Court Opinion

ID: 8203801
Source: CourtListenerOpinion
Date Created: 2022-09-09 23:49:54.831671+00
Date Added: 2024-06-11T16:41:04.085867
License: Public Domain

DAVID T. PROSSER, J.
¶ 202. {concurring). This case has important ramifications for the practice of medicine in Wisconsin. The facts are not difficult to understand, but the "duties" that arise from those facts (and the way those duties are analyzed and stated) present critical policy questions for the court and society. I concur in the decision to affirm the court of appeals and the circuit court, but I am unable to join the lead opinion.
BACKGROUND
¶ 203. On June 13, 2003, Thomas W Jandre (Jandre), then 48, was working as a heavy equipment operator for a construction/excavation company. On his way to a job site, he drank some coffee and it came out through his nose. He began to drool, his speech was slurred, and the left side of his face was drooping. He was unsteady, dizzy, and his legs felt weak. Co-workers transported Jandre to St. Joseph's Hospital in West Bend where he had trouble walking up the curb and needed help to get to the emergency room. The obser*113vations of Jandre's co-workers and of an emergency room nurse were recorded in Jandre's chart.
¶ 204. The emergency room physician was Dr. Therese Bullis. As carefully explained by the lead opinion, Dr. Bullis examined Jandre and took appropriate steps to come to a differential diagnosis including "Bell's Palsy, stroke, TIA [transient ischemic attack], all of those stroke syndromes including ischemic as well as hemorrhagic, tumors, syndromes like — things like Guillain-Barre, MS [multiple sclerosis], and multiple other things like that." Lead op., ¶ 41.
¶ 205. The lead opinion describes the different possible causes listed in the differential diagnosis and explains what Dr. Bullis did and did not do to reach a final diagnosis. Lead op., ¶¶ 42-49.
¶ 206. A parallel discussion is provided by the court of appeals:
Dr. Bullis testified that she observed left-side facial weakness and mild slurred speech. She made a differential diagnosis — which she testified was a "list" of what she was "evaluating the patient for" — of some kind of stroke or Bell's palsy.
The testimony at trial established that there are two types of stroke: (1) ischemic, during which the blood supply to the brain is cut off, most commonly due to blockage in the carotid artery in the neck, and (2) hemorrhagic, during which there is bleeding in the tissue of the brain. There are also two types of temporary blockages, or "mini-strokes," a transient ischemic accident ("TIA") and a reversible ischemic neurological deficit ("RIND"), both of which are warning signs of a "full blown" stroke, which can cause death or permanent injury. A TIA is temporary and does not usually result in long term damage. A RIND is similar to a TIA but lasts more than twenty-four hours. Dr. Bullis ordered a CT scan for Jandre, which can determine *114whether a patient suffered from a hemorrhagic stroke, a brain bleed or a tumor. The results of the CT scan were normal. Dr. Bullís conceded that the CT scan would not detect an ischemic stroke. Although there is a test to determine whether a patient suffered an ischemic stroke — a carotid ultrasound, which was available at St. Joseph's Hospital — Dr. Bullís did not order one.
The trial testimony also established that Bell's palsy is an inflammation of the seventh cranial nerve, which is responsible for facial movement. It is not life-threatening, and the majority of people who suffer from Bell's palsy recover after several weeks or months without any further symptoms. There is no test for Bell's palsy. It is diagnosed by ruling out everything else.
Jandre v. Physicians Ins. Co. of Wis., 2010 WI App 136, ¶¶ 6-8, 330 Wis. 2d 50, 792 N.W2d 558.
¶ 207. By ordering a CT scan, Dr. Bullis eliminated hemorrhagic stroke and brain tumor as possible causes of Jandre's distressed condition. Lead op., ¶ 43. By listening to Jandre's carotid arteries with a stethoscope, she may have reduced the odds that an ischemic stroke event should be her final diagnosis. See id., ¶¶ 44-45. However, neither of these procedures could establish that Jandre was suffering from Bell's palsy, or eliminate the possibility that he had suffered an ischemic stroke event. Under the circumstances, in settling on Bell's palsy as her final diagnosis, the emergency room physician failed to eliminate a far more serious possible cause of Jandre's condition.
¶ 208. It is hard to dispute that a reasonable person under the circumstances confronting Jandre would want to know the possibility that he had suffered some kind of stroke — and that a non-invasive diagnostic technique (a carotid ultrasound) was available at the hospital to confirm or eliminate that possibility. It also is hard to imagine a physician providing this explana*115tion to a patient and then not recommending the carotid ultrasound procedure.
¶ 209. The informed consent statute reads in part: "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 those treatments." Wis. Stat. § 448.30. The statute was interpreted by this court in Martin v. Richards, 192 Wis. 2d 156, 176, 531 N.W2d 70 (1995), as follows:
The applicable statutory standard in informed consent cases in Wisconsin which is explicitly stated in Scaria [v. St. Paul Fire & Marine Ins. Co., 68 Wis. 2d 1, 227 N.W.2d 647 (1975)] and subsequently codified in sec. 448.30, Stats., is this: given the circumstances of the case, what would a reasonable person in the patient's position want to know in order to make an intelligent decision with respect to the choices of treatment or diagnosis?
Id. (emphasis added).
¶ 210. The Martin case repeatedly referred to diagnosis as well as treatment. That is why this court in Buhh v. Brusky, 2009 WI 91, ¶ 3, 321 Wis. 2d 1, 768 N.W.2d 903, concluded that "Wis. Stat. § 448.30 requires any physician who treats a patient to inform the patient about the availability of all alternate, viable medical modes of treatment, including diagnosis, as well as the benefits and risks of such treatments." Id. (emphasis added).
¶ 211. In 2001, long before Buhh was decided by this court, the Wisconsin Civil Jury Instructions Committee produced an instruction (Wis JI — Civil 1023.2, Professional Negligence: Medical: Informed Consent) which read in part:
*116A doctor has the duty to provide (his) (her) patient with information necessary to enable the patient to make an informed decision about a (diagnostic) (treatment) (procedure) and alternative choices of (diagnostic) (treatments) (procedures). If the doctor fails to perform this duty, (he) (she) is negligent.
To meet this duty to inform (his) (her) patient, the doctor must provide (his) (her) patient with the information a reasonable person in the patient's position would regard as significant when deciding to accept or reject (a) (the) medical (diagnostic) (treatment) ( procedure). In answering this question, you should determine what a reasonable person in the patient's position would want to know in consenting to or rejecting a medical (diagnostic) (treatment) (procedure).
The doctor must inform the patient whether (a) (the) (diagnostic) (treatment) (procedure) is ordinarily performed in the circumstances confronting the patient, whether alternate (treatments) (procedures) approved by the medical profession are available, what the outlook is for success or failure of each alternate (treatment) (procedure), and the benefits and risks inherent in each alternate (treatment) (procedure).
[If (doctor) offers to you an explanation as to why (he) (she) did not provide information to (plaintiff), and if this explanation satisfies you that a reasonable person in (plaintiff's position would not have wanted to know that information, then (doctor) was not negligent.]
Wis JI — Civil 1023.2 clearly includes diagnosis in its formulation.
¶ 212. The circuit court faithfully followed this instruction in the present case. Thereafter, the jury returned a verdict in favor of the Jandres on the informed consent claim.
*117DISCUSSION
¶ 213. "Appellate courts in Wisconsin will sustain a jury verdict if there is any credible evidence to support it." Morden v. Cont'l AG, 2000 WI 51, ¶ 38, 235 Wis. 2d 325, 611 N.W.2d 659. "[I]f there is any credible evidence, under any reasonable view, that leads to an inference supporting the jury's finding, we will not overturn that finding." Id. We will "search the record for credible evidence that sustains the jury's verdict, not for evidence to support a verdict that the jury could have reached but did not." Id., ¶ 39. We will uphold the jury's verdict even though the evidence is contradicted and the contradictory evidence is stronger and more convincing to us than the evidence that supports the verdict. Id.; Weiss v. United Fire & Cas. Co., 197 Wis. 2d 365, 390, 541 N.W.2d 753 (1995).
¶ 214. In this case, there is ample evidence to support the verdict. To reverse the decision of the court of appeals would require us to overrule or withdraw language from past cases and change the law. Such action is not warranted on the facts presented.
¶ 215. Having determined that this court should affirm the decision of the court of appeals, I nonetheless acknowledge that I share some of the concerns articulated by Justice Roggensack in her dissent and by Judge Ralph Adam Fine in his concurring opinion in the court of appeals. Jandre, 330 Wis. 2d 50, ¶¶ 44-49 (Fine, J., concurring). These concerns are that the law of informed consent is being expanded beyond its original scope and purpose, with profound consequences for the practice of medicine.
A
¶ 216. There has been a dramatic evolution in informed consent theory in the last half-century. This *118history is briefly chronicled in Martin, 192 Wis. 2d at 169-76. See also Bubb, 321 Wis. 2d 1, ¶¶ 47-56.
¶ 217. Initially, "informed consent was based upon the tort of battery. When a patient failed to authorize treatment or consented to one form of treatment and the physician performed a substantially different treatment, the patient had a cause of action for battery." Martin, 192 Wis. 2d at 170.
¶ 218. Over time, "the basis for liability in informed consent cases changed to a negligence theory of liability: a physician's failure to obtain a patient's informed consent is a breach of a professionally-defined duty to treat a patient with due care." Id., at 171.
¶ 219. There are several key words and phrases in the above-quoted sentence: (1) "negligence," (2) "informed consent," (3) "professionally-defined duty," and (4) "treat."
¶ 220. "Negligence" and "professionally-defined duty" are closely linked in the traditional medical malpractice case. A physician is required to conform to the accepted standard of reasonable care. The court has stated that a qualified medical practitioner, "be he a general practitioner or a specialist, should be subject to liability in an action for negligence if he fails to exercise that degree of care and skill which is exercised by the average practitioner in the class to which he belongs, acting in the same or similar circumstances." Shier v. Freedman, 58 Wis. 2d 269, 283-84, 206 N.W.2d 166 (1973).
¶ 221. Significantly, expert testimony is almost always needed to support a finding of negligence in a medical malpractice case. Kuehnemann v. Boyd, 193 Wis. 588, 592, 214 N.W. 326 (1927), overruled in part on other grounds by Fehrman v. Smirl, 20 Wis. 2d 1, 121 N.W.2d 251 (1963). "Without such testimony the jury *119has no standard which enables it to determine whether the defendant failed to exercise the degree of care and skill required of him." Id,.; Francois v. Mokrohisky, 67 Wis. 2d 196, 197-98, 226 N.W2d 470 (1975); Zintek v. Perchik, 163 Wis. 2d 439, 455, 471 N.W2d 522 (Ct. App. 1991).
¶ 222. The "negligence" standard in informed consent cases in Wisconsin is very different. The physician's "duty" is not defined by professionals; it is defined by a jury determination of what a reasonable person in the patient's position would want to know. The role of expert testimony in this exercise is not clear.1
¶ 223. In the landmark case of Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972), which has often been lauded by this court, the need for expert testimony in informed consent was addressed as follows:
The guiding consideration our decisions distill,... is that medical facts are for medical experts and other facts are for any witnesses — expert or not — having sufficient knowledge and capacity to testify to them. It is evident that many of the issues typically involved in nondisclosure cases do not reside peculiarly within the medical domain. Lay witness testimony can competently establish a physician's failure to disclose particu*120lar risk information, the patient's lack of knowledge of the risk, and the adverse consequences following the treatment. Experts are unnecessary to a showing of the materiality of a risk to a patient's decision on treatment, or to the reasonably, expectable effect of risk disclosure on the decision. These conspicuous examples of permissible uses of nonexpert testimony illustrate the relative freedom of broad areas of the legal problem of risk nondisclosure from the demands for expert testimony that shackle plaintiffs' other types of medical malpractice litigation.
Id. at 792 (emphasis added) (footnotes omitted).
¶ 224. The Martin case traces the history of moving away from a "professionally-defined duty." The court said: "Courts are split on how to apply a negligence theory to informed consent cases . . . differing on what constitutes 'sufficient information' for purposes of disclosure. Many courts only require disclosure of information that the patient can prove is customarily disclosed by other medical professionals." Martin, 192 Wis. 2d at 171 (citation omitted).
¶ 225. The court then noted that Canterbury took a different tack, concluding that a professional standard "was inconsistent with patients' rights to make their own health care decisions." Id. at 171. "Therefore, a growing number of courts require physicians to disclose what a reasonable person in the patient's position would want to know." Id. at 172.
¶ 226. In Scaria, this court adopted "the standard expounded in Canterbury." Martin, 192 Wis. 2d at 173. The Scaria court rejected a trial court's instruction that limited a doctor's disclosures to "those disclosures which physicians and surgeons of good standing would make under the same or similar circumstances, having due regard to the patient's physical, mental and emo*121tional condition." Scaria, 68 Wis. 2d at 12 (quotation marks omitted). The Scaria court explained its decision as follows:
We are not dealing primarily with the professional competence nor the quality of the services rendered by a doctor in his diagnosis or treatment. The right to be recognized and protected is the right of the patient to consent or not to consent to a proposed medical treatment or procedure. Because of the patient's lack of professional knowledge, he cannot make a rational reasonable judgment unless he has been reasonably informed by the doctor of the inherent and potential risks. The right of the patient and the duty of the doctor are standards recognized and circumscribed by the law and are not entirely dependent upon the customs of a profession. . . . [T]he duty to disclose or inform cannot be summarily limited to a professional standard that may be nonexistent or inadequate to meet the informational needs of a patient.
Id. (emphasis added).
¶ 227. Scaria was not a unanimous opinion. Justice Robert W Hansen, joined by Justice Leo B. Hanley, dissented. Justice Hansen observed that a physician's duty to make reasonable disclosure is "correctly stated ... in terms of a duty on the part of the doctor, not a right or expectation on the part of the patient." Scaria, 68 Wis. 2d at 22-23 (R. Hansen, J, dissenting). Justice Hansen added:
If the standards of the profession are adequate as to the duty of a brain surgeon in diagnosis, treatment and surgical procedures, they ought be equally adequate as to what ought be disclosed as to nature of the surgery and collateral risks involved. . .. The writer has more confidence in the standards of the professional group involved than in court or jury deciding what disclosures need or ought be made to a patient facing the surgeon's *122scalpel. Children play at the game of being a doctor, but judges and juries ought not.
Id. at 23-24.
¶ 228. Justice Hansen lost this battle, and Wisconsin law on informed consent has proceeded forward on an objective "reasonable person under the same or similar circumstances" standard ever since.
¶ 229. The court's standard makes good sense to this writer in circumstances like the circumstances in which the standard was created. For instance, in Canterbury, Dr. Spence, a neurosurgeon, performed a laminectomy on a 19-year-old boy without informing either the boy or his mother of the risk of paralysis incidental to the surgery. Canterbury, 464 F.2d at 776-77. "[E]ven years later, [the plaintiff] hobbled about on crutches, a victim of paralysis of the bowels and urinary incontinence." Id. at 776.
¶ 230. In Scaria, the plaintiff became "a paraplegic as a result of a percutaneous femoral aortogram, a radiological procedure whereby a dye is injected into the aorta through a catheter inserted in the groin so that the arteries leading to the kidneys can be visualized by the use of X rays." Scaria, 68 Wis. 2d at 4. There was "considerable dispute" between surgeon and patient about what the doctor told the patient about the "possible complications" of the procedure. Id. at 6-7.
¶ 231. These two cases are textbook examples to support the proposition that "[ejvery human being of adult years and sound mind has a right to determine what shall be done with his own body." Canterbury, 464 F.2d at 780 (quoting authorities). They are very different from cases that do not involve any invasion of the body, either for treatment or for diagnosis. As the scope and application of informed consent are extended to new realms, we ought to ask whether the reasonable *123patient standard — without any defined role for medical experts — is still always appropriate.
¶ 232. This question is underscored by Wis. Stat. § 448.02, relating to the Medical Examining Board. Subsection (3) of this statute reads in part:
(3) Investigation; Hearing; Action.
(a) The board shall investigate allegations of unprofessional conduct and negligence in treatment by persons holding a license .. . granted by the board. An allegation that a physician has violated s.... 448.30 .. . is an allegation of unprofessional conduct.
Wis. Stat. § 448.02(3)(a) (emphasis added).
¶ 233. Chapter 375, Laws of 1981, which created Wis. Stat. § 448.30 (the informed consent statute), also amended § 448.02 to add the important sentence: "An allegation that a physician has violated s. 448.30 is an allegation of unprofessional conduct."
¶ 234. Today, then, a physician must worry not only about his or her patient's condition but also about tort liability and professional discipline, both of which may be grounded on a jury verdict that is not tied to a professionally defined standard of care. This necessarily encourages the practice of defensive medicine. Defensive medicine is a physician's natural response to the fear of strict liability.
¶ 235. Under these circumstances, I believe it is fair to ask whether this court's opinions in informed consent cases serve to prevent strict liability in fact or perception, or whether they have the opposite effect at great cost to health care in Wisconsin.
B
¶ 236. Another of the key terms in the sentence quoted in ¶ 17, supra, is the word "treat."
*124¶ 237. "Treat" is not a defined term. This undefined term appears six times in different forms in Wis. Stat. § 448.30.
¶ 238. The title reads: "Information on alternate modes of treatment."
¶ 239. The first sentence reads: "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." Wis. Stat. § 448.30.
¶ 240. Subsection (5), one of the exceptions to the general rule, reads: "Information in emergencies where failure to provide treatment would be more harmful to the patient than treatment." Wis. Stat. § 448.30(5).
¶ 241. The Bubb court concluded that Wis. Stat. § 448.30 "requires any physician who treats a patient to inform the patient about the availability of all alternate, viable medical modes of treatment, including diagnosis, as well as the benefits and risks of such treatments." Bubb, 321 Wis. 2d 1, ¶ 78 (emphasis added).
¶ 242. The phrase "including diagnosis" was based on language in Martin. Moreover, the aortogram described in Scaria was an invasive diagnostic procedure that was intended "to determine whether there was a narrowing of the arteries leading to the kidneys that might be causing the high blood pressure." Scaria, 68 Wis. 2d at 5.
¶ 243. Especially in an emergency room, it would be difficult to draw a line between diagnostic procedures and treatment, and it would be illogical to distinguish among invasive procedures under the statute— including many but excluding others on the sole basis that they were diagnostic.
*125¶ 244. President George W Bush recently observed (in a much broader context) that: "You cannot solve a problem until you diagnose it."2 Most people who go to an emergency room expect health care providers to diagnose their problem so that they can proceed to address it. The phrase "including diagnosis" in Bubb envisions "diagnosis" as a form of treatment.
¶ 245. Nevertheless, the statute appears to distinguish treatment from diagnosis.3 Once diagnosis is determined to come within treatment, we are likely to be confronted with an endless variety of choices and options, some of which will entail no bodily invasion whatsoever. Many states appear not to embrace diagnosis in their informed consent statutes or cases for this very reason.
¶ 246. Inasmuch as the court has determined that "treatment" includes diagnosis, it becomes imperative for policy makers to fashion reasonable limits to that term and to the duty imposed by statute upon Wisconsin's physicians.
*126c
¶ 247. The other word in the sentence quoted in ¶ 218, supra, that deserves examination is "consent," which is contained in the phrase "informed consent."
¶ 248. When it is used as a noun, "consent" has a well-established meaning. The American Heritage Dictionary of the English Language 401 (3d ed. 1992) defines the noun "consent" as "1. Acceptance or approval of what is planned or done by another; acquiescence. See Synonyms at permission. 2. Agreement as to opinion or a course of action."
¶ 249. Neither "consent" nor "informed consent" is part of Wis. Stat. § 448.30. However, informed consent to treatment is a central policy objective of the relevant cases and statutes. "The right to be recognized and protected is the right of the patient to consent or not to consent to a proposed medical treatment or procedure." Scaria, 68 Wis. 2d at 12.
¶ 250. Canterbury expanded this concept when it proclaimed the "patient's right of self-determination on particular therapy." Canterbury, 464 F.2d at 784. Martin, in turn, translated Canterbury to mean that "every human being has a right to make his or her own medical decisions." Martin, 192 Wis. 2d at 172.
¶ 251. The case before us appears to represent an even greater expansion of a patient's rights: a patient shall be given sufficient information about the availability of all alternate, viable medical modes of treatment (or diagnosis) so that the patient may not only reject a recommended mode of treatment or diagnosis but also select a different one. If this statement is correct, the right described goes well beyond any recognized definition of "consent."
*127¶ 252. An amicus brief filed by the Wisconsin Medical Society, et al., complains that under the court of appeals' interpretation of the statute, which this court affirms:
Physicians would effectively be required to tell their patients "I believe in my diagnosis but if my diagnosis is wrong, here are all the other things you should consider." No other area of human interaction embraces the proposition that a professional must give a layperson the choice of usurping their professional judgment. There is no practical guidance on how to meet this obligation.
¶ 253. Another amicus, Dean Health System Inc., et al., asserts that Wis. Stat. § 448.30 "does not require —and should not be expanded to require — that the patient be allowed to select from an extensive list of procedures on demand."
¶ 254. I have already stated that this court's informed consent jurisprudence may promote the practice of defensive medicine. The abandonment of the limitations of "consent" has a corresponding impact on patients. If a physician does not practice defensive medicine, his patient is empowered to make his or her own medical decisions, selecting modes of treatment or diagnosis pro se, potentially at great cost to the health care system.
¶ 255. These concerns must be addressed and answered more effectively than anything written in this opinion.
D
¶ 256. The lead opinion provides a trenchant argument for affirmance and for the current direction of *128Wisconsin law. I am unable to join the opinion because of the reservations I have about the direction we are going.
¶ 257. Chapter 375, Laws of 1981, includes a provision requiring the Medical Examining Board to "adopt rules to implement s. 448.30." That requirement is presently embodied in Wis. Stat. § 448.40(2)(a).
¶ 258. The Board promulgated rules in 1983. See Wis. Admin. Code ch. Med. 18 Alternative Modes of Treatment (Dec. 1999).
¶ 259. Nearly three decades have passed since the adoption of Wis. Stat. § 448.30 and the rules implementing the statute. Much has changed in the intervening years. Perhaps the time has come for a thorough review of the rules by a blue ribbon committee, including but not limited to medical professionals, so that physicians are given clear guidance as to their obligations under this statute.
¶ 260. A blue ribbon committee would be better equipped to wrestle with the serious policy questions raised here than an individual justice.
¶ 261. For the foregoing reasons, I respectfully concur.

 In this case, the plaintiffs standard of care expert, Dr. Zun, testified regarding the alternate diagnostic procedures Dr. Bullis ought to have discussed with Jandre under Wisconsin's informed consent statute. Even under the Canterbury decision, discussed infra, expert testimony would seem to be required in cases where an individual was injured because he or she was not informed of an alternate diagnostic procedure, which would have discovered the true illness that was affecting the patient. The roles of alternate diagnostic procedures to assess a given condition would seem to be medical facts beyond the comprehension of lay jurors. Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972).

 George W Bush, Decision Points 274 (2010).

 Wisconsin Stat. § 448.30 is derived from 1981 Assembly Bill 941 introduced by Rep. Betty Jo Nelsen. The analysis of the bill prepared by the Legislative Reference Bureau reads in part:
In Scoria v. St. Paul Marine and Fire Insurance Co., 68 Wis. 2d 1 (1975), the Wisconsin supreme court has stated that a physician has a duty to make disclosures to a patient that appear reasonably necessary under the existing circumstances to enable a reasonable person intelligently to exercise the right to consent or refuse treatment. A physician can he guilty of malpractice if failure to make these disclosures is causally related to a patient's injury. The court stated that a causal relation exists if a prudent person would have decided against the treatment had the person been informed of the risks involved and alternatives available.
Drafting file, 1981 A.B. 941, Legislative Reference Bureau, Madison, Wis.