When Kris Knowles was 12 days old he was admitted to the hospital at Ellsworth Air Force Base near Rapid City, South Dakota, for treatment of a fever. Although nurses’ aides recorded Kris’ temperature throughout the night they failed to inform nurses or physicians that his temperature was steadily declining. As a result, Kris developed hypoglycemia and suffered respiratory arrest resulting in severe and permanent brain damage. William Knowles, and his wife Jane, filed suit individually and as guardians of Kris (plaintiffs) in federal district court against the United States (defendant) for medical malpractice, emotional distress, and loss of consortium. The United States admitted liability and invoked the $1 million damages cap pursuant to South Dakota law on medical malpractice damages. Knowles appealed. The Eighth Circuit certified a number of questions for review by the South Dakota Supreme Court, principally of which was whether the damages cap violated the state and federal constitutions.