge that she wished to cease the VBAC and instead have another 
cesarean delivery.  Figge again instructed Janice to remain 
patient because he wanted to give the VBAC more time.  When 
Janice protested, again complained of the pain, and again 
requested a cesarean delivery, Figge tersely responded to the 
No.  96-3676 
 
 
5 
effect that if he performed a cesarean delivery on every woman 
who wanted one that all deliveries would be by cesarean section. 
¶7 
Janice later testified at trial that she was upset and 
intimidated by Figge's comment.  As a result, she did not again 
bring the issue of ceasing the VBAC to Figge's attention.  Figge 
later testified that he sensed no barrier between Janice and 
himself from that conversation.  He further testified that at 
the 1:00 p.m. visit he knew that Janice would have preferred to 
have a cesarean delivery but that he thought the better course 
of treatment was to continue with the VBAC.  Figge also 
testified that he would have acquiesced if Janice had further 
persisted in her requests for a cesarean delivery. 
¶8 
Janice's labor still did not progress as Figge would 
have liked.  At 2:00 p.m. Figge again visited Janice's room to 
check on her condition.  Figge again counseled Janice against 
the cesarean delivery and continued to advocate for continuing 
with the VBAC.  After Figge's earlier terse statement, Janice 
did not reiterate her desire for a cesarean section.  Figge 
interpreted her silence as her concurrence in continuing with 
the VBAC. 
¶9 
At 3:40 p.m. Kimberly's heart rate dropped.  Figge was 
summoned and performed an emergency cesarean section at just 
after 4:00 p.m.  It was too late.  Janice's uterus had ruptured 
depriving Kimberly of oxygen.  Kimberly was born a spastic 
quadriplegic and she cannot move below her neck or speak.  The 
parties have stipulated that had Kimberly been delivered prior 
to 3:29 p.m. she would have been born a healthy child. 
No.  96-3676 
 
 
6 
¶10 The Schreibers sued Figge and his insurer, alleging 
both that Figge was negligent in his misdiagnosis of Janice's 
abdominal pain and that he violated Janice's informed consent 
rights.  At some point in the litigation the Schreibers dropped 
their medical malpractice claim and proceeded to trial solely on 
the informed consent cause of action.   
¶11 After a trial to the court, the circuit court found 
that Janice made an informed consent to the VBAC prior to the 
beginning of her labor.  The circuit court also found that by 
the 8:00 a.m. meeting, Janice would have opted to discontinue 
the VBAC and instead have another cesarean delivery if Figge had 
offered her the choice.  Although she repeatedly communicated 
this preference to Figge, he did not comply with her request.  
He knew the cesarean delivery was a viable medical option but 
did not consider it to be medically indicated.  The circuit 
court held that Figge's duty was to manage Janice's labor in a 
way that would safely achieve the goal of delivery by VBAC upon 
the onset of labor. 
¶12 The circuit court further concluded that Figge was 
under no obligation to re-advise Janice of her medical options 
or seek new consent when her labor did not progress as planned. 
 The court reasoned that a doctor would only need to re-obtain 
consent 
when 
there 
was 
a 
substantial 
medical 
change 
in 
circumstances so that the patient faced risks unconsidered when 
the original consent was given.  The court determined that the 
risks Janice faced when her labor did not progress were no 
different than the risks she was made aware of when she 
No.  96-3676 
 
 
7 
originally gave her consent.  The circuit court concluded that 
there was no substantial change in circumstances and dismissed 
the Schreibers' case. 
¶13 The Schreibers appealed and contended that Janice's 
statements to Figge that she no longer wanted to continue with 
the VBAC were a withdrawal of her consent which triggered 
Figge's duty to have a new informed consent discussion.  A 
divided court of appeals reversed the circuit court and 
concluded that where two or more medically acceptable options 
for treatment are present, the "competent patient has the 
absolute right to select from among [those] treatment options 
after being informed of the relative risks and benefits of each 
approach."  Schreiber v. Physicians Ins. Co., 217 Wis. 2d 94, 
103, 579 N.W.2d 730 (Ct. App. 1998).  It grounded its holding 
both in the informed consent statute and the common law right of 
bodily integrity from which the statute is derived.  Id. at 103-
04.  The court of appeals determined that in order for the 
doctrine of informed consent to be effective, it must require a 
physician to do more than outline the methods of treatment 
available to a patient.  Informed consent must also bind the 
physician to follow the course of treatment chosen by the 
patient so long as that chosen treatment is medically viable.  
Id. at 105.   
¶14 The court of appeals reasoned that both the VBAC and 
cesarean delivery were viable medical options from the beginning 
of labor.  Janice at first chose the VBAC.  Some time into her 
labor she changed her mind and chose a cesarean delivery.  Thus, 
No.  96-3676 
 
 
8 
the court of appeals concluded that Figge violated Janice's 
informed consent right by refusing to follow her clearly 
communicated choice of treatment during labor.  Id. at 107.  
Figge and Physicians Insurance petitioned this court for review. 
  
¶15 Before delving into our analysis we first sound a 
cautionary note.  This opinion does not address controversial 
issues at each end of the medical spectrum.  Namely, this 
opinion should not be interpreted as creating a patient's right 
to demand any treatment she desires.  Further, this opinion 
should not be interpreted as requiring physicians to perform 
procedures they do not consider medically viable, procedures for 
which they lack the appropriate expertise, or procedures to 
which they are morally opposed.  Rather, this case is decided on 
narrow and discrete issues:  (1) Did Janice withdraw her 
consent; (2) if so, did that withdrawal together with the 
existence of viable medical options for treatment trigger 
Figge's duty under the informed consent statute to again discuss 
the benefits and risks of her medical options; and (3) if such a 
duty exists, should an objective or subjective test be applied 
to the question of whether Figge's failure to conduct another 
informed consent discussion caused the Schreibers' injuries? 
¶16 The issues present a mixed question of fact and law.  
We defer to the circuit court's findings of fact unless they are 
unsupported by the record and are therefore clearly erroneous.  
Clarmar Realty Co., Inc. v. City of Milwaukee Redevelopment 
Authority, 129 Wis. 2d 81, 94, 383 N.W.2d 890 (1986); Wis. Stat. 
No.  96-3676 
 
 
9 
§ 805.17(2).  However, the application of those facts to the 
pertinent law is a question of law which we review independently 
of the determinations rendered by the court of appeals and 
circuit court but benefiting from their analyses.  Miller v. 
Thomack, 210 Wis. 2d 650, 658, 563 N.W.2d 891 (1997). 
¶17 The doctrine of informed consent traces its origins to 
the common law notion that an adult has a "right to determine 
what shall be done with his own body . . . ."  Schloendorff v. 
Society of New York Hospital, 105 N.E. 92, 93 (N.Y. 1914), 
overruled on other grounds, Bing v. Thunig, 143 N.E.2d 3 (N.Y. 
1957).  Originally founded on the common law tort of assault and 
battery, see Paulsen v. Gundersen, 218 Wis. 578, 584, 260 N.W. 
448 (1935), the limitations of that theoretical framework became 
apparent with the passage of time.  Trogun v. Fruchtman, 58 
Wis. 2d 569, 598-99, 207 N.W.2d 297 (1973).  Namely, a doctor's 
performance of an unauthorized treatment did not intuitively 
coincide with the "intentional, antisocial nature of battery" 
nor did it adequately reflect the fact that patients "consent" 
on some level whenever they see a doctor.  Martin v. Richards, 
192 Wis. 2d 156, 171, 531 N.W.2d 70 (1995).  As a result, 
negligence—the doctor's failure to exercise reasonable care to a 
patient—replaced 
intentional 
battery 
as 
the 
theoretical 
underpinning for the doctrine.  Id.   
¶18 Over twenty years ago this court gave shape to the 
doctrine as it currently exists in Wisconsin.  Scaria v. St. 
Paul Fire & Marine Ins. Co., 68 Wis. 2d 1, 227 N.W.2d 647 
(1975).  In light of the fundamental purpose driving the 
No.  96-3676 
 
 
10
doctrine, we concluded that a physician's duty to reveal the 
risks and benefits of available treatment options extended to 
the information a reasonable patient would need to know in order 
to make an informed decision.  Id. at 12-13.  We stressed that 
physicians were not required to disclose absolutely every fact 
or remote possibility that could theoretically accompany a 
procedure.  Rather, the touchstone of the test was what the 
reasonable person in the position of the patient would want to 
know.  Id. at 13.   
¶19 Within a few years after we decided Scaria, the 
legislature codified Scaria's test as Wis. Stat. § 448.30.3  The 
statute requires physicians to disclose information to patients 
about the viable medical modes of treatment so that when the 
patient chooses a method of treatment, that choice is made 
                     
3 448.30 Information on alternate modes of treatment.  Any 
physician who treats a patient shall inform the patient about 
the availability of all alternate, viable medical modes of 
treatment and about the benefits and risks of these treatments. 
The physician's duty to inform the patient under this section 
does not require disclosure of: 
(1) 
Information 
beyond 
what 
a 
reasonably 
well-
qualified 
physician 
in 
a 
similar 
medical 
classification would know. 
(2) 
Detailed 
technical 
information 
that 
in 
all 
probability a patient would not understand. 
(3) Risks apparent or known to the patient. 
(4) Extremely remote possibilities that might falsely 
or detrimentally alarm the patient. 
(5) 
Information in 
emergencies where 
failure to 
provide treatment would be more harmful to the patient 
than treatment. 
(6) 
Information 
in 
cases 
where 
the 
patient 
is 
incapable of consenting. 
No.  96-3676 
 
 
11
knowing both the reasonable risks and benefits of her decision. 
  
¶20 There is no question on appeal that prior to Janice's 
labor, Figge satisfied the requirements of the informed consent 
statute.  That issue was contested at trial and was resolved in 
favor of Figge.  The Schreibers do not challenge that finding on 
appeal.  Were that the whole of the story, this case would not 
have come before this court.  The Schreibers argue that after 
Janice's 
initial 
consent 
but 
before 
Kimberly's 
birth 
a 
substantial change of circumstances occurred that nullified the 
original consent and obligated Figge to again have an informed 
consent discussion with Janice.  That substantial change of 
circumstances was Janice's withdrawal of her consent where 
another medically viable option existed. 
¶21 There is little doubt that consent, once given, is not 
categorically immutable.  See Mack v. Mack, 618 A.2d 744 (Md. 
1993) ("a corollary to [informed consent] is the patient's 
right, in general, to refuse treatment and to withdraw consent 
to treatment once begun").  If we determine as a matter of fact 
that consent was withdrawn, we must also determine as a matter 
of law whether consent can be withdrawn at this particular stage 
of the procedure. 
¶22 The circuit court concluded that Janice initially 
agreed to the VBAC and that once labor began she could not 
change her decision unless there was a substantial change in 
medical circumstances.  It is undisputed that during her labor 
Janice told Figge on three separate occasions that she wanted to 
No.  96-3676 
 
 
12
cease the VBAC and have a cesarean delivery.  Moreover, Janice 
sent her husband to tell the nurse to relay the message to Figge 
yet another time.  Though she never said the magic words, "I 
revoke" we conclude that her repeated statements are a clear 
indication of her withdrawal of consent.  The circuit court 
thought likewise, concluding that if Figge had put the "choice 
to her squarely," she would have chosen the cesarean.  Even 
Figge recognized that Janice no longer desired to continue with 
the VBAC.  He testified that he would have done the cesarean 
section had Janice persisted.4  We are unsure, after three 
unsuccessful personal attempts and a fourth unsuccessful attempt 
through the nurse, how much more Janice could have done to 
convince Figge.   
¶23 Regardless of whether she factually withdrew her 
consent, the circuit court concluded that once a procedure has 
been initiated the time for a decision and discussions relating 
to that decision has passed.  We reject the notion that the 
                     
4 Figge's testimony on cross-examination was as follows: 
Q. 
[A]s a hypothetical matter, if after [Figge 
discussed the matter with Janice,] Mrs. Schreiber had 
refused your recommendation, your recommendation being 
[to continue the VBAC], if there would have been a 
refusal to accept what you were recommending to the 
patient, Doctor, and a demand made at that point for 
repeat cesarean, what would you have done? 
 
A. 
Well, like I said, I would still have tried to 
encourage her to proceed, but, you know, if I wasn't 
able to convince her so that she would be comfortable 
proceeding and persisted, I think I would have to –
probably have to go along with that request, but I 
have never had that situation. 
No.  96-3676 
 
 
13
onset of a procedure categorically forecloses a patient's 
withdrawal of consent.  To be sure, at some point in virtually 
every medical procedure a patient reaches a point from which 
there is no return.  However, that point need not be arbitrarily 
created at the commencement of treatment.  Rather it varies with 
the nature and circumstances of the individual procedure and 
continues so long as there exist alternative viable modes of 
medical treatment.  
¶24 In this case, a cesarean delivery at all times 
remained a viable medical alternative to the VBAC and ultimately 
that is how Figge delivered Kimberly.  Unlike the circuit court, 
we determine that since alternative viable modes of medical 
treatment existed, Janice was still able to withdraw her consent 
to the VBAC. 
¶25 Having determined 
that Janice had 
withdrawn her 
consent to the VBAC, we must now examine the effect, if any, of 
that withdrawal.  The Schreibers contend that her withdrawal 
both removed Figge's authority to continue with the VBAC and 
obligated him to conduct another informed consent discussion.  
We agree. 
¶26 In considering Figge's authority to continue with the 
VBAC, we note well-settled law provides that a physician, absent 
exigent circumstances, may not perform a procedure on a 
competent adult without consent.  See, e.g., Lojuk v. Quandt, 
706 F.2d 1456, 1460 (7th Cir. 1983) (applying Illinois law); see 
also In the Matter of Guardianship of L.W., 167 Wis. 2d 53, 68, 
482 N.W.2d 60 (1992) ("The logical corollary of the doctrine of 
No.  96-3676 
 
 
14
informed consent is the right not to consent—the right to refuse 
treatment."); Paulsen, 218 Wis. at 583-84.  Figge would not 
assert that absent Janice's consent to the VBAC he would 
nonetheless be authorized to attempt the procedure.  The 
function of withdrawal, in effect, places Janice and Figge in 
their original position—a physician, a patient, and a series of 
options for treatment.  It creates a blank slate on which the 
parties must again diagram their plan.   
¶27 Since Figge no longer had consent to continue with the 
VBAC we are persuaded that Janice's withdrawal obligated Figge 
under the statute to again have an informed consent discussion 
with her.  The circuit court reasoned that the physician's duty 
to again conduct an informed consent discussion occurred only if 
the medical circumstances were so changed as to alter the risks 
a patient faced from the time he or she first consented.  Though 
not cited by the circuit court, this is essentially the position 
taken by the Colorado Supreme Court in Gorab v. Zook, 943 P.2d 
423, 430-31 (Colo. 1997). 
¶28 In Gorab, the Colorado Supreme Court concluded that, 
under Colorado law, a physician has no general duty to continue 
to explain the treatment options and their corresponding risks 
once the physician obtains consent and begins the procedure.  
Id. at 430.  However, the Colorado court noted that "where a 
new, previously undisclosed, and substantial risk arises, there 
may be an additional and independent duty to warn" the patient 
of that risk.  Id.  The Gorab court, much like the circuit court 
in this case, concluded that because any risks the patient faced 
No.  96-3676 
 
 
15
during the procedure were risks previously disclosed, the 
physician was not under a duty to conduct another informed 
consent discussion. 
¶29 As a general principle, we find Gorab's and the 
circuit court's rationale convincing.  If a patient consents to 
a procedure knowing the risks, the physician has satisfied his 
or her duty under the informed consent statute.  We conclude, 
however, the circuit court erred in its determination of what 
could constitute a substantial change of circumstances.  The 
circuit court only considered medical changes of circumstances. 
 We conclude that it needed to consider legal changes of 
circumstances as well.  A withdrawal of consent during the 
course of treatment to the treatment agreed upon before 
treatment constitutes a substantial change in circumstances 
triggering a physician's duty under the informed consent statute 
to re-advise the patient of the available treatment options and 
their risks. 
¶30 Either a substantial medical or substantial legal 
change of circumstances results in an alteration of the universe 
of options a patient has and alters the agreed upon course of 
navigation through that universe.  Where the change is medical, 
the alteration is a new risk or benefit previously unforeseen.  
Where the change is legal, the alteration is a withdrawal of an 
option previously foreseen.  Though these cases travel from 
different directions, they arrive at the same destination:  a 
new informed consent discussion.  This discussion, much like any 
other such discussion, would have entailed the risks and 
No.  96-3676 
 
 
16
benefits at that time of the medically viable modes of treatment 
and again presented her an opportunity to choose her treatment.  
¶31 This conclusion does not alter the principles of 
informed consent.  Rather it more fully articulates those 
principles by applying the doctrine in a factual context we have 
previously not faced.  Our cases to date have only dealt with 
the initial adequacy of the informed consent discussion.  See, 
e.g., Johnson v. Kokemoor, 199 Wis. 2d 615, 545 N.W.2d 495 
(1996) (informed consent discussion before the procedure did not 
adequately inform the patient of morbidity rates and the 
physician's lack of experience in performing the procedure); 
Martin, 192 Wis. 2d at 167-69 (the informed consent discussion 
did not reveal the availability of a CT scanner and the 
unavailability of a neurosurgeon at the particular hospital); 
Scaria, 68 Wis. 2d at 3-9 (the informed consent discussion 
failed to inform patient that dye used for x-rays could cause 
paralysis or death); Trogun, 58 Wis. 2d at 592-604 (the informed 
consent discussion failed to explain potential side effects of 
drug for tuberculosis). 
¶32 This 
case, 
however, 
asks 
us 
to 
determine 
the 
continuing vitality of an informed consent discussion.  We 
decline to view the informed consent discussion as a solitary 
and blanketing event, a point on a timeline after which such 
discussions are no longer needed because they are "covered" by 
some articulable occurrence in the past.  Rather, a substantial 
change in circumstances, be it medical or legal, requires a new 
informed consent discussion.  See, e.g., Paulsen, 218 Wis. at 
No.  96-3676 
 
 
17
583-84 (consent for "simple" mastoid operation not sufficient 
for "radical" version of the same operation).  To conclude 
otherwise would allow a solitary informed consent discussion to 
immunize a physician for any and all subsequent treatment of 
that patient.  
¶33 Consistent with Wis. Stat. § 448.30 Figge had a duty 
to conduct another informed consent discussion and should have 
again presented Janice her treatment options and given her the 
opportunity to choose.  His failure to do so was a violation of 
that duty. 
¶34 As with any negligence action, a party must show the 
breach of a duty that caused an injury.  Having determined that 
Figge breached his duty under the informed consent statute, we 
now turn to whether the circuit court erred in applying an 
objective test to the question of whether Figge's failure to 
again conduct an informed consent discussion was a cause of the 
Schreibers' injuries.  See Martin, 192 Wis. 2d at 182. 
¶35 Since at least Scaria, this court has agreed with the 
majority of American jurisdictions in employing what is known as 
the "objective test."  Scaria, 68 Wis. 2d at 12-15.  The 
objective test focuses on what the attitudes and actions of the 
reasonable person in the position of the patient would have been 
rather than on what the attitudes and actions of the particular 
patient of the litigation actually were.  It asks two questions. 
 First, did the physician fail to give information that a 
reasonable patient would want to know?  Kokemoor, 199 Wis. 2d at 
632.  Second, given the additional information, would the 
No.  96-3676 
 
 
18
reasonable patient have acted differently than they did without 
the information?  Martin, 192 Wis. 2d at 182.  
¶36 We adopted this objective test because it is more 
amenable to the adverse nature of litigation.  Litigation rarely 
occurs in the absence of injury.  With this in mind, we have 
concluded that the objective test is more "workable and more 
fair" than asking the fact finder to determine the question of 
liability in large part on the credibility of a plaintiff whose 
testimony is tempered by the occasion of an undesirable event.  
Scaria, 68 Wis. 2d at 15; Canterbury v. Spence, 464 F.2d 772, 
791 (D.C. Cir. 1972) ("[The subjective test] calls for a 
subjective determination solely on testimony of a patient-
witness shadowed by the occurrence of the undisclosed risk.").  
¶37 We reaffirm our commitment to the objective test when 
faced with a traditional informed consent case.  The rationale 
for the objective test set forth in Scaria has worn well in the 
decades that have passed since its announcement and remains a 
durable fabric for the future.  In traditional informed consent 
cases, an injured patient alleges that the physician failed to 
reveal some pertinent information, and that the patient would 
not have consented to the course of treatment if the pertinent 
information was disclosed.  See, e.g., Kokemoor, 199 Wis. 2d at 
641-47 (physician failed to adequately explain morbidity rates 
and the physician's lack of experience performing the particular 
procedure); Martin, 192 Wis. 2d at 167-69 (the informed consent 
discussion did not reveal the availability of a CT scanner and 
the 
unavailability 
of 
a 
neurosurgeon 
at 
the 
particular 
No.  96-3676 
 
 
19
hospital); Scaria, 68 Wis. 2d at 3-9 (physician failed to inform 
patient that dye used for x-rays could cause paralysis or 
death).  Thus, our law has framed the cause question essentially 
as, "Would a reasonable patient have acted differently if the 
informed consent discussion had occurred?"  See Martin, 192 
Wis. 2d at 182.   
¶38 However, in this type of case the underlying rationale 
for the objective test, as noted above, is not implicated.  The 
traditional informed consent case necessarily requires a fact 
finder to do more than find facts; it requires the fact finder 
to be prophetic.  The fact finder is not only asked to determine 
what actually did happen but is also asked to determine what 
would have happened if the informed consent discussion had 
occurred.  The fact finder is asked to construct a puzzle with 
pieces missing and, where missing, to create them so that the 
puzzle is complete. 
¶39 Yet, in this case, the fact finder is asked only to 
determine what did occur and to put the existing pieces of the 
puzzle together.  Janice does not contend that she did not have 
adequate information about her delivery options so that, if she 
had more information, she would have chosen the cesarean 
delivery.  Her claim is based on Figge's failure to conduct an 
informed 
consent 
discussion 
which 
deprived 
her 
of 
the 
opportunity for her choice of treatment after she clearly 
expressed her withdrawal of consent for the VBAC.  
¶40 In this type of informed consent case where the issue 
is not whether she was given the pertinent information so that 
No.  96-3676 
 
 
20
her choice was informed, but rather whether she was given an 
opportunity to make a choice after having all of the pertinent 
information, the cause question is transformed into, "What did 
the patient himself or herself want?"  In these cases, the 
objective test is not needed and may lead to absurd results.  It 
is not needed because the danger it alleviates—relying on an 
injured plaintiff's testimony to determine what would have 
occurred—does not exist because the fact finder is not asked to 
determine what would have occurred but only what did occur.  It 
can lead to absurd results when the known and concrete choice of 
the actual person may well be ignored if it does not comport to 
what the hypothetical reasonable person would have chosen. 
¶41 Having determined above that Janice did withdraw her 
consent and that her withdrawal triggered Figge's duty to have 
another informed consent discussion, by applying the subjective 
test we further conclude that had Janice been given the 
opportunity for a choice in treatment she would have chosen the 
cesarean delivery.  Our conclusion is based not on speculation 
but on the record and factual findings of the circuit court.  
There can be no serious disagreement that Janice stated that she 
wanted the cesarean delivery.  Figge's testimony indicates that 
he knew Janice wanted the cesarean delivery.  Further, the 
circuit court found that she already had all of the necessary 
information and that "if the choice had been put to her squarely 
she would have opted for a [cesarean] section."  Applying the 
objective test to a case such as this would result in the 
evisceration of Janice's actually expressed and understood 
No.  96-3676 
 
 
21
choice of treatment in favor of what the hypothetical reasonable 
person would have chosen.  When we actually know what was chosen 
based on the disclosure of all of the pertinent information, we 
need not engage in the hypothetical exercise of what the 
reasonable person would have chosen. 
¶42 In summary, we determine that Janice withdrew her 
consent to a vaginal delivery.  Because alternative viable modes 
of medical treatment existed at that time, her withdrawal 
constituted a substantial change in circumstances obligating 
Figge under Wis. Stat. § 448.30 to conduct a new informed 
consent discussion and affording Janice the opportunity for a 
choice of treatment.  Figge's failure to conduct such a 
discussion deprived Janice of the opportunity to proceed with 
her actual and clearly expressed choice, a cesarean delivery.  
In applying the subjective test to causation, we conclude that 
the plaintiffs' damages flowed from Figge's failure to conduct 
the informed consent discussion.  Accordingly, we affirm the 
court of appeals. 
By the Court.—The decision of the court of appeals is 
affirmed and the cause remanded to the circuit court to 
determine damages. 
 
 
 
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