Opinion ID: 2801079
Heading Depth: 3
Heading Rank: 3

Heading: In Utero Cases

Text: As a threshold matter, claims for fetal injuries brought by the offspring of servicewomen ordinarily do not pose substantial doctrinal questions under Feres’s genesis test. After all, such causes of actions are third-party civilian claims against the government, typical of the sort that invite a Feres inquiry into whether the third-party injury derives from a service person’s incident-to-service injury. But to counterbalance the harsh results often associated with the application of Feres to third parties, some courts have resisted the genesis test in prenatal cases. See, e.g., Brown, 462 F.3d at 616; Mossow v. United States, 987 F.2d 1365, 1369–70 (8th Cir. 1993); Romero v. United States, 954 F.2d 223, 226 (4th Cir. 1992); Del Rio v. United States, 833 F.2d 282 (11th Cir. 1987); Lewis v. United 7 There is no reason to categorically exclude consideration of these factors when divining the source of the third-party injury. But, contrary to the comprehensive treatment-focused approach adopted by some circuits, we emphasize the primacy of identifying an injury to a service member and tracing the third-party injury to it as the crucial elements. -19- States, 173 F. Supp. 2d 52, 56–57 (D.D.C. 2001), vacated in part on other grounds, 290 F. Supp. 2d 1 (D.D.C. 2003). These courts justify an “in utero exception” because there is either no injury to the mother or, in fewer cases, injuries to the mother and to the fetus are unrelated. In either scenario, the fetus’s injury must be independent—that is, it cannot be derivative of the service member’s nonexistent or wholly separate injury. But this rule is not really an “exception” at all; rather, the upshot of the genesis test in such situations is that the third-party injury did not have its genesis in an incident-to-service injury to the service person. 8 By its very terms, the genesis test under Feres will never bar a third party’s claim absent a servicemember injury. And where there is a clear severability between the injuries to the fetus and those to the mother, the genesis test will likewise not preclude recovery. The Nature of In Utero Injuries A number of cases have analyzed in utero injuries under the Feres doctrine. And like with the genesis test more generally, these courts have struggled to ascertain the crux of the genesis test for in utero injuries, disagreeing about 8 Plaintiff alleges that the in utero exception is an entirely separate rule from the genesis test that applies to cases involving fetuses. Due to some conflicting case law, this classification makes some sense but is irrelevant in any event. Because the totally independent injury to the fetus is a raison d’etre for the in utero rule, it serves to negate the derivativeness that is required for the genesis test. As we have said, properly construed, the in utero exception is better described as a particular class of cases under which application of the genesis test reveals an independent third-party injury not barred by Feres. -20- whether the starting point is an injury to the service member or simply treatment directed at or for the benefit of the service member. Plaintiff here oscillates between these approaches, urging that we consider a narrow application of Feres for claims by infants injured during childbirth under either standard. Based on the cases from other circuits, plaintiff’s hedging is understandable, and the Sixth Circuit’s decision in Brown is a useful illustration of the interaction between the competing principles. See 462 F.3d at 611–16. In that case, the court was forced to grapple with its circuit’s own precedent, Irvin v. United States, 845 F.2d 126 (6th Cir. 1988), which had broadly adopted the genesis test for in utero injuries because “[t]he treatment accorded [to a fetus’s] mother is inherently inseparable from the treatment accorded . . . [to] a fetus in his mother’s body.” Brown, 462 F.3d at 617 (quoting Scales v. United States, 685 F.2d 970, 974 (5th Cir. 1982)). To break away from this authority, the Brown court cited with approval the collection of in utero cases, “conclud[ing] that the child’s FTCA claim was not barred by Feres because the child had sustained an independent injury.” Id. at 613 (“[S]ome of the cases are factually similar to the case before this Court in that they allege a negligent injury only to the child, rather than an injury to both the child and the service member.”). It further distinguished Irvin because “the death of the Irvin infant was caused by (and was therefore derivative of) an injury suffered by the child’s mother.” Id. at 614. This made all of the difference in the world because, as the court repeatedly underscored, -21- “Deborah Brown sustained no physical injury whatever from the effects of the negligent prenatal treatment, from her pregnancy, or from Melody’s birth.” Id. at 611 (emphasis added). As we read the opinion, this focus on the injury permitted the Sixth Circuit to apply the genesis test, but escape the weight of Irvin’s seemingly broad holding and permit the military dependent to recover for her injuries. Brown’s articulation of the service person’s injury as the place to start is sound, and other courts have gravitated toward an injury-focused approach for cases involving fetal injuries. For example, in Romero, the Fourth Circuit found that “[i]n our view the relevant inquiry in a genesis analysis is whether a service member was injured, not whether the negligent act occurred during active duty service.” Romero, 954 F.2d at 226. The court in Romero was persuaded in part by the fact that the military mother “suffered no physical injury as a result of the allegedly negligent conduct.” Id. at 224. Similarly in Mossow, the Eighth Circuit noted that “[b]ecause [the baby’s] injury is not derivative of an injury to a service member, we find his cause of action for legal malpractice is not barred by the genesis test under Feres.” 987 F.2d at 1370. And finally, the Ninth Circuit’s recent decision in Ritchie convincingly explains why the only sustainable way to approach the genesis test is through a focus on the service member’s injury itself. Ritchie, 733 F.3d at 877–88. In that case, the court applied the genesis test to dismiss claims for fetal injury brought -22- about because the fetus’s servicewoman mother was forced, against doctor’s orders, to participate in physical training while pregnant. The court first found that the in utero exception was inapplicable based on Ninth Circuit precedent, instead applying a version of the genesis test to find that examining the fetus’s claim would involve second-guessing military orders and thus could not be maintained. Id. at 875–76. Addressing the plaintiff’s urging that the court adopt the in utero exception, the court commented in dicta that the result would be unchanged. Indeed, the court found that “[o]nly where a fetus alone suffers injury can the claim survive Feres.” Id. at 877–88 (“[A] civilian fetus’s claim may only escape Feres if its servicewoman mother suffered no injury from the purportedly negligent acts.”). Other Approaches The injury-focused approach, however, has not gained universal acceptance in the in utero cases. For example, the district court in Lewis found a different result flowed from Romero, concluding that “[t]he crucial issue . . . is whether the negligent medical treatment leading to [the baby’s] injury was provided to him or to his mother.” Lewis, 173 F. Supp. 2d at 57. 9 But, at the very least, the internal 9 Lewis and the Eleventh Circuit’s decision in Del Rio are outliers to the extent that they found no Feres bar even when the fetus’s injuries stemmed from an injury to the servicewomen mother. These cases are unfaithful to Feres for all of the reasons we discuss herein. -23- inconsistencies in Romero are evidence as to why the treatment-focused approach is unworkable: Admittedly, in satisfying its duty of care to Joshua, proper prenatal treatment would have involved his mother’s body. The sole purpose of the treatment, however, would have been directed at Joshua. Mrs. Romero suffered from a congenital cervical weakness. This condition apparently placed Joshua at risk of injury. It did not, however, affect Mrs. Romero’s health. Presumably her state of health would have been the same whether the physician placed the sutures or not. If the treatment had been administered, its sole purpose would have been directed at preventing injury to Joshua. The failure to place the sutures during the prenatal period and to cut them immediately preceding birth was the direct cause of the injuries to Joshua, a civilian. Because the purpose of the treatment was to insure the health of a civilian, not a service member, Feres does not apply. Romero, 954 F.2d at 225. As this suggests, the difficulties in ascertaining the beneficiary of the treatment are never more pronounced than in a case involving mother and fetus. It is difficult to comprehend how courts are well-positioned to determine whether a particular negligent act was directed at the mother, at the fetus, or at both. 10 Faced with the dilemma of the inherently-inseparable nature of prenatal and neonatal treatment, the Romero court strained to demonstrate that the 10 Even some cases that ultimately applied Feres as a bar to third-party claims misguidedly stressed the importance of the target of the negligence. See Scales, 685 F.2d at 974 (“In cases that allow the dependents of servicemen to sue the government, the negligent conduct is directed to the dependent alone and does not involve any decisions by the military toward enlisted personnel.”). -24- government’s conduct was directed at, and intended to benefit, the fetus in order to avoid Feres’s application. But Romero’s analysis is unpersuasive, especially to the extent that it sought to differentiate in utero cases from other third-party Feres claims that required application of the genesis test. Id. at 226. (“We are persuaded that a genesis analysis is inappropriate here.”). In any event, this distinction was unnecessary because as the court ultimately concluded, the fetus’s “injury did not derive from any injury suffered by a service member . . . . Because no service person was injured [the fetus’s] claim is not Feres-barred.” Id. at 226. Bending over backwards to discern the target and beneficiary of the treatment only served to confuse what could have been a straightforward injury-focused approach that would have led to the same result. Injury-Focused Approach Regardless of the split in authority pertaining to the primary concern in the in utero cases, we are convinced that the injury-focused approach is the one required by Supreme Court precedent. As we have said, at a doctrinal level, we need not look much further than Stencel Aero to confirm that the heart of the genesis test is a service member’s incident-to-service injury. Even more fundamentally, the service member’s injury—and by extension, the derivative nature of a third-party injury—is the touchstone of all Feres claims. See Madsen v. United States ex rel. U.S. Army, Corps of Engineers, 841 F.2d 1011, 1012 (10th -25- Cir. 1987) (stressing that Feres’s incident-to-service test is fundamentally concerned with the relationship between the injury and the service member’s status, not the negligence itself). Along the same lines, it is worth reiterating that Feres is a jurisdictional doctrine that directs our focus to the injury as a threshold matter, largely independent of the viability of plaintiff’s negligence or other tort claims. Remember that if Feres applies, then the government is immune to lawsuits notwithstanding the FTCA’s broad waiver. And although we proceed on summary judgment, 11 this preliminary analysis of jurisdiction limits our full-fledged consideration of whether the government owed a duty to any party or whether that duty was breached. But the treatment-focused approach takes us away from the typical Feres question and requests that we purely investigate the merits of the plaintiff’s negligence claim, asking us to analyze the existence of a duty, whether that duty was breached, whether the government caused the alleged injury and so forth. In the end, “[t]he mere fact that the cause of action is not derivative . . . but is an original and distinct cause of action . . . does not remove it from the 11 We note that on summary judgment, we consider the merits of the case to the extent that they are intertwined with the question of subject matter jurisdiction. See Pringle, 208 F.3d at 1222. And while this procedural posture changes both the standard and the evidence available for our consideration, it is not an invitation to forego the jurisdictional question to reach the merits. In other words, we consider certain “aspect[s] of the substantive claim,” id. at 1223, that bear on our jurisdictional analysis, see id. at 1223 n.3 (explaining how important jurisdictional facts under Feres “overlap with the merits of the FTCA claim”). -26- prohibition of Feres.” De Font, 453 F.2d at 1240 (emphasis added). In many ways, the treatment-focused approach requests that we put the cart before the horse. The Feres doctrine has always operated as an antecedent jurisdictional hurdle—that is, it activates an inquiry into our ability to even consider the merits of the tort alleged against the government. The injury-focused approach appreciates this prefatory concern, deferring any substantial merits discussion related to the actions of the government vis-a-vis the third party. In order to reach those questions, we must proceed past the Feres bar and to do so, we consider the relationship between the third-party injury and the service member’s injury as a threshold matter. 12 And the treatment-focused approach could produce anomalous results. For example, in many cases treatment is simultaneously provided for the benefit of both mother and fetus. Oftentimes, only one of the two is injured by medical negligence. In addition, a common scenario might involve treatment aimed solely to benefit the fetus, but which results in an injury to the mother. If the baby suffers an obviously derivative injury as a result of the accidental injury to the mother, then Feres should bar the claim regardless of the fact that the treatment 12 One might question whether discussion of the service person’s injury and the causal link between the service member’s injury and the third-party injury impermissibly ushers in negligence principles. But our examination of those elements exists on a jurisdictional, rather than a merits-based, plane. To the extent that we discuss injury or causation, we do so not with an eye toward whether those elements might state a prima facie tort against the government, but out of fidelity to Feres and Stencel Aero to decide whether we have jurisdiction. -27- was originally intended to benefit only the baby. By the same token, we can envision a scenario where treatment was provided solely for the mother’s benefit, but negligence in providing such treatment injured the baby alone. In those cases, Feres would not operate as a bar because the injury could not be derivative of the non-existent injury to the mother. One final point: we do not intend our rule here to convey that the source and scope of the treatment is irrelevant or necessarily incompatible with the inquiry under Feres. An examination of the treatment may, for instance, be crucial in determining whether the service person was injured at all, see Brown, 462 F.3d at 612–13, or whether that injury was in fact incident to military service, see Monaco, 661 F.2d at 133. But any review of the treatment can only be a means to an end—the end being whether the third-party injury is derivative of the service person’s incident-to-service injury. Phrased another way, our point is simply that looking to the target of the alleged negligence—or the treatment—is not the applicable test. It is not the case that deciphering the target of treatment will always resolve the inquiry. But we leave open the possibility that identifying a separate negligent act may help to establish a direct and non-derivative injury to the fetus. 13 13 The injury-focused approach is not without its flaws, as the concurrence well points out. But the injury focus fittingly accounts for the different outcomes in cases involving fetal claims. Compare Brown, 462 F.3d at 611 (“Deborah Brown sustained no physical injury whatever from the effects of the negligent (continued...) -28- For those reasons, we disagree with the concurrence. A treatment- or conduct-focused approach has its own virtues, as the concurrence explains. But it also has its own vices, and we think the injury focus is most consistent with Stencel Aero and the complexities of fetal injury cases. 14 After all, the FTCA is a broad waiver of sovereign immunity and the Feres doctrine excepts a class of service member claimants who are injured incident to military service. Feres is concerned not so much with the government’s conduct per se but with whether the claimant’s injuries arose from that service. We share some of the concurrence’s concerns about application of the genesis test, but those concerns are not enough to adopt a categorical bar for any fetal injuries arising from obstetric care.